Topical budesonide may decrease endoscopic strictures after EMR, ESD

Amit Bhatt, MD

Endoscopic resection caused a paradigm shift in the management of early esophageal cancer, lesions that previously underwent surgical resection are now removed endoscopically. With the development of endoscopic submucosal dissection, even larger lesion could be removed in one piece.

However, endoscopic resection does present challenges. As we started performing endoscopic resections of larger tumors, we realized that if we resected tumors that involved greater than 50% of the esophageal circumference, there was a risk of developing an esophageal stricture. Many of these post resection strictures can be refractory, requiring multiple repeated endoscopic dilations to respond, and each dilation would carry its own risks and inconveniences.  

This can have profound impact on the quality of life of patients, as well as putting them under the risk and costs of multiple endoscopic procedures.

There's been a lot of work trying to prevent post-ESD strictures, and numerous agents and methods have been evaluated. The mainstay of therapy established in Japan has been steroid therapy, with injection of steroids into the submucosa of the ESD resection base, and oral steroid therapy post resection. Oral steroid therapy can come with significant side effects, and many of the elderly patients who develop esophageal cancer may not tolerate them well.  

In the Western world, swallowed topical steroids have been used as post-ESD stricture prevention, similar to the treatment of eosinophilic esophagitis. Theoretically, they would be able to deliver local steroid effect to the resection base, without significant systemic effects, but there is only limited data about using topical steroids as post endoscopic stricture prevention.

This study is well done; it used propensity score weighted logistic regression to try to match the two patient groups between budesonide and no budesonide. The researchers used an established risk factor for stricture formation, which is greater than 50% of esophageal circumference resected. It should be known that a higher proportion of circumferential resection was performed in the budesonide cohort, and circumferential resection has been shown in other studies to be at risk for developing refractory strictures despite the use of post-ESD stricture prevention methods. The findings of the study weren't definitive; they showed that topical budesonide may be associated with reduced risk for esophageal stricture. Further multicenter data are required, but it is a start in the right direction.