Intralesional Steroid Injection to Prevent Stricture after Near-Circumferential Endosopic Submucosal Dissection for Superficial Esophageal Cancer
A 72-year-old man visited our hospital for the treatment of esophageal cancer. He had undergone a low anterior resection for colorectal cancer 1 year previously. Oral capecitabine was administered after surgery as an adjuvant treatment. There were no significant abnormal findings in the physical examination. All the laboratory findings were within normal limits. Computed tomography and positron emission tomography revealed no distant metastasis. An initial upper endoscopy showed a lugol-voiding lesion involving more than three-quarters of the circumference of the lower esophagus, extending 39 to 43 cm from the incisors (). Endoscopic ultrasound revealed no evidence of submucosal invasion or regional lymph node metastasis. Histopathological findings from another hospital revealed high-grade squamous cell dysplasia, but squamous cell carcinoma could not be excluded. We decided to perform ESD. Because the lesion was near circumferential, a high probability of post-ESD stricture was expected. In this case, we needed to obtain clearer views and to control the scope in detail throughout the procedure; therefore, this patient underwent ESD with tracheal intubation and general anesthesia in an operating room.\nThe ESD procedure was performed using a single-channel upper endoscope (GIF-H260Z; Olympus, Tokyo, Japan) with a transparent cap. Circumferential markings were made using a hook knife (KD-620LR; Olympus) just outside the lesion, on soft coagulation mode of a high-frequency generator for electrosurgery with an automatically controlled system for cutting and coagulation (ERBE, Tübingen, Germany). A total amount of 80 mL normal saline solution mixed with epinephrine was injected into the submucosal layer to lift the mucosa including the tumor. After the lesion was lifted, mucosal incision and dissection was made with a hook knife and an IT knife (KD-611L; Olympus) (). The en bloc resection was completed without complications (). Bleeding in the post-ESD ulcer was coagulated with hemostatic forceps. The total procedure time was approximately 55 minutes. Just after dissection and hemostasis, a single-session endoscopic triamcinolone injection was administered (). Triamcinolone acetonide (Triam, 40 mg/mL; Shinpoong Co., Seoul, Korea) was diluted with saline to make a 20 mg/mL solution. A total of 80 mg (4 mL) triamcinolone was injected into the deep submucosa and the superficial proper muscle layer of the ulcer base at eight sites, with a 0.5 mL dose at each site. The depth of needling was as shallow as producing a small amount of spillage into the esophageal lumen side during injection to avoid possible abscess formation. The resected area was 54×27 mm in size. Three neoplastic lesions (38×17, 11×7, and 7×3 mm) were found in the specimen (). The histopathologic diagnosis was well-differentiated intramucosal invasive carcinoma confined to the lamina propria without lymphovascular invasion.\nSerial esophagography was performed 2 and 4 weeks later to assess the post-ESD stricture. Mild irregular segmental narrowing was seen in the lower esophagus, but no definite passage disturbance was observed (). Follow-up upper endoscopy was performed after 4 months, which revealed only a post-ESD scar (). The scope was passed without resistance. The patient did not complain of dysphagia and showed a good outcome for 6 months after ESD. Moreover, no single session of EBD has been needed.