Independent risk factors for esophageal refractory stricture after extensive endoscopic submucosal dissection

Background: Endoscopic submucosal dissection (ESD) is accepted as a standard therapeutic technique for superficial esophageal neoplasms (SENs). However, esophageal refractory stricture is a serious adverse event secondary to extensive ESD (≥ 3/4 of the luminal circumference). This retrospective study aimed to investigate the risk factors for refractory postoperative stricture after extensive ESD.

Methods: The data of patients who underwent esophageal ESD at the Endoscopy Center of Changhai Hospital were reviewed between January 2011 and September 2019. Risk factors for postoperative refractory stricture [≥ 6 sessions of endoscopic balloon dilation (EBD)] after extensive ESD were then identified using univariate analysis and multivariate logistic regression analysis.

Results: A total of 69 SENs in 67 patients treated by extensive ESD were enrolled in this study. The refractory stricture incidence was 62% (43/69). Significant differences between non-refractory stricture group and refractory stricture group were observed in depth of infiltration (m1or m2/m3 or sm1:20/6 vs. 17/26, P = 0.003), longitudinal resection length (< 50 mm/ ≥ 50 mm:19/7 vs. 10/33, P < 0.001), circumferential range (3/4~ < 1/1:20/6 vs. 19/24, P = 0.008), muscular injury (NO/YES:18/8 vs. 19/24, P = 0.043), and clip number (≤ 5/ > 5:15/11 vs. 12/31, P = 0.014). Multivariate analysis revealed that longitudinal resection length ≥ 50 mm (odds ratio [OR] 11.099, 95% confidence interval [CI] 2.620-47.019), depth of infiltration above m2 (OR 5.716, 95%CI 1.324-24.672) and muscular injury happened (OR 4.431, 95%CI 1.052-18.659) were independent risk factors for refractory stricture. In addition, the EBD sessions for treatment of refractory stricture was related to longitudinal resection length (relation coefficient γ = 0.528; P <0.05).

Conclusions: The longitudinal resection length, depth of tumor infiltration and muscular injury are the reliable risk factors for esophageal refractory stricture after extensive ESD.