Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma

Background and study aims: Growing evidence suggests that esophageal stricture frequently develops after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in early esophageal cancer patients, with an incidence proportional to the greater extent of mucosal defects resulting from improved EMR/ESD techniques. There seems to be a potential risk of perforation during bougienage in such patients.

Patients and methods: 648 stricture dilations for 78 lesions in 76 patients were consecutively included. The outcomes after combined use of Maloney and Savary wire-guided bougienage for esophageal strictures after EMR/ESD were analyzed in a single-institute retrospective case series study. The perforation rate was determined and risk factors for perforation were identified.

Results: Patients underwent a median of 5.0 dilation procedures performed over a median 3.0 months for post-EMR/ESD strictures. Initial dilation was done a median 14 days following endoscopic resection. Perforations developed in seven patients (7/648 dilation procedures, 1.1 %), all in the lower esophagus, and bleeding occurred in one patient (0.1 % dilations). Two independent risk factors for development of perforation during dilation therapy for post-EMR/ESD stricture were identified: multiple dilations (odds ratio [OR] 1.2; P = 0.012), and lower site of stricture (OR 12.8; P = 0.043). Dysphagia was ameliorated by the dilations, and no patient required surgery.

Conclusions: A specific emerging risk of perforation in dilation therapy for post-EMR/ESD strictures was identified. Carefully planned treatment is necessary in patients with severe post-EMR/ESD strictures especially strictures requiring multiple dilations or located in the lower esophagus.

References

• 1 Katada C, Muto M, Manabe T et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions.  Gastrointest Endosc. 2003;  57 165-169
• 2 Hernandez L J, Jacobson J W, Harris S. Comparison among the perforation rates of Maloney, balloon, and Savary dilation of esophageal strictures.  Gastrointest Endosc. 2000;  51 460-462
• 3 Saeed Z A, Winchester C B, Ferro P S et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.  Gastrointest Endosc. 1995;  41 189-195
• 4 Saeed Z A. Balloon dilation of benign esophageal stenoses.  Hepatogastroenterology. 1992;  39 490-493
• 5 Saeed Z A, Ramirez F C, Hepps K S et al. An objective end point for dilation improves outcome of peptic esophageal strictures: a prospective randomized study.  Gastrointest Endosc. 1997;  45 354-359
• 6 Said A, Brust D J, Gaumnitz E A et al. Predictors of early recurrence of benign esophageal strictures.  Am J Gastroenterol. 2003;  98 1252-1256
• 7 Chiu Y C, Hsu C C, Chiu K W et al. Factors influencing clinical application of endoscopic balloon dilation for benign esophageal strictures.  Endoscopy. 2004;  36 595-600
• 8 Takahashi H, Arimura Y, Hosokawa M et al. Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video).  Gastrointest Endosc. 2010;  72 255-264
• 9 American Society for Gastrointestinal Endoscopy Guideline . Esophageal dilation. (Guideline).  Gastrointest Endosc. 2006;  63 755-760
• 10 Inoue H, Endo M. A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope.  Surg Endosc. 1992;  6 264-265
• 11 Makuuchi H. Endoscopic mucosal resection for early esophageal cancer: indication and techniques.  Dig Endosc. 1996;  8 175-179
• 12 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 S67-S70
• 13 Seewald S, Ang T L, Omar S et al. Endoscopic mucosal resection of early esophageal squamous cell cancer using the Duette mucosectomy kit.  Endoscopy. 2006;  38 1029-1031
• 14 Silvis S E, Nebel O, Rogers G et al. Endoscopic complications. Result of the 1974 American Society of Gastrointestinal Endoscopy survey.  JAMA. 1976;  235 928-930
• 15 Riley S A, Attwood S EA. Guidelines on the use of oesophageal dilatation in clinical practice.  Gut. 2004;  53 i1-i6
• 16 Soehendra N, Seewald S, Groth S et al. Use of modified multiband ligator facilitates circumferential EMR in Barrett’s esophagus.  Gastrointest Endosc. 2006;  63 847-852
• 17 American Society for Gastrointestinal Endoscopy Guideline . Esophageal dilation.  Gastrointest Endosc. 1998;  48 702-704
• 18 Mackler S A. Spontaneous rupture of the esophagus. An experimental and clinical study.  Surg Gynecol Obstet. 1952;  95 345-356
• 19 McLean G K, LeVeen R F. Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage.  Radiology. 1989;  172 983-986
• 20 Rajan E, Gostout C, Feitoza A et al. Widespread endoscopic mucosal resection of the esophagus with strategies for stricture prevention: A preclinical study.  Endoscopy. 2005;  37 1111-1115
• 21 Zein N N, Greseth J M, Perrault J. Endoscopic intralesional steroid injections in the management of refractory esophageal strictures.  Gastrointest Endosc. 1995;  41 596-598
• 22 Ramage Jr. J l, Rumalla A, Baron T H et al. A prospective, randomized, double-blind, placebo-control trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures.  Am J Gastroenterol. 2005;  100 2419-2425
• 23 Altintas E, Kacar S, Tunc B et al. Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation.  J Gastroenterol Hepatol. 2004;  19 1388-1391
• 24 Sakurai T, Miyazaki S, Miyata G et al. Autologous buccal keratinocyte implantation for the prevention of stenosis after EMR of the esophagus.  Gastrointest Endosc. 2007;  66 167-173
• 25 Nieponice A, McGrath K, Qureshi I et al. An extracellular matrix scaffold for esophageal stricture prevention after circumferential EMR.  Gastrointest Endosc. 2009;  69 289-296