A nomogram and risk stratification system predicting esophageal stricture and validation of prophylactic efficacy of functional exercise combined with glucocorticoids in preventing stricture after extensive ESD for early esophageal cancer

Abstract

Background: Esophageal stricture following endoscopic submucosal dissection (ESD) for early esophageal cancer significantly impairs quality of life; this study aimed to develop a stricture prediction model and validate prophylactic efficacy of functional exercise combined with glucocorticoids for lesions involving ≥ 3/4 esophageal circumference.

Methods: This retrospective study analyzed 1043 patients who underwent ESD between September 2015 and December 2024. Risk factors were identified using univariate and multivariate logistic regression. A nomogram and risk stratification system were developed. Separately, 70 patients with ≥ 3/4 circumferential involvement were compared. To mitigate selection bias, a propensity score-matched (PSM) cohort was generated by matching patients based on key baseline characteristics (including gender, age, smoking/drinking history, longitudinal length, postoperative pathological type, infiltration depth, and lesion location) using a 1:1 nearest neighbor method. This process yielded 44 matched patients (22 per group: GC + Exercise vs. GC), in whom the stricture rates, refractory stricture rates, time to stricture onset (days), and number of EBD sessions were compared.

Result: Esophageal stricture occurred in 49 patients. Independent risk factors included circumferential range, longitudinal length, infiltration depth, and lesion location. According to the risk of postoperative esophageal stenosis, a nomogram and risk stratification system were developed. Based on the predicted probability of esophageal stricture, patients are classified into low-risk (2.3%), intermediate-risk (48.8%), and high-risk categories (75%). Separately, in the PSM cohort, the GC + Exercise group (n = 22) showed significantly lower stricture rate (31.8% vs 63.6%, P = 0.035), refractory stricture rate (4.5% vs 31.8%, P = 0.046), delayed stricture onset (median 68.0 vs 33.0 days, P = 0.009), and decreased EBD sessions (median 2.0 vs 4.5, P = 0.018). No adverse events were observed.

Conclusion: Our nomogram accurately stratifies post-ESD stricture risk; for the primary risk factor (≥ 3/4 circumference), GC + Exercise demonstrated favorable prophylactic efficacy, representing an effective prevention strategy for extensive strictures.

Keywords: Early esophageal cancer; Endoscopic submucosal dissection; Esophageal stricture; Functional exercise; Glucocorticoids; Nomogram.