Comparison of Primary Endoscopic Submucosal Dissection versus Primary Endoscopic Mucosal Resection for Barrett’s Esophageal Neoplasia Treatment

Abstract Background Endoscopic resection of Barrett’s esophageal neoplasia is commonly performed using either endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR). While submucosal dissection enables en bloc resection, institutional approaches vary. We compared clinical, histopathologic, and oncologic outcomes between a primary submucosal dissection strategy and a mucosal resection-based strategy with selective use of submucosal dissection. Methods This retrospective cohort study included all patients with Barrett’s esophageal neoplasia treated at two European tertiary referral centers. At Karolinska University Hospital, the primary submucosal dissection strategy was adopted, whereas at Erasmus Medical Center the mucosal resection-based strategy was employed. Patients with prior endoscopic therapy or hematologic disorders were excluded. Primary outcomes were local recurrence, synchronous and metachronous lesions prior to ablation, and cancer- or treatment-related mortality. Secondary outcomes included resection quality, adverse events, and the need for repeated resections. Time-to-event analyses were performed using Kaplan–Meier and Cox regression models. Results A total of 332 patients were included (132 in the primary submucosal dissection group and 200 in the mucosal resection–based group). En bloc resection was more frequent with the primary submucosal dissection strategy (98.5% vs 40.0%, p < 0.001). Compared with the EMR-based strategy, the pESD strategy was associated with significantly lower local recurrence (3.0% vs 10.0%, p = 0.02) and fewer resection sessions per patient, whereas rates of synchronous and metachronous lesions were similar between groups. Adverse events and cancer- or treatment-related mortality did not differ between strategies. Conclusions Both strategies are safe. However, the primary submucosal dissection strategy is associated with lower local recurrence and fewer resection sessions.