Title : The prevention of post-ESD stricture of large early esophageal cancer by periodic triamcinolone injection
Abstract:
Objective:Endoscopic submucosal dissection (ESD) is widely used for early esophageal cancer,but the post-ESD stricture rate of patients with a post-ESD mucosal defect of ≥ 3/4 of the esophageal circumference is extremely high(even reach 90%).Long term repeated endoscopic dilation is required for these patients,whose life quality is significantly reduced. There are many methods and reports for preventing esophageal post-ESD stricture,but the effectiveness is unclear and no standardized prevention method has been established yet.The aim of this study is to investigate the efficacy and safety evaluation of periodic steroid injections in preventing post-ESD stricture for large (diameter ≥ 3/4 circumference) early esophageal cancer, as well as to determine the appropriate number of local injections for preventing stricture.
Method: This study included 45 patients with early-stage esophageal cancer with tumors that had at least 3/4 or the whole circumference. They were divided into an observation group (12 cases with lesions ≥ 3/4 circumference; 6 cases with circumferential lesions) and the control group (21 cases with lesions ≥ 3/4 circumference;6 cases with circumferential lesions).ESD was performed for the obove patients.The observation group received 50-100mg of triamcinolone acetonide injection into the submucosal layer of the wound after ESD immediately,followed by endoscopic and injection of triamcinolone acetonide under endoscopy every 7-10 days after ESD. The injection endpoint was complete repair of squamous epithelium ≥ 1/3 circumference; The control group only received injection of triamcinolone acetonide into the submucosal layer of the wound on the day of ESD.During follow-up, if endoscopy ( diameter ≥ 8.9mm) failed, esophageal stricture was determined and endoscopic (balloon/probe) dilation was performed with local injection of triamcinolone acetonide. The observation indicators were the rate of esophageal stricture after injection of triamcinolone acetonide after ESD, the number of endoscopic dilations after stricture, and the incidence of adverse events.
Result:Compared with the control group, the observation group showed a significant reduction in stricture rate (11.1%, 2/18; control group: 48%, 13/27 cases; χ 2=6.667a, P=0.01), and a decrease in the number of dilations after stricture (median 3.5, range 2-5; median 6, range 3-17 in the control group),; The stricture rate in the observation group (16.7%,1/6) was significantly lower than that in the control group (100%, P=0.015?;In the study,the median number of injections of Amphotericin was observed to be 5 times (range 3-9 times);During the follow-up period of the observation group, one case of delayed perforation adverse event occurred, with a complication rate of 5.6% (1/18).The control group had a complication rate of 11% (3/27), both of which were caused by repeated dilation. One patient developed deep muscle layer tear, and two patients developed esophageal perforation.
Conclusion:The incidence of stricture after ESD surgery for large esophageal cancer is high.Periodic injection of triamcinolone acetonide can prevent post-ESD stricture in large early esophageal cancer,especially in circumferential lesions,Which is safe and easy to implement.
