Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan.
Division of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan.
Scand J Gastroenterol. 2021 Jun;56(6):647-655. doi: 10.1080/00365521.2021.1910998. Epub 2021 Apr 15.
Endoscopic submucosal dissection (ESD) for extensive esophageal cancer is sometimes associated with post-ESD stenosis, despite preventative steroid therapy. In this retrospective multicenter analysis, we evaluated the factors associated with therapy resistance.
We enrolled 73 patients with 75 extensive esophageal cancers treated with ESD. Stenosis prevention was performed using two esophageal triamcinolone acetonide (TA)-fillings, and repeated if stenosis was found on follow-up. Therapy-resistance factors associated with incidence of severe stenosis requiring endoscopic balloon dilation (EBD) were evaluated, including age, gender, previous treatment history, tumor location, morphology, resection size, histologic type, invasion depth, and horizontal resection grade (HR-grade 1, ≥ 9/12 and <10/12 of the circumference; grade 2, ≥ 10/12 and <11/12; grade 3, ≥ 11/12 but not circumferential; and grade 4, entirely circumferential).
Severe stenosis occurred in 17.3%(13/75) of cases, with a median of two EBDs (range, 1-6 times). Severe stenosis was significantly associated with HR-grade elevation and previous treatment history ( < .05); multivariate analysis showed both as independent therapy-resistance factors ( < .05). Patients without previous treatment history demonstrated severe stenosis at 12.9%(9/70): 0%(0/26) HR-grade 1, 18.8%(3/16) grade 2, 17.6%(3/17) grade 3, and 27.3%(3/11) grade 4, showing a risk of HR-grade 2 or more resection but an acceptable stenosis prevention even after entirely circumferential resection. Conversely, patients with previous treatment history demonstrated severe stenosis at a high frequency of 80%(4/5).
Esophageal TA-filling is a promising stenosis-preventive steroid therapy, even in entirely circumferential ESD cases. However, HR-grade 2 or more elevation and previous treatment history were independently associated with therapy resistance.
尽管采用了预防性类固醇治疗，内镜黏膜下剥离术（ESD）治疗广泛的食管癌有时仍会导致术后狭窄。在这项回顾性多中心分析中，我们评估了与治疗抵抗相关的因素。
我们纳入了 73 名患有 75 例广泛食管癌的患者，这些患者均接受了 ESD 治疗。采用两次食管曲安奈德（TA）填充进行狭窄预防，如果在随访中发现狭窄，则重复进行。评估与需要内镜球囊扩张（EBD）的严重狭窄发生率相关的治疗抵抗因素，包括年龄、性别、既往治疗史、肿瘤位置、形态、切除大小、组织学类型、浸润深度和水平切除分级（HR 分级 1，≥9/12 且<10/12 周长；分级 2，≥10/12 且<11/12；分级 3，≥11/12 但非全周；分级 4，全周）。
严重狭窄发生率为 17.3%（13/75），中位数为 2 次 EBD（范围 1-6 次）。严重狭窄与 HR 分级升高和既往治疗史显著相关（<.05）；多因素分析显示两者均为独立的治疗抵抗因素（<.05）。无既往治疗史的患者严重狭窄发生率为 12.9%（9/70）：HR 分级 1 为 0%（0/26），分级 2 为 18.8%（3/16），分级 3 为 17.6%（3/17），分级 4 为 27.3%（3/11），提示 HR 分级 2 或更高的切除存在风险，但即使全周切除也可接受狭窄预防。相反，有既往治疗史的患者严重狭窄发生率较高，为 80%（4/5）。
食管 TA 填充是一种有前途的预防狭窄的类固醇治疗方法，即使在全周 ESD 情况下也是如此。然而，HR 分级 2 或更高和既往治疗史与治疗抵抗独立相关。
