Omae Masami, Maltzman Henrik, Vujasinovic Miroslav, Wang Naining, Baldaque-Silva Francisco
Department of Upper Abdominal Diseases Karolinska University Hospital Stockholm Sweden.
Department of Medicine Huddinge Karolinska Institutet Stockholm Sweden.
DEN Open. 2024 Jul 22;5(1):e403. doi: 10.1002/deo2.403. eCollection 2025 Apr.
A 73-year-old male patient was referred to us with a long Barrett's esophagus (BE). He had a history of pulmonary embolism under anticoagulant therapy. Esophagogastroduodenoscopy showed a C8M9 BE with no macroscopic lesions. Random biopsies from the BE revealed multifocal high-grade dysplasia. The case was discussed in a multidisciplinary team conference and the decision for full resection of BE with endoscopic submucosal dissection (ESD) was made. Considering the large ESD resection and the high risk of stricture, we developed a novel preventive technique: the "steroid lifting method" for submucosal injection during ESD. Complete circumferential ESD with en bloc resection was performed using the "steroid lifting method", without adverse events. Oral liquids were initiated on day 1 and the patient was discharged on day 4. Oral prednisolone (30 mg per day) was started and tapered for a total of 6 weeks. The pathological examination confirmed multifocal high-grade dysplasia, with radical and curative resection. The patient had neither stricture, dysphagia nor recurrence of Barrett's mucosa at the 2, 6, 12, and 24-month follow-up. International guidelines recommend oral prednisolone and triamcinolone injection to prevent stricture formation in large ESD of esophageal squamous cell carcinoma. However, there is no solid data on BE ESD. The risk factors for stricture formation and the optimal preventive management after large BE ESD is not known. The "steroid lifting method" might be an option in this context. Large prospective studies addressing stricture formation and preventive measures on BE ESD are necessary.
一名73岁男性患者因长段巴雷特食管（BE）转诊至我院。他有肺栓塞病史，正在接受抗凝治疗。食管胃十二指肠镜检查显示为C8M9型BE，无肉眼可见病变。对BE进行随机活检发现多灶性高级别异型增生。该病例在多学科团队会议上进行了讨论，决定采用内镜黏膜下剥离术（ESD）对BE进行完整切除。考虑到ESD切除范围大且狭窄风险高，我们开发了一种新的预防技术：ESD术中黏膜下注射的“类固醇提升法”。采用“类固醇提升法”进行了完整的环周ESD并整块切除，未发生不良事件。术后第1天开始口服流食，患者于第4天出院。开始口服泼尼松龙（每日30 mg），并逐渐减量，共持续6周。病理检查证实为多灶性高级别异型增生，达到根治性切除。在2个月、6个月、12个月和24个月的随访中，患者既无狭窄、吞咽困难，也无巴雷特黏膜复发。国际指南推荐口服泼尼松龙和曲安奈德注射以预防食管鳞状细胞癌大ESD术后狭窄形成。然而，关于BE ESD尚无确凿数据。BE ESD术后狭窄形成的危险因素及最佳预防管理尚不清楚。在此背景下，“类固醇提升法”可能是一种选择。有必要开展关于BE ESD术后狭窄形成及预防措施的大型前瞻性研究。
