Esophageal ESD and stricture prevention(GIE, Jan-2026)

The study published in Gastrointestinal Endoscopy (GIE), January 2026 focuses on esophageal endoscopic submucosal dissection (ESD) and strategies for preventing esophageal strictures, a common and serious complication following extensive resections. Below is a detailed summary of the key findings and advancements discussed in the study:

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Background on Esophageal ESD and Stricture Formation

1. Preferred Therapy: Esophageal ESD is now the standard treatment for large esophageal dysplastic and superficial neoplastic lesions due to its precision and efficacy.

2. Stricture Risk: The risk of esophageal strictures increases significantly when more than 75% of the esophageal circumference is resected. Strictures result in severe patient morbidity, frequently necessitating repeated endoscopic dilations, which negatively impact quality of life.

3. Limitations of Current Prevention Strategies: Existing methods to prevent strictures, such as steroid therapy, stents, tissue shielding, and dilations, have shown inconsistent results. No single approach has emerged as clearly superior.

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Introduction of Submucosal Steroid Pre-Injection Strategy (SSPS)

1. Novel Technique: SSPS involves injecting steroids into the submucosa before the ESD procedure. This is combined with two postoperative intralesional steroid injections, creating a multiphase steroid delivery system.

2. Rationale for Pre-Injection: Pre-resection steroid injection ensures uniform distribution and prolonged submucosal exposure, aligning with the critical healing period when strictures typically form.

3. Comparator Therapy: The control group received intralesional steroids post-ESD along with an extended course of oral steroids.

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Key Findings

1. Lower Stricture Rates: SSPS demonstrated significantly lower stricture rates compared to the control group. The benefit was consistent even after adjusting for lesion location, width, and length.

2. Safety Profile: No adverse events were reported in patients treated with SSPS, addressing concerns about potential risks such as delayed perforation.

3. Encouraging Results for Full Circumferential ESD: Achieving a low stricture rate in cases of full circumferential ESD is clinically notable and represents a significant advancement.

4. Potential Mechanical Dilation Effect: The repeated passage of the endoscope during follow-up steroid injections may have had a mechanical dilation effect, unintentionally contributing to stricture prevention.

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Challenges and Considerations

1. Visualization and Equipment Limitations: The opacity of steroids without contrast dye can impair visualization during dissection. Additionally, the increased viscosity of the steroid injectate may not be compatible with certain ESD knives.

2. Complexity in Attribution: The multiple interventions in the SSPS group make it difficult to attribute the benefit solely to pre-resection steroid injection.

3. Theoretical Risks: While no delayed perforations were observed in the study, the potential risk remains a theoretical concern.

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Emerging Alternative Strategies

The study highlights other promising approaches for stricture prevention, including:

1. Endoscopic vacuum therapy.

2. Peptide gels.

3. Tissue shields.

These strategies are in early stages of development and require further investigation.

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Call for Further Research

1. Need for Prospective Trials: The study emphasizes the importance of well-designed, prospective trials to validate the efficacy of SSPS and compare it with emerging modalities.

2. Future Directions: Further research is needed to refine SSPS, address its limitations, and determine its long-term outcomes in diverse patient populations.

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Conclusion

The introduction of SSPS represents a promising advancement in the prevention of esophageal strictures following ESD, particularly for extensive or full circumferential resections. With its favorable safety profile and significant reduction in stricture rates, SSPS has the potential to improve patient outcomes. However, challenges such as equipment compatibility, visualization issues, and the complexity of attributing benefits to pre-resection steroids warrant further investigation. Prospective trials are essential to confirm these findings and to compare SSPS with other emerging strategies.