Esophageal stricture is one of the most challenging complications following endoscopic submucosal dissection (ESD) for superficial esophageal cancer. Mucosal defects ≥5 cm in length or involving the entire circumference are considered high risk for post-ESD stricture, with chemoradiotherapy or surgery often recommended for these conditions, even when dealing with superficial lesions. Although combined local and systemic steroid therapies are widely used for stricture prevention, their efficacy, optimal dosage, and clinical indications remain insufficiently established. This study evaluated the effectiveness and limitations of steroid-based prophylaxis in preventing esophageal stricture after extensive ESD.

We retrospectively reviewed 72 patients who underwent esophageal ESD at our institution between 2007 and 2024, in whom the mucosal defect involved ≥3/4 of the circumference. In analysis 1, patients were classified into a sub-circumferential group (SC group; n = 61, ≥3/4 but less than full circumference) and a circumferential group (C group; n = 11, full circumference). Lesion characteristics, preventive strategies, and post-ESD stricture outcomes were compared between the groups. In analysis 2, patients were divided into groups with and without stricture according to the need for endoscopic balloon dilation when a standard endoscope could not pass through the post-ESD site for identifying postoperative esophageal stricture risk factors. Subgroup comparisons were further conducted in the 61 patients who received steroid-based prophylaxis.

In analysis 1, mean longitudinal mucosal defect length was significantly greater in the C group than in the SC group (81 mm vs. 47 mm, p <0.01). Local steroid injection was performed in 45 (74%) SC and 11 (100%) C patients, respectively (p = 0.10), with significantly higher total doses in the C group (150 mg vs. 100 mg, p <0.01). Oral steroids were administered for 11 (18%) SC and 10 (91%) C cases (p = 0.01). Stricture occurred in 15 (25%) SC and 4 (40%) C patients (p = 0.66), with a median of 4 (1–21) and 8 (3–11) dilation sessions, respectively (p = 0.34). In analysis 2, esophageal stricture was recorded in 19 of 72 (26%) patients. Median resection length was similar between patients with and without stricture (50 mm vs. 49 mm). Median total triamcinolone dose was 100 mg (18 mg/cm of lesion length) and not associated with stricture formation. Lesions located in the upper esophagus (Ce + Ut) tended to exhibit a higher stricture rate (55%) compared with lower lesions (21%), although this difference did not reach statistical significance (p = 0.056). Among the 61 patients receiving steroid prophylaxis, 13 (21%) experienced strictures. However, triamcinolone dose, dose/cm of lesion length, lesion length, circumferential extent, muscularis injury, and lesion location showed no significant associations with stricture development. All 11 circumferential lesions measured ≥5 cm. Three (27%) cases developed stricture despite both local and systemic steroid prophylaxis, requiring a mean of 6 endoscopic balloon dilations.

Combined steroid prophylaxis lowered overall stricture rates. Under steroid administration, conventional risk factors were no longer associated with stricture development. Upper esophageal locations tended to exhibit higher risk, but no clear independent predictors were identified. All full-circumferential lesions were ≥5 cm, with 3 displaying stricture despite combined steroid prophylaxis. Although the sample size limits comparative analysis across lesion lengths, these results show that stricture is not inevitable, even in extensive full-circumferential disease. Therefore, ESD remains a feasible option for selected ≥5 cm circumferential lesions under adequate steroid prophylaxis.