Introduction
Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer. However, esophageal stricture following endoscopic ESD is a common and severe complication, leading to malnutrition, increased financial burden, and reduced quality of life.
Aims & Methods
This study aimed to develop a risk prediction model for stricture after non-circumferential ESD to improve prevention, treatment, and personalized management of post-ESD esophageal stricture. Clinical data were retrospectively collected from patients with suspected early esophageal squamous cell carcinoma undergoing ESD between January 2014 and December 2022 at four tertiary hospitals in Sichuan Province, China.
Cases were divided into non-circumferential and circumferential ESD groups. Non-circumferential ESD cases were split into a development cohort (70%) and a validation cohort (30%). Independent risk factors for stricture were identified using univariate and multivariate logistic regression analyses. A risk scoring model was established and internally validated.
For patients with circumferential lesions, a case-control study was first conducted to validate the efficacy of steroid-based interventions in reducing stricture rates, followed by subgroup analyses comparing the therapeutic differences between oral administration alone and oral combined with local injection.
Results
Among 2009 enrolled patients, the stricture rate was 12.9% (259/2009). Data from 1854 non-circumferential ESD cases were used for model construction. Independent risk factors included wound circumferential extent, lesion location, intraoperative titanium clip usage, and non-R0 resection. The risk stratification model (score range: 0–8) categorized patients into low- (0–2 points, 1.7% stricture), intermediate- (3–5 points, 25%), and high-risk (6–8 points, 80%) groups. In the validation cohort, the model demonstrated an AUC of 0.864 (95% CI: 0.814–0.914, P<0.001), Hosmer-Lemeshow test (P=0.187), and Brier score of 0.0456, indicating excellent discrimination and calibration (Table 1）.
Among 155 patients undergoing circumferential esophageal ESD, the stricture rate was 72.9% (113/155). The stricture rate was 100% (14/14) in the non-steroid group versus 70.2% (99/141) in the steroid group (P=0.017). Patients receiving steroids required an average of 7.4 ± 8.9 dilation sessions, which was significantly lower than the non-steroid group (P=0.031). Nevertheless, no significant differences were observed between oral steroids alone and combined oral with local injection steroids in preventing strictures (P=0.908) or reducing dilation sessions (P=0.652).
Table 1. Predictive Scoring System for Post-ESD Stricture (Non-Circumferential Lesions）
| Factor | High-Risk Subgroup | P-value | OR (95% CI) | Score |
|---|
| Circumferential Extent | ≥3/4 (vs. <3/4) | <0.001 | 15.708 (6.8–36.2) | 3 |
| Lesion Location | Upper Thoracic (vs. Lower) | 0.006 | 2.479 (1.3–4.7) | 1 |
| Cervical (vs. Lower) | <0.001 | 13.750 (4.1–46.0) | 3 |
| Intraoperative Clip | Yes (vs. No) | 0.010 | 2.705 (1.3–5.7) | 1 |
| Non-R0 Resection | No (vs. Yes) | 0.038 | 2.103 (1.0–4.3) | 1 |
Conclusion
This multicenter study identified wound circumferential extent, lesion location, titanium clip use, and non-R0 resection as independent risk factors for stricture after non-circumferential ESD. A validated risk stratification model (low/intermediate/high-risk) enables tailored postoperative management. While steroids reduced strictures in circumferential ESD, oral versus combined oral/local injection regimens showed no difference in efficacy or dilation frequency.
References
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