THE ROLE OF PREVENTATIVE THERAPIES IN STRICTURE FORMATION POST ESOPHAGEAL ENDOSCOPIC RESECTION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background
Endoscopic resection is the standard of care for superficial esophageal neoplasms. Advances in techniques have allowed extensive resections resulting in circumferential defects, which substantially increases the risk of stricture formation requiring ongoing intervention. Although several prophylactic strategies have been described to mitigate the stricture risk, a comprehensive understanding of their usefulness remains uncertain. The aim of this study is to review and analyse the current literature with regards to stricture prophylaxis.

Methods
A comprehensive literature search was conducted in Ovid MEDLINE All, Ovid Embase Classic+Embase, Scopus, CINAHL Complete via EBSCOhost, and Ovid EBM Reviews - Cochrane Central Register of Controlled Trials from database inception to August 1, 2023. Randomized controlled trials (RCTs) and observational studies (retrospective or prospective) focusing on prophylactic stricture prevention interventions were included. Standard meta-analyses were employed using the random-effects model, and heterogeneity was assessed by I2% statistics. The primary outcome was the stricture rate amongst different interventions.

Results
The interventions included steroids, botulinum toxin, mechanical therapies, and novel or emerging techniques, compared to either no therapy or alternative prophylactic therapy. The pooled stricture/restenosis rate in the no-intervention group was 51.2% (95% CI: 36.6-65.6; I2 = 90%) across 16 studies. Notably, oral steroid administration demonstrated a significantly lower pooled stricture/restenosis rate at 27.6% (95% CI: 18.7-38.7; I2 = 0%) across 11 studies. Steroid injection and balloon dilation presented pooled rates of 28.1% (95% CI: 16.9-43; I2 = 79%) and 66.8% (95% CI: 48.4-81.2; I2 = 55%).

There was a significant risk reduction in stricture/restenosis with steroid injection with a pooled risk ratio of 0.44 (95% CI: 0.29-0.65; P < 0.001), oral steroid administration (RR 0.43, 95% CI: 0.25-0.73; P = 0.002) and topical steroid application (RR 0.46, 95% CI: 0.23-0.91; P = 0.02). Additionally, the combination of Polyglycolic Acid (PGA) and stent intervention was associated with a risk ratio of 0.41 (95% CI: 0.23-0.74; P 0.003) when compared to stent alone.

Conclusions
Our study highlights the varying effectiveness of prophylactic interventions in preventing esophageal stricture formation post-endoscopic resection. Notably, oral steroid administration and steroid injection showed significant reductions in stricture rates as compared to no interventions.