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Journal of Digestive Diseases 2014; 15; 224–229

doi: 10.1111/1751-2980.12136

Original article

Endoscopic balloon dilatation for benign esophageal stricture after endoscopic submucosal dissection for early esophageal neoplasms Jing Jing LIAN, Li Li MA, Jian Wei HU, Shi Yao CHEN, Wen Zheng QIN, Mei Dong XU, Ping Hong ZHOU & Li Qing YAO Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilatation (EBD) for benign esophageal strictures after ESD for early esophageal neoplasms. METHODS: Data of 335 patients who were treated with ESD for early esophageal neoplasms from October 2006 to August 2012 were retrospectively reviewed. The characteristics of the patients who underwent EBD for post-ESD stricture were analyzed. RESULTS: A total of 117 dilatation procedures were performed in 29 patients with post-ESD

esophageal stricture. The mean number of EBD sessions was 4.0 (range 1–15) and no complications occurred during the procedures. The median follow-up period for the 29 patients since their last session of EBD was 20 months (range 1–48 months). Of the 28 patients who were followed up for more than 3 months after achieving dysphagia relief, two had recurrent dysphasia and EBD was reintroduced. The treatment success rate was 92.9% (26/28). CONCLUSION: EBD is a safe and effective modality for the treatment of benign esophageal stricture after ESD for early esophageal neoplasms.

KEY WORDS: dilatation, endoscopic balloon, endoscopic submucosal dissection, esophageal neoplasms, esophageal stricture.

INTRODUCTION En bloc resection of gastrointestinal (GI) neoplasms using endoscopic submucosal dissection (ESD), regardless of their location and size, has been reported to be more effective than that with endoscopic mucosal resection (EMR).1 ESD allows a precise pathological evaluation of the horizontal and vertical Correspondence to: Shi Yao CHEN, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University,180 Fenglin Road, Shanghai 200032, China. Email: [email protected] Conflict of interest: None. © 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd

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surgical margins as well as the depth of tumor invasion, and the vascular and lymphatic involvement, resulting in an effective prevention of any residual tumors or tumor recurrence. ESD for the removal of superficial esophageal neoplasms has gained widespread acceptance as an alternative to surgery in recent years, especially in Asian countries. However, besides perforation and bleeding, postoperative esophageal stricture is another complication that could be frequently observed after the removal of large esophageal neoplasms by ESD. Dysphagia caused by postoperative stricture would substantially lead to decreased quality of life of the patients and requires further therapies. Although its exact incidence is unknown, postoperative esophageal stricture is thought to be related to the extent of the circumference being

Journal of Digestive Diseases 2014; 15; 224–229

EBD for esophageal stricture after ESD

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Figure 1. The procedure of endoscopic submucosal dissection (ESD) for early esophageal neoplasms. (a) Chromoendoscopy with iodine staining shows a discolored area in the esophagus. (b) The esophageal tumor is removed en bloc with tumor-free lateral and basal margins. (c) Artificial ulcer after ESD.

resected. In Ono et al.’s study2 it was reported that 90% of the patients with lesions extended more than three-quarters of the luminal circumference had postoperative stricture after ESD. Although a few studies have reported new methods for dealing with esophageal strictures, esophageal dilatation is still the preferred choice in clinical practice. Endoscopic balloon dilatation (EBD) has been widely used as an effective modality in treating benign stricture after esophagectomy, and its efficacy might be affected by the length and diameter of the strictures before this procedure.3–5 However, few studies have been published on the effect of EBD for post-ESD esophageal stricture. In fact, we have treated more than 100 patients at our endoscopic center each year with ESD for esophageal neoplasms and observed that some of these patients suffered from esophageal stricture occuring during the follow-up that requires dilatation therapy. In this study, we aimed to evaluate the efficacy and safety of EBD for benign fibrotic strictures after ESD for early esophageal neoplasms. PATIENTS AND METHODS Patients Data of 335 patients with superficial esophageal neoplasms who were treated with ESD at the Endosopic Center of Zhongshan Hospital, Fudan University (Shanghai, China) from October 2006 to August 2012 were retrospectively reviewed. EBD was performed in the patients with confirmed benign esophageal stricture after ESD. The characteristics of these patients who underwent EBD were collected. The study was approved by the Institutional Ethics Committee of Zhongshan Hospital, Fudan University.

ESD for early esophageal neoplasms ESD were performed by three experienced endoscopists (Shi Yao CHEN, Mei Dong XU and Ping Hong ZHOU) in our center, each of them performs more than 300 ESD procedures per year. Standard single accessorychannel endoscope (GIT-H260; Olympus, Tokyo, Japan) and occasionally a dual-channel endoscope (GIF-2T240; Olympus) were used for the ESD procedures. A transparent cap was attached to the tip of the endoscope in order to get a direct view of the submucosal layer. All the patients were treated under general anesthesia with propofol (0.5 mL/kg). Before ESD, the tumor margin was marked with several marker dots approximately 5 mm away from the lesion using iodine stain under endoscopy. A solution (100 mL normal saline + 1 mL indigo carmine [Micro-Tech (Nanjing) Co., Ltd., Nanjing, Jiangsu Province, China] + 1 mL epinephrine) was injected into the submucosa around the lesion with a 23G disposable needle (Olympus) to lift the lesion off the submucosal layer. The mucosal and submucosal layers were then precutted outside the marker dots with a hook knife (Olympus). The submucosal connective tissues beneath the lesion were dissected to remove the lesion completely, during which the solution was injected again if necessary (Fig. 1). When active bleeding occurred during the ESD procedure, endoscopic hemostasis was performed immediately either with the knife itself or hemostatic forcpes. The exposed vessels of the artificial ulcers were treated with argon plasma coagulation to prevent delayed bleeding. Close attention was paid to avoid perforation during the electrocautery coagulation. After ESD, all the patients were given individual proton pump inhibitor therapy, antibiotic prophylaxis and hemocoagulase

© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd

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JJ Lian et al.

Journal of Digestive Diseases 2014; 15; 224–229

Figure 2. Endoscopic balloon dilatation in patients with esophageal stricture after endoscopic submucosal dissection (ESD) for early esophageal neoplasms. (a) Severe stricture after ESD. (b) Insertion of balloon through the stricture. (c) Balloon dilatation for the stricture. (d) The appearance of the esophagus after balloon inflation.

injection. The procedure time, the location and extent of the lesions as well as the complications of ESD were recorded. EBD All the patients underwent EBD at the Outpatient Endoscopic Center in our hospital. The patients’ vital signs such as oxygen saturation, heart rate and blood pressure were persistently monitored. The size of the balloon was chosen according to the degree of the esophageal stricture; for example, balloons of 15–18 mm or 12–15 mm in diameter were applied for moderate (5–10 mm) and severe strictures (

Endoscopic balloon dilatation for benign esophageal stricture after endoscopic submucosal dissection for early esophageal neoplasms.

The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilatation (EBD) for benign esophageal strictures after ESD for ea...
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