Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 21, 2015; 21(23): 7120-7133
Published online Jun 21, 2015. doi: 10.3748/wjg.v21.i23.7120
Useful strategies to prevent severe stricture after endoscopic submucosal dissection for superficial esophageal neoplasm
Kaname Uno, Katsunori Iijima, Tomoyuki Koike, Tooru Shimosegawa
Kaname Uno, Katsunori Iijima, Tomoyuki Koike, Tooru Shimosegawa, Division of Gastroenterology, Tohoku University Hospital, Miyagi 981-8574, Japan
Author contributions: All authors equally contributed to this paper.
Conflict-of-interest: The authors declare no conflict of interests.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Kaname Uno MD, PhD, Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi 981-8574, Japan.
Telephone: +81-22-7177171 Fax: +81-22-7177174
Received: February 10, 2015
Peer-review started: February 11, 2015
First decision: March 10, 2015
Revised: March 24, 2015
Accepted: April 28, 2015
Article in press: April 28, 2015
Published online: June 21, 2015

The minimal invasiveness of endoscopic submucosal dissection (ESD) prompted us to apply this technique to large-size early esophageal squamous cell carcinoma and Barrett’s adenocarcinoma, despite the limitations in the study population and surveillance duration. A post-ESD ulceration of greater than three-fourths of esophageal circumference was advocated as an important risk factor for refractory strictures that require several sessions of dilation therapy. Most of the preoperative conditions are asymptomatic, but dilatation treatment for dysphagia associated with the stricture has potential risks of severe complications and a worsening of quality of life. Possible mechanisms of dysphasia were demonstrated based on dysmotility and pathological abnormalities at the site: (1) delayed mucosal healing; (2) severe inflammation and disorganized fibrosis with abundant extracellular matrices in the submucosa; and (3) atrophy in the muscularis proper. However, reports on the administration of anti-scarring agents, preventive dilation therapies, and regenerative medicine demonstrated limited success in stricture prevention, and there were discrepancies in the study designs and protocols of these reports. The development and consequent long-term assessments of new prophylactic technologies on the promotion of wound healing and control of the inflammatory/tumor microenvironment will require collaboration among various research fields because of the limited accuracy of preoperative staging and high-risk of local recurrence.

Keywords: Esophageal stricture, Dysphasia, Endoscopic submucosal dissection

Core tip: The number of cases of refractory post-endoscopic submucosal dissection (ESD) strictures will increase as the indications for ESD expand. Dysphagia related to the stricture is primarily treated using repeated dilatation treatments, which risk complications and a diminished quality of life. Dysmotility and inflammation-associated disorders at the site may reflect the mechanisms of dysphasia. However, anti-scarring agent administration, endoscopic modalities, and regenerative medicine have limited effects. The development and subsequent long-term assessment of new technologies for the prevention and control of carcinogenesis will be required based on the limited accuracy of preoperative staging and the risk of local recurrence.