Post written by Robert Bechara, MD, from the Queens University, Kingston Health Sciences Center, Kingston, Ontario, Canada.
The introduction of endoscopic submucosal dissection (ESD) has revolutionized the management of superficial gastrointestinal neoplasia. In the esophagus, the stricture rate after a circumstantial ESD (cESD) without any prophylaxis medications is virtually 100%. There have been many reported stricture prophylaxis regimens that include systemic steroids, polyglycolic acid sheets, and injected steroids into the submucosa at various intervals among others.
Our video presents a case of 62-year-old woman with Barrett’s esophagus with multifocal high-grade dysplasia that was resected by cESD. Stricture prophylaxis regimen utilized post-ESD comprised of prednisone, sucralfate suspension, topical budesonide, double dose proton pump inhibitor, and prophylactic balloon dilation prior to stricture formation. Significant strictures have seldom been encountered with the use of this regimen post-cESD. However, potential serious adverse events associated with systemic steroid use must be discussed with the patient and monitored diligently.
The evolution of re-epithelialization post cESD was demonstrated endoscopically at various stages of the healing process until complete re-epithelialization was observed at 32 weeks. Observing the natural progression of re-epithelialization provided early insight into the development of stricture formation. This enabled timely interventions where periodic balloon dilations were performed at the first sign of narrowing during the follow-up endoscopies. In our experience, if patients do not require prophylactic dilation between weeks 5-8, they are subsequently not required and complete re-epithelialization occurs without stricture formation. However, these regimens will require further investigation in a prospective study.
Circumferential ESD permits complete histologic excision of neoplastic tissue and eradication of Barrett’s esophagus in a single session. More widespread adoption of performing cESD is partly dependent on the introduction of effective and easy to administer regimen that minimize use of systemic steroid. As stricture prophylaxis is further optimized, cESD will likely be more widely adopted as a single session treatment option for Barrett’s associated neoplasia and Barrett’s eradication.
Circumferential ESD permits complete histologic excision of neoplastic tissue and eradication of Barrett’s esophagus in a single session. More widespread adoption of performing cESD is partly dependent on the introduction of an effective and easy to administer regimen that minimizes systemic steroid usage. As stricture prophylaxis is further optimized, cESD will likely be more widely adopted as a treatment option for Barrett’s-associated neoplasia.
Read the full article online.
The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.