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

Abstract

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.

Fig. 1

Groups classified according to width of mucosal defect. Patients who underwent endoscopic resection (ER) for large superficial esophageal squamous cell carcinoma (ESCC): Group A, ≥ 3/4 and < 7/8; Group B, ≥ 7/8 and less than the entire circumference; Group C, the entire circumference.

Fig. 2

Representative case (case 1). 59-year-old male who underwent endoscopic resection for large superficial esophageal squamous cell carcinoma: a Endoscopic view of the tumor after Lugol’s staining. The tumor spread to about 3/4 of the circumference of the esophageal lumen. b Endoscopic view of the ulcer bed immediately after ESD. The width of the mucosal defect was ≥ 7/8 and less than the entire circumference (Group B). Then, steroid injection alone was performed as a prophylactic treatment. c The esophageal stricture occurred at 42 days after ESD and subsequently endoscopic balloon dilation (EBD) was performed.

Fig. 3

Representative case (case 2). 76-year-old male who underwent endoscopic resection for large superficial esophageal squamous cell carcinoma: a Endoscopic view of the tumor after Lugol’s staining. The tumor spread to about 7/8ths of the circumference of the esophageal lumen. b Endoscopic view of the ulcer bed immediately after ESD. The width of the mucosal defect was the entire lumen circumference (Group C). Then, steroid injection followed by oral steroid was administered as a prophylactic treatment. c Endoscopic view on the 35th day. The mucosal defect was still undergoing re-epithelialization, and an ordinary sized endoscope could pass. d Endoscopic view on the 120th day. The complete epithelialization is shown and an ordinary sized endoscope could pass without dysphagia.