Post written by Wen-Lun Wang, MD, PhD, and Ching-Tai Lee, MD, from the Department of Gastroenterology and Hepatology, E-Da Hospital, Kaohsiung, Taiwan.

Endoscopic radiofrequency ablation (RFA) has shown good efficacy and safety in eradicating Barrett’s neoplasia as well as flat-type early esophageal squamous cell neoplasia (ESCN). However, a post-RFA stricture is still a major concern, especially when treating ultralong-segment ESCNs.

In this prospective study, we found that oral administration of steroids at a dose of 30 mg/day on the third day after extensive RFA (>10 cm) and continued for 4 weeks significantly reduced the stricture risk to 4%, much lower than 44% in the historical control group. Moreover, the number of balloon dilatation sessions required to resolve the stricture also was much lower in the study group than in the control group.

To the best of our knowledge, this study is the first to investigate the effectiveness of steroids in preventing post-RFA esophageal strictures. Oral prednisolone could therefore potentially reduce the overall cost and adverse events associated with mechanical dilation of esophageal strictures. These promising findings also may suggest that the indication of RFA could be expanded to extensive esophageal lesions.

It is crucial to emphasize that the study exclusively enrolled patients with flat-type esophageal squamous precancerous lesions, not histology-confirmed squamous cancer, potentially resulting in a lower risk of cancer progression.

Nevertheless, we suggested that RFA should be used judiciously, given its significant limitation of lacking post-treatment specimens for evaluation. It should be reserved specifically for precancerous lesions unamenable to endoscopic submucosal dissection (ESD), such as the study population with ultralong ESCNs.

Previously, we found that longitudinal tumor size was a significant predictive factor for post-RFA strictures, and that early intervention or prevention for strictures should be applied for those with long-segment (>9 cm) ESCNs. The duration of administration of oral prednisolone is generally significantly shorter for RFA (4 weeks) than ESD (8 weeks), which may be because the ablation wound is shallower, and the epithelium recovers much sooner than with ESD.

In addition, oral steroids are safer than intralesional steroid injections. In the present study, only 2 cases developed asymptomatic candida esophagitis, and both cases resolved spontaneously without treatment. No cases of delayed wound healing or GI upset were found.

Yet, corticosteroid treatment may raise concerns related to adverse effects, including immunosuppression, optical damage, psychiatric disturbances, diabetes, peptic ulceration, and osteoporosis. The promising results of this research have prompted us to conduct a study to define the optimal dose and duration of corticosteroid treatment to prevent post-RFA esophageal strictures.

A-D, Representative case from the control group. Esophageal stricture developed at 1 month after radiofrequency ablation (RFA) for a large unstained lesion in the control group without steroid administration. E-H, Representative case from the study group. After the administration of oral prednisolone on day 3 after extensive RFA, no esophageal stricture was found in the study group.

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