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Safer local injection of triamcinolone acetonide for preventing post‐endoscopic submucosal dissection esophageal stenosis

ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) is an established treatment for superficial neoplasia throughout the digestive tract, including the esophagus. While large-sized esophageal superficial neoplasia can be resected en bloc with ESD, there is a 90% probability of postoperative stenosis when the mucosal defect is over three-quarters of the circumference after treatment. Once stenosis occurs, the patient’s quality of life decreases significantly, and frequent balloon dilation is often needed to treat stenosis. Therefore, preventing stenosis after extensive esophageal ESD is essential. One method involves the local injection of triamcinolone acetonide (TA) into the thin submucosal layer remaining in the mucosal defect. Generally, a needle is used for submucosal injections during ESD; however, sharp-tipped needles may mistakenly traverse the submucosa, injecting TA into the muscle layer. Reportedly, this increases the risk of accidental esophageal perforation and abscess formation. Here, we report a new method of injecting TA to prevent stenosis after ESD (Video S1). The local injection was TA diluted to 5 mg/mL with saline solution. Instead of a conventional injection needle, we used a spraying tube (fine jet, spray type; TOP Corporation, Tokyo, Japan) with a dull, round tip. The spraying tube was inserted into the submucosal layer remaining at the ulcer base after ESD. When the syringe is pressed, a small, cloudy protrusion forms in the remaining submucosal layer at the ulcer base, indicating that sufficient triamcinolone has been injected. Considering that TA injection into the muscularis propria is unlikely with this method, it is considered an extremely safe method that is easy, fast, and requires no careful manipulation. Although the tube’s tip is dull, the amount of TA injected is sufficient and similar to when an injection needle is used (Fig. 1).