Prevention of post endoscopic submucosal dissection stricture

Hwoon-Yong Jung, MD, PhD, AGAF, FASGE
Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea

The most common late complication after esophageal endoscopic dissection (ESD) is esophageal stricture. Esophageal stricture usually occurs within 2–4 weeks after ESD, which usually presents with accompanied by different degrees of dysphagia. The reported incidence rate of strictures after esophageal ESD is 6.9% –18%. As large-sized superficial esophageal squamous cell neoplasms are now becoming candidates for ESD, the development of post-ESD stricture has recently become a major and inevitable concern that may require treatment over a long period of time. Previous studies have reported that resection margins extending up to 75% of the entire esophageal circumference, a longitudinal >30 mm of mucosal defect, resection of cervical esophagus and excessive cautery during the procedure were the independent risk factors for post-ESD esophageal stricture formation. Various innovative and preventive modalities (including intralesional injection or oral administration of steroids and endoscopic transplantation of cell sheets, endoscopic balloon dilatation (EBD) followed by the administration of anti-inflammatory drugs, and the insertion of stents) can be beneficial in reducing the risk of stricture formation. Steroids can inhibit the local inflammatory response, reduce proline hydroxylase activity, and promote collagen enzyme activity to reduce fiber connective tissue formation. EBD has been reported to be effective method in controlling post-ESD stricture. Recently, endoscopic incisional therapy (EIT) using an electrocautery method has also been reported as effective in treating esophageal stricture. EIT can be administered as a primary treatment modality for short segment strictures and strictures with uneven fibrosis in the stenosis rim. In conclusion, the prevention and proper treatment of stricture are crucial to maintain a good quality of life in patients after ESD.