Prophylactic steroid administration for strictures after endoscopic resection of large superficial esophageal squamous cell carcinoma

Background and study aims: One of the major complications after endoscopic resection (ER) for large superficial esophageal squamous cell carcinoma (ESCC) is benign esophageal stricture, which can reduce quality of life even if ESCC achieves a cure without organ resection. Recently, steroid administration has been reported as a prophylactic treatment to prevent esophageal strictures. This retrospective study evaluated the stricture rate according to the different width of mucosal defects due to ER and compared it to that seen with prophylactic steroid administration.

Patients and methods: Between June 2007 and December 2013, we enrolled patients with ESCC who had 3/4 or larger circumferential mucosal defects due to ER. In December 2009, steroid injections (triamcinolone acetonide 50 mg) into the ulcer bed due to ER were introduced. Beginning in November 2012, we commenced oral steroid administration (prednisolone 30 mg/day, tapered gradually for 8 weeks) in addition to steroid injection. Patients were classified into 3 groups according to the width of mucosal defect after ER (Group A, ≥ 3/4 and < 7/8; Group B, ≥ 7/8 and less than the entire circumference; and Group C, the entire circumference). We retrospectively evaluated the stricture rate by comparing no treatment, steroid injection, or steroid injection followed by oral steroid according to the width of mucosal defect.

Results: A total of 115 patients met the selection criteria. In Group B, no treatment had a significantly higher stricture rate (100 %, vs. steroid injection: 56 % P = 0.015; vs steroid injection followed by oral steroid: 20 % P < 0.001). Conversely, in Group C, the stricture rate was high, regardless of treatment (no treatment: 100 %; steroid injection: 100 %; steroid injection followed by oral steroid: 71 %).

Conclusions: Although prophylactic steroid administration is effective to prevent strictures for 7/8 circumference or larger mucosal defects, it is ineffective for whole-circumference defects. Further investigation is required.

• References

• 1 Kuwano H, Nishimura Y, Oyama T. Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus April 2012 edited by the Japan Esophageal Society. Esophagus 2015; 12: 1-30
• 2 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: 67-70
• 3 Ono S, Fujishiro M, Niimi K et al. Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. Gastrointest Endosc 2009; 70: 860-866
• 4 Mizuta H, Nishimori I, Kuratani Y et al. Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer. Dis Esophagus 2009; 22: 626-631
• 5 Ono S, Fujishiro M, Niimi K et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-665
• 6 Katada C, Muto M, Manabe T et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003; 57: 165-169
• 7 Yoda Y, Yano T, Kaneko K et al. Endoscopic balloon dilatation for benign fibrotic strictures after curative nonsurgical treatment for esophageal cancer. Surg Endosc 2012; 26: 2877-2883
• 8 Ezoe Y, Muto M, Horimatsu T et al. Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection. J Clin Gastroenterol 2011; 45: 222-227
• 9 Yamaguchi N, Isomoto H, Nakayama T et al. Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2011; 73: 1115-1121
• 10 Hashimoto S, Kobayashi M, Takeuchi M et al. The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection. Gastrointest Endosc 2011; 74: 1389-1393
• 11 Sato H, Inoue H, Kobayashi Y et al. Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone. Gastrointest Endosc 2013; 78: 250-257
• 12 Soetikno RM, Gotoda T, Nakanishi Y et al. Endoscopic mucosal resection. Gastrointest Endosc 2003; 57: 567-579
• 13 Fujishiro M, Yahagi N, Kakushima N et al. Endoscopic submucosal dissection of esophageal squamous cell neoplasms. Clin Gastroenterol Hepatol 2006; 4: 688-694
• 14 Hanaoka N, Ishihara R, Takeuchi Y et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012; 44: 1007-1011
• 15 Kochman ML, McClave SA, Boyce HW. The refractory and the recurrent esophageal stricture: a definition. Gastrointes Endosc 2005; 62: 474-475
• 16 Muto M, Ezoe Y, Yano T et al. Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video). Gastrointest Endosc 2012; 75: 965-972
• 17 Yano T, Yoda Y, Satake H et al. Radial incision and cutting method for refractory stricture after nonsurgical treatment of esophageal cancer. Endoscopy 2013; 45: 316-319
• 18 Repici A, Vleggaar FP, Hassan C et al. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc 2010; 72: 927-934
• 19 Pauli EM, Schomisch SJ, Furlan JP et al. Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model. Surg Endosc 2012; 26: 3500-3508
• 20 Honda M, Nakamura T, Hori Y et al. Process of healing of mucosal defects in the esophagus after endoscopic mucosal resection: histological evaluation in a dog model. Endoscopy 2010; 42: 1092-1095
• 21 Nonaka K, Miyazawa M, Ban S et al. Different healing process of esophageal large mucosal defects by endoscopic mucosal dissection between with and without steroid injection in an animal model. BMC gastroenterology 2013; 13: 72
• 22 Honda M, Nakamura T, Hori Y et al. Feasibility study of corticosteroid treatment for esophageal ulcer after EMR in a canine model. J Gastroenterol 2011; 46: 866-872
• 23 Yano T, Muto M, Hattori S et al. Long-term results of salvage endoscopic mucosal resection in patients with local failure after definitive chemoradiotherapy for esophageal squamous cell carcinoma. Endoscopy 2008; 40: 717-721
• 24 Uno K, Iijima K, Koike T et al. A pilot study of scheduled endoscopic balloon dilation with oral agent tranilast to improve the efficacy of stricture dilation after endoscopic submucosal dissection of the esophagus. Journal Clin Gastroenterol 2012; 46: e76-82
• 25 Ohki T, Yamato M, Ota M et al. Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets. Gastroenterology 2012; 143: 582-588 e581-582
• 26 Iizuka T, Kikuchi D, Yamada A et al. Polyglycolic acid sheet application to prevent esophageal stricture after endoscopic submucosal dissection for esophageal squamous cell carcinoma. Endoscopy 2015; 47: 341-344
• 27 Wen J, Yang Y, Liu Q et al. Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer. Digest Dis Sci 2014; 59: 658-663
• 28 Kataoka M, Anzai S, Shirasaki T et al. Efficacy of short period, low dose oral prednisolone for the prevention of stricture after circumferential endoscopic submucosal dissection (ESD) for esophageal cancer. Endosc Int Open 2015; 3: E113-117