Risk Factors For Esophageal Stricture After Endoscopic Submucosal Dissection With 1/2-3/4 Circumferential Mucosal Defect

Background and objectiveEndoscopic submucosal dissection(ESD)is a useful,minimally invasive procedure for the management of early esophageal or precancerous lesions.ESD has the advantage of enabling en bloc removal of tumors regardless of their size.However,ESD can result in a large artificial ulcer,which may lead to a considerable deformity.Circumferential mucosal defects of more than three-fourths the esophageal circumference is significant risk factor for the development of post-ESD strictures of the esophagus.Intralesional steroid injections,oral steroids or endoscopic balloon dilation can achieve remission of dysphagia.Nevertheless,steroid treatment may be associated with various adverse effects,including immunosuppression,osteoporosis,diabetes,peptic ulceration,psychiatric disturbances,and optical damage.Also,the risk of dialation-related complications,including potentially life-threatening perforation and bleeding,is also increasing.However,postoperative strictures occurred in 5%-28%of patients with circumferential mucosal defects between half and three-fourths(1/2 to 3/4)of the circumferential extension,there is a lack of large sample studies about the risk factors for postoperative stenosis and prognosis.In this study,we aim to analyze the risk factors and prognosis for postoperative esophageal stricture after endoscopic submucosal dissection(ESD)with mucosal defect of 1/2 to 3/4 circumferences.MethodsA total of 396 patients with early esophageal cancer or precancerous lesions treated by ESD at Drum Tower Hospital,Medical School of Nanjing University,were enrolled between January 2013 and August 2016.Clinical and pathological parameters,including patient-,lesion-,procedure-,and biopsy-related factors,were analyzed for postoperative stricture risk factors.The clinical data of 144 patients with mucosal defect of 1/2 to 3/4 circumferences were futher analyzed.Results1.Fifty-six cases developed post-ESD strictures in 396 patients,the total stenosis rate was 14.1%.Esophageal endoscopic submucosal defect of 1/2 to 3/4 circumferences with postoperative strictures in 25 cases,the incidence of stenosis was 17.4%.Strictures occurred after the postoperative 15-90 days with the mean stricture period 60.80±32.65 days.Twenty-five patients developed esophageal strictures,as mild and moderate esophageal strictures in 16,8 cases(64.0%,16/25 vs.32.0%,8/25),respectively.Only one person appeared severe esophageal stricture(4.0%),in 16 cases(64.0%,1/25).2.Results of univariate and multivariate analysis showed that circumferential mucosal defects of more than three-fourths the esophageal circumference and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus.There was no significant difference between two groups in regard of gender,age,family history,operation time,invasion depth and complications after ESD were observed in the patients with esophageal mucosal dissection 1/2 to 3/4(P>0.05).While pathological type with esophageal squamous cell carcinoma(SCC)and the rate of lesions in the upper esophagus in stenosis group was higher than that in control group(P<0.05).There was no significant correlation between the upper esophageal lesion and postoperative stenosis(R=0.147,P=0.484).3.Esophageal submucosal dissection 1/2 to 3/4 circumference with 16 cases of mild strictures,13 cases without accepted any therapy,1 case expanded one time and 2 cases of expanded two times.While 8 cases of moderate stenosis accepted dilation treatment,the mean dilation frequency was 2.5 times(the interval between each time 2 to 4 weeks).One patient with severe stenosis underwent 10 times dilation and treatment cycle lasted for six months.The follow-up period ended in January 2017,all patients with stenosis symptoms improved significantly.ConclusionsThe early esophageal squamous cell carcinoma with upper esophagus lesion in the stenosis group was significantly higher than that in the non-stenosis group with mucosal defect 1/2 to 3/4 circumferences while it had lower stenosis rate.