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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
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10.1055/a-2346-4577
E-Videos-2024-03-4904-EV
E-Videos
Successful prevention of balloon dilatation after complete circumferential endoscopic submucosal dissection including long-segment Barrett’s esophagus
http://orcid.org/0000-0003-4916-6063
Okimoto Kenichiro MD
http://orcid.org/0000-0001-5314-9325
Matsumura Tomoaki Dr.
Matsusaka Keisuke Dr.
Ohta Yuki Dr.
Taida Takashi Dr.
Kato Jun Dr.
Kato Naoya Prof.
1 Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
2 12737 Department of Pathology, Chiba University, Chiba, Japan
3 92154 Endoscopy Center, Chiba University Hospital, Chiba, China
Correspondence Kenichiro Okimoto, MD Department of Gastroenterology, Graduate School of Medicine, Chiba UniversityInohana 1-8-1Chiba City, 260-8670Japanokimoto-k@chiba-u.jp
03 7 2024
12 2024
1 7 2024
56 Suppl 1 E582E583
The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmc Triamcinolone acetonide (TA) injection into submucosa is useful for prevention of stricture after esophageal endoscopic submucosal dissection (ESD) 11 . However, despite attempts with steroid use, complete circumferential esophageal ESD still leads to high stricture rates (36.4% to 85.7% 22 33 44 ). Although endoscopic balloon dilatation (EBD) is often necessary for stricture relief, it carries the risk of perforation 22 . In addition, in long-segment Barrett’s esophagus (BE) with Barrett's esophageal adenocarcinoma (BEA), post-ESD ulcers can be too long, making EBD challenging. Thus, alternative stricture methods preventing EBD are needed.

Here we present a case of successful prevention of EBD after a circumferential ESD for BEA in long-segment BE (longitudinal length of resected area was 12 cm endoscopically) with intensive TA injections ( Video 1Video 1 ). ESD utilized MucoUp (Seikagaku, Tokyo, Japan and Boston Scientific Japan, Kanagawa, Japan) with indigo carmine, 1.5-mm DualKnife J (Olympus Medical Systems, Tokyo, Japan), and the clip-and-line method 55 . En bloc resection, including the entire long-segment BE (Prague classification C8M9), was performed ( Fig. 1Fig. 1 ). The pathological finding was BEA with unclear horizontal margin and negative vertical margin ( Fig. 2Fig. 2 ).

Weekly intensive triamcinolone acetonide injections were beneficial for preventing stricture in complete circumferential esophageal endoscopic submucosal dissection.

Video 1

Video 1

Fig. 1 Fig. 1 The details of endoscopic submucosal dissection (ESD). a The patient was diagnosed with circumferential Barrett's adenocarcinoma with long-segment Barrett’s esophagus (BE) (C8M9 according to the Prague classification). The yellow arrows indicate the proximal boundary of long-segment BE. b ESD was performed with the clip-and-line method. c ESD was performed by creating a submucosal tunnel. The yellow arrows indicate the edge of the submucosal tunnel. d Immediately after ESD, en bloc resection was performed including the entire long-segment BE. The longitudinal length of the post-ESD defect measured endoscopically was up to 12 cm from the oral to the anal side. e A total of 100 mg of triamcinolone acetonide (TA) was locally injected into the remaining submucosa.

Fig. 2 Fig. 2 Pathological findings of the resected specimen. Histological photograph of an adenocarcinoma at the esophagogastric junction. Atypical glandular epithelium forms irregular tubules, creating polypoid, protruding lesions. Immunostaining shows a mutant pattern of p53 overaccumulation. Meanwhile, a flatly spreading adenocarcinoma is observed around the protrusions. Submucosal esophageal glands in the columnar epithelium region are identified, suggesting an adenocarcinoma arising in Barrett's esophagus.

TA (KENACOLT-A 50 mg/5 mL; Bristol Myers Squibb, Tokyo, Japan) was diluted to 5 mg/mL with normal saline. A 26-gauge 4-mm needle (SG-A 26G FE 4 mm 2200 mm; TOP Corporation, Tokyo, Japan) was used for injection. TA injection into the submucosa, starting immediately post-ESD, was performed at intervals of 0.5 mL (TA 2.5 mg), preventing injury to the muscularis propria. Subsequent injections occurred 3 days post-ESD and then weekly for 21 weeks, with additional injections on weeks 23 and 25, totaling 25 sessions. A total of 50–100 mg TA was administered in each session. At 40 weeks post-ESD, complete epithelialization without stricture was achieved ( Fig. 3Fig. 3 ).

Fig. 3 Fig. 3 The healing process of the post-ESD ulcer. The epithelialization progressed in chronological order from Fig. 3Fig. 3 a–f . A total of 50 mg or 100 mg of TA was locally injected into the regenerating submucosal layer from Fig. 3Fig. 3 a–e , respectively. a 1 week after ESD (3rd local injection of TA). b 4 weeks after ESD (6th local injection of TA). c 8 weeks after ESD (10th local injection of TA). d 12 weeks after ESD (14th local injection of TA). e 20 weeks after ESD (22nd local injection of TA). f 40 weeks after ESD. Complete epithelialization without any stricture was achieved, and a φ9.8-mm scope (GIF-H290T; Olympus Medical Systems, Tokyo, Japan) passed easily.

Weekly intensive TA injections alone were beneficial for preventing stricture in complete circumferential esophageal ESD even if the resected area was long.

Endoscopy_UCTN_Code_TTT_1AO_2AO

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E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos .

Conflict of Interest The authors declare that they have no conflict of interest.
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