Predictors of Postoperative Stricture After Endoscopic Submucosal Dissection for Large Superficial Esophageal Squamous Cell Neoplasms

Abstract

Introduction: Endoscopic submucosal dissection (ESD) has been widely accepted for resecting superficial esophageal squamous cell neoplasms (ESCNs). The aim of this study was to evaluate the predictors for postoperative stricture after ESD for large ESCNs (>3/4 circumferential mucosal defect). Methods: We consecutively enrolled 63 patients with large ESCNs(Histologic depth<sm1) who underwent ESD at the Chinese PLA General Hospital were enrolled. Patients were grouped as post-ESD stricture group and no post-ESD stricture group according to stricture occurrence or not after ESD. The demographic characteristics of the patients and the tumor and technical factors were analyzed for investigating predictive factors of postoperative stricture. Results: All the ESD procedures were successfully performed for 63 patients of which 25(39.4%) taking prophylactic methods for preventing post-ESD stricture. The rates of postoperative stricture for different circumferential defects of ≥3/4 to <7/8, ≥7/8 to <4/4 and 4/4 were 38.2%(13/34), 50.0%(6/12) and 76.5%(13/17) respectively. The total stricture rate was 50.8%(32/63). Patients with post-ESD stricture had a significantly higher degree of circumferential mucosal defect(P=0.036), larger longitudinal tumor size ((5.72±2.16) versus (4.24±1.61) cm, P = 0.003) and more patients with presence of muscle injury(9 vs 2, P = 0.023).There was no significant differences in age, sex, tumor location, macroscopic type, procedure time, the longitudinal diameter of specimens, the circumferential diameter of specimens, en bloc resection, histological depth and taking prophylactic measures (P>0.05). After multivariate analysis, circumferential mucosal defect (≥ 7/8) and not taking prophylactic measures are predictors for stricture development in patients with large ESCNs after ESD. Conclusion: Circumferential mucosa defect >7/8 is the main factor leading to the stricture of the esophagus after ESD for large early ESCNs. For patients with post- operative circumferential mucosa defect >3/4, appropriate preventive measures can effectively reduce the incidence of postoperative stricture after ESD.354_A Figure 1. Groups according to circumferential mucosal defect. Patients who underwent ESD or ESTD for large superficial esophageal squamous cell carcinoma(ESCC):Group A, ≥3/4 and <7/8; Group B, ≥7/8 and <4/4; Group C, entire circumferential mucosal defect(4/4)354_B Figure 2. Stricture was encountered after submucosal dissection (ESD) involving total circumferential resection. A. Chromoendoscopy with iodine staining revealed a discolored area in the lower esophagus. B. Entire (4/4) circumferential mucosal defect after ESD. C. Resected sleeved specimen with the lesion in an en bloc resection, the length of which was approximately 4.5 cm. D. A fully covered esophageal stent was implanted for prevention of stricture. E. Endoscopy displayed stricture 63 days after ESD. F. Endoscopic balloon dilatation is performed against the postoperative stricture. G. The stricture site was dilated after balloon dilatation, a 9.8-mm-diameter esophagogastroduodenoscopy (EGD) could be passed through this lumen. H. The lumen 7 months after ten EBD treatments.354_C Figure 3. The detailed data of the 63 patients enrolled in the study.