Tu1031 COMBINATION THERAPY WITH TRIAMCINOLONE INJECTION AND POLYGLYCOLIC ACID SHEETS WITH FIBRIN GLUE APPLICATION TO PREVENT STRICTURE AFTER ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION

Endoscopic submucosal dissection (ESD) is now globally accepted as a minimally invasive treatment for superficial esophageal neoplasia and allows en-bloc resection of a lesion irrespective of its size. ESD of more than three-fourths of the circumference of the esophagus is a high risk for postoperative stricture. However, standard methods to prevent esophageal stricture after widespread ESD remain undetermined. Therefore, we assessed the effect of combination triamcinolone injection and polyglycolic acid (PGA) sheet shielding with fibrin glue to prevent post-ESD stricture. Immediately after ESD of more than three-fourths of the esophageal circumference, triamcinolone (5 mg/ml) was injected into the submucosal layer along the inner edge of the post-ESD ulcer (0.1 ml each). A PGA sheet was cut into an oblong shape to fit the ulcer size and was deployed using a modified clip-and-pull method to cover the ulcer. Fibrin glue was then instilled over the sheet to adhere it to the ulcer. Between August 2016 and September 2017, eight consecutive patients who underwent widespread esophageal ESD after the combination triamcinolone injection and PGA sheet shielding with fibrin glue were enrolled and monitored for 8 weeks. The mean age was 67.8 ± 9.5 years (five men and three women). All cases were diagnosed as having squamous cell carcinoma (depth of tumor invasion: 2 EP, 4 LPM, 1 MM, and 1 SM1), which was located in the middle esophagus in three cases and in the lower esophagus in five cases. The mean size of the longitudinal resected lesion (eight semi-circumferential) and its resection time was 51.2 ± 13.2 (40–70) mm and 105 ± 30.5 (70–163) min, respectively. The mean volume of the injected triamcinolone was 14 ± 5.2 mg, and the mean maximum longitudinal diameter of the PGA sheet was 58.7 ± 18.1 (40–80) mm. The mean time of triamcinolone injection, PGA sheet with fibrin glue application, and combination treatment was 8.5 ± 3.4 (5–14), 36.2 ±10.5 (20–52), and 44.7 ± 12.5 (30–66) min, respectively. No stricture or dysphagia symptoms were observed in seven cases. Post-ESD stricture only occurred in one case (12.5%) at 29 days after ESD, with two sessions of endoscopic balloon dilatation required. No adverse events were observed during the study. In conclusion, our results showed that the combination of triamcinolone injection and the shielding method using PGA sheet and fibrin glue could be safe and effective for preventing esophageal stricture after semi-circumferential ESD.