Safe technique of steroid injection utilizing submersion in saline to prevent stricture after esophageal endoscopic submucosal dissection

ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) for widespread superficial esophageal cancer often causes esophageal stricture. Although locoregional steroid injection prevents such stricture, it is sometimes challenging to inject the steroid into the submucosal layer as injection into the muscle layer may cause esophageal perforation. Here, we introduce a safe technique for steroid injection into the submucosal layer that uses submersion of the esophageal lumen with saline and creates a continuous flow; this avoids steroid injection into the muscle layer. An 80-year-old man with widespread superficial esophageal cancer in the lower thoracic esophagus underwent ESD (Fig. 1A). After en bloc resection, the mucosal defect was found to be approximately 70% of the circumference of the esophageal lumen (Fig. 1B). Therefore, we attempted to inject triamcinolone into the resected submucosal layer to prevent esophageal stricture after the ESD procedure. First, the esophageal lumen was filled with saline using a water-jet endoscope (GIF-Q260J; Olympus Medical Systems Corporation, Tokyo, Japan) through the overtube (Video S1). Next, the submucosal layer was splashed continuously with saline using the jet endoscope. Then, triamcinolone was injected into the submucosal layer using a 4-mm length needle (Needle Master, NM-610L-0426; Olympus). This was made easier by the lifting and floating of the submucosal layer from the muscle layer, which allows for easier injection into the target tissue and improves on conventional methods (Fig. 1C). Using this technique, 40 sequential injections of 0.5 mL (2 mg) triamcinolone were performed for a total of 80 mg. Eight weeks after ESD, scar formation was found but no stricture was observed (Fig. 1D). This method could be a safe procedure for steroid injection into the submucosal layer to prevent stricture as it reduces the risk of injection into the muscle layer. Both injections by water-jet endoscope and underwater floating may play significant roles. Authors declare no conflicts of interest for this article.