Use of stent for prevention of esophageal stricture after circumferential endoscopic submucosal dissection

A 71-year-old man who presented with heartburn underwent gastroscopy in the First Affiliated Hospital of Zhejiang Chinese Medical University which showed large red lesions in the esophagus at 29–32 cm from the incisors, approximately the whole circumference of the esophagus. He had been diagnosed with early esophageal cancer (EEC) of the esophagus judged to be T1aN0M0 (stage I) and had undergone endoscopic submucosal dissection (ESD). Upon pathological examination, a well-differentiated squamous cell carcinoma was found to have invaded the muscularis mucosa without penetration. Vertical and horizontal resectionmargins were negative for carcinoma. After treatment by endoscopic submucosal dissection at the resection site, a fully covered esophageal self-expanding nitinol stent was inserted and covered the entire esophageal mucosal circumference (Fig. 1). After the procedure, proton pump inhibitors were given to the patient for 3 days. One month later, there was a small stricture but no obvious symptoms of stricture and no other serious complications after the stent was removed. Esophageal stenosis is the most common complication after ESD. Risk factors for esophageal stricture mainly include cervical location, tumor size >3/4 circumference and diameter >40 mm, and resection site at least 50%of the circumference. In a randomized controlled trial, temporary covered esophageal stents showed promising results. However, prophylactic stenting is associated with stent migration, stent-related strictures and chest pain. Recyclable all-coated esophageal self-expanding nitinol stent with a silk thread attached to the edge of the proximal wire proved to be beneficial to prevent stent migration. Recently, tissue-engineering techniques have gradually been applied in the prevention and treatment of ESD, and reduce the possibility of balloon dilatation. However, biodegradable stent has disadvantages. Yano et al. summarized that long-term efficacy was limited after ESD. The present case shows that prophylactic esophageal stenting provided significant benefit. However, stenting with promising results has been described and evaluated only in small one-arm studies and deserves further evaluation in the future.