The optimal management strategy for multifocal dysplastic Barrett’s esophagus (MDBE), particularly the choice between endoscopic resection and ablative therapies, remains under debate.

We present a case series of three patients treated with circumferential endoscopic submucosal dissection (ESD) for MDBE, with the aim of achieving complete eradication of Barrett’s epithelium.

We further describe our preventive approach to post-ESD stricture formation.

Three patients with Barrett’s esophagus and multifocal dysplasia, all previously diagnosed with high-grade dysplasia (HGD), underwent circumferential ESD.

Pre-operative evaluation included high-resolution magnifying endoscopy combined with conventional chromoendoscopy with acetic acid to identify dysplastic areas.

Given the presence of multiple suspicious foci, complete resection of all Barrett’s epithelium was performed.

All procedures were performed using a multi-tunneling ESD technique; in two cases (66.6%), clip-and-thread traction was applied.

To prevent esophageal stricture, patients received triamcinolone injection evenly across the resection bed, followed by an oral budesonide regimen (1 mg TID with tapering). Surveillance endoscopy was performed every two weeks to evaluate the need for dilation.

All three patients were male, with a mean age of 61.3 years (49–74).The mean length of resected specimens was 6.4 cm (4.1 cm in C3M4, 6.3 cm in C4M6, and 9 cm in C8M9).

Mean procedure time was 224.3 minutes (150, 176, 347). 

All patients recovered uneventfully and were discharged 24 hours post-procedure with dietary instructions, sucralfate, oral budesonide, and PPI therapy.

All resections were R0 and considered curative. Histology confirmed multifocal HGD in all cases, with one patient showing a 28-mm area of SM1 (220 μm) adenocarcinoma (LVI-). 

One patient (33.3%) was upstaged compared with the initial biopsy.

No strictures or recurrences occurred during follow-up, and none required endoscopic dilation.

Complete squamous re-epithelialization was achieved by 32 weeks in all patients.

Mean disease-free survival was 7.3 months (6, 8, 8).

Despite inherent limitations (small sample size, short follow-up), circumferential ESD for MDBE appears to be a feasible, safe, and potentially cost-effective approach—avoiding the need for additional ablative therapy—when multifocal dysplasia or early submucosal invasive neoplasia is identified on pre-ESD magnifying endoscopy.

The combination of intralesional triamcinolone and oral budesonide was effective in preventing esophageal strictures, eliminating the need for dilation in this series.