Hybrid Endoscopic Stricturotomy (HES) for the treatment of post-colorectal Endoscopic Submucosal Dissection (ESD) symptomatic strictures: a preliminary case series

Aims Endoscopic submucosal dissection (ESD) is widely used for treating large colorectal lesions but can lead to post-procedural strictures in 0.49-19.7% of cases [1] [2]. We developed a novel technique called Hybrid Endoscopic Stricturotomy (HES) combining incision and endoscopic balloon dilation (EBD) for treating post-ESD strictures. This study evaluates the safety and efficacy of HES.

Methods This retrospective study analysed data from a prospectively maintained registry, from November 2019 to October 2024. HES was performed on patients who developed symptomatic post colorectal ESD strictures defined as a lumen calibre that does not allow the passage of the endoscope (9.6 mm diameter) after conventional EBD treatment. The HES technique involved incision followed by EBD. An L-shaped knife was used to radially incise the stenotic tissue in four quadrants. Then, a wire-guided balloon dilator was gradually inflated to a diameter larger than the stenosis. Endoscopic follow-up were scheduled every 2-4 weeks, with additional HES sessions if lumen calibre did not improve. The primary outcome was clinical success (as lumen calibre≥2 mm and symptom resolution); secondary outcomes included technical success, adverse events (AEs), and stricture recurrence.

Results Of 265 patients (median age 71 years, 57.1% male) treated with colorectal ESD, 7 patients (2.64%) developed strictures; all in the rectum. Lesions treated with ESD had a median length of 85mm on the major axis and 70mm on the minor axis. All lesions were classified as IIa+Is according to the Paris classification, except for one lesion arising on an anastomosis classified as IIa. The dentate line was involved in 5/7 cases (71.4%). Resection circumference was 100% in 2/7 patients (28.6%), 91-99% in 1/7 patient (14.3%), 76-90% in 1/7 patient (14.3%), 51-75% in 2/7 patients (28.6%), and 0-50% in 1/7 patient (14.3%). Median initial stricture diameter was 5mm (IQR 2). The median number of EBD sessions before HES was 3 (range 2-5). Median stricture diameter after EBD treatment was 6mm (IQR 2) Clinical and technical success was achieved in 100% of cases. The median number of HES treatment sessions was 2 (range 2-3). No AEs were reported. Over a median follow-up of 225 days (IQR 95 days), no symptomatic recurrences were observed.

Conclusions HES is a novel, safe and effective technique for treating post colorectal ESD strictures refractory to conventional EBD. Larger studies are needed to validate these preliminary results.

Publication History

Article published online:
27 March 2025

• References

• 1 Ohara Y, Toyonaga T, Tanaka S. et al. Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms. Endoscopy 2015; 48: 62-70
• 2 Hayashi T, Kudo S, Miyachi H. et al. Management and risk factor of stenosis after endoscopic submucosal dissection for colorectal neoplasms. Gastrointestinal Endoscopy 2017; 86: 358-369