Longitudinal mucosal incision prior to balloon dilation: Novel and advanced approach for severe esophageal stenosis

Stricture is a common complication following esophageal endoscopic submucosal dissection (ESD), occurring in 94.1% of cases involving resection of three-quarters or more of the circumference if no preventive measures are implemented. [1] [2]. Standard treatments, such as balloon dilation with local or systemic steroid administration, are recommended in current guidelines [3]. However, some refractory strictures remain unresponsive, significantly reducing patient quality of life to such measures. This report presents a novel endoscopic approach to treat such cases.

A 70-year-old male underwent ESD for a circumferential esophageal cancer followed by 100 mg of triamcinolone injection at another hospital. However, strictures developed 1 month later ([Fig. 1] a). Subsequent balloon dilations were performed biweekly without improvement, leading the patient to seek care at our hospital.

Fig. 1 a Refractory esophageal stenosis can be seen, which prevents scope passage. b A longitudinal mucosal incision was carefully made on the stenosis site. c Subsequently, balloon dilation was performed to 15 mm. d There was no sign of perforation after the procedure.

Upon performing balloon dilation again for the stricture measured about 8 mm, we identified that same lacerations were consistently forming only in the 4 o’clock direction. Therefore, we adopted a strategy of performing mucosal incisions prior to balloon dilation to redistribute pressure applied to the stricture site during dilation ([Video 1]). Endoscopic ultrasonography using a miniature probe (UM-S20–17R) was performed preoperatively to assess wall thickness.

This video shows a new method of longitudinal mucosal incision prior to balloon dilation for refractory esophageal stenosis caused by circumferential endoscopic submucosal dissection.Video 1

Using a needle knife (KD-645L: Olympus), longitudinal mucosal incisions were carefully made on the stricture at the 6 o’clock and 8 o’clock positions ([Fig. 1] b). Balloon dilation then was performed using a balloon device (KD-645L, 12 to 15 mm: Olympus) to expand the stricture to 15 mm ([Fig. 1] c). Lacerations at the incision points were extended and additional tearing was observed at the 4 o’clock position, which was less severe than in previous procedures as we expected ([Fig. 1] d). Subsequently, 40 mg triamcinolone was injected into the incision site. Four weeks later, follow-up endoscopy revealed that the stricture had resolved, allowing the endoscope to pass through smoothly ([Fig. 2]). This improvement was still evident at 8-week follow-up.

Fig. 2 This image shows the stenosis site 1 month after the procedure. The endoscope could be passed through it.

Balloon dilation often fails to apply pressure in various directions at the stenosis site, which may be a major cause of lack of improvement. Longitudinal incisions at other points can distribute the pressure during dilation, which may offer promising new treatment for refractory stenosis cases.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Ono S, Fujishiro M, Niimi K. et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-665
• 2 Shi Q, Ju H, Yao LQ. et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014; 46: 640-644
• 3 Ishihara R, Arima M, Iizuka T. et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc 2020; 32: 452-493

Publication History

Received: 31 December 2024

Accepted after revision: 27 March 2025

Article published online:
12 May 2025