Post written by Kotaro Shibagaki, MD, PhD, from the Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan.
The esophageal extensive ESD causes a postoperative severe stenosis, which requires endoscopic balloon dilation. The most popular preventive procedure is perhaps an endoscopic local injection of triamcinolone acetonide (TA), but it has a big problem in clinical feasibility due to the difficulty of even TA-injection to the large resected surface. We propose the esophageal TA-filling method as a novel local steroid administration procedure. The TA-saline solution is endoscopically filled in the esophagus twice, on the day after ESD and one week later. In this case series study, 22 consecutive patients with early esophageal cancer were treated by either subcircumferential or circumferential ESD (15 and 7 procedures, respectively). The procedure highly prevented the esophageal stenosis after esophageal extended ESD (the incidence of severe stenosis was 4.5%, 1/22; confidence interval, 0.1%-22.8%).
Figure 1. The esophageal triamcinolone acetonide (TA)–filling method. The procedure is performed under conscious sedation to avoid the gag reflex. The endoscope is inserted into the gastric antrum (A) and then pulled back into the esophagus while suctioning as much intraesophagogastric air as possible (B). A saline TA solution (80 mg/4 mL) is infused into the esophagus, followed by 20 mL of additional pure saline solution, and any remaining intraesophageal air is suctioned endoscopically for 2 minutes after drug infusion. C, The left lateral decubitus position is maintained for 5 minutes after pulling out the endoscope to maintain the drug solution in the esophagus (D). Note: Fluoroscopy is unnecessary in this procedure. The images were photographed by mixing additional saline solution with gastrografin just for visually understandable explanation with the approval of the patient.
We conducted this study to statistically certify the efficacy of this novel stenosis-preventive method after esophageal extensive ESD. We expect this method will be accepted worldwide to be a standard measure to prevent stenosis after extensive esophageal ESD.
The most important point is the stenosis-preventive effect of esophageal the TA-filling method not only for subcircumferential but also for circumferential esophageal ESD, although circumferential resection has the problem that it needs a long time for complete mucosal healing and additional TA-filling procedures. The previously reported methods are basically for stenosis prevention after subcircumferential resection.
To certify the feasibility and reproducibility of our method, we have started a multicenter phase II study.
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