Esophageal endoscopic submucosal dissection (ESD) involving >75% of the circumference is associated with refractory stricture in >70–90% of cases. Extensive circumferential resections progress to refractory strictures that are challenging to manage. This adverse event severely impairs quality of life and limits ESD indications for superficial squamous cell carcinoma. The prophylactic, topical, and oral administration of corticosteroids has partially addressed this problem. Several other prophylactic therapies have been proposed, and recently, autologous and allogenic adipose tissue-derived stromal cells (ADSC) injection has emerged from animal trials. The advantages of ADSC are their paracrine activity, promoting local immunomodulation, cell recruitment and neovascularization, their ability to differentiate into mesenchymal and non-mesenchymal lineage, and modulation of keratinocyte-fibroblast interaction, reducing excessive fibrosis development. 

We report a novel prophylactic strategy using immediate injection of mechanically processed autologous adipose-derived stromal cells (ADSCs) directly into the post-ESD ulcer bed. A 71 male-patient, diagnosed with superficial esophageal squamous cell carcinoma (SCC), occupying 80% of luminal circumference. He was referred to our center for treatment and underwent a 90% of esophageal circumference, 8 cm-long ESD. Once ESD was finished, the plastic surgeon made a bilateral inguinal liposuction using two 10mL syringes. The content was decanted for ten minutes, and then the liquid part of the material was discarded. Afterwards, the fat was washed with fisiologic solution, transferred to 5mL syringes, coupled with a transfer connector, already coupled with and empty 5mL syringe. The material was transferred 10 times for adipose tissue progressive fractioning, until a final product was obtained. This product was then injected onto the ESD resection bed, as homogeneously as possible, through a 5Fr catheter. Oral prednisolone (30 mg/day with 8-week tapering) was also administered as an adjunct per institutional protocol.

Pathology revealed early squamous cell carcinoma, invading the lamina propria (pT1a – M2), without angiolymphatic or perineural invasion, with free margins. Serial endoscopies at 2, 3, 4, 5, 6, 8 and 12 weeks showed progressive healing with fibrin coverage and tissue retraction, but no luminal narrowing. At week 8, the ulcer was completely healed with only cicatricial retraction; a standard 9.8 mm gastroscope passed without resistance. The patient developed transitory dysphagia, that completely resolved six weeks afterwards, and needed diet adaptation throughout this period. In none of the endoscopies narrowing of the lumen was observed, and there was no need of endoscopic dilatation. A new endoscopy was performed twelve weeks after the procedure, revealing the same aspect described on the eighth week. The patient remains clinically well, without dysphagia or weight loss, until now, five months after the procedure. 

This first experience suggests the feasibility and promising efficacy of immediate autologous ADSC injection for preventing refractory stricture after high-risk oesophageal ESD, with rapid processing and no added adverse events. This strategy may improve extensive esophageal resections prognosis and consequently bring a new perspective for patient’s quality of life. However, this is an initial pilot study, probably the pioneer of this therapy in humans, and further multicentre trials are essential to establish its role in extensive circumferential ESD.