Reply to Singh et al.

We appreciate the comments by Singh et al. regarding our editorial on recurrence rates following endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for treatment of dysplastic Barrett’s esophagus (BE). Their emphasis on the patient perspective raises a critical and often underrepresented consideration in clinical decision making. However, we respectfully assert that the patient-centered outcomes and evidence-based clinical endpoints are not mutually exclusive, and both perspectives must guide treatment strategies in BE management.

We do not question the clinical relevance of achieving en bloc resection with ESD. In an ideal world, every nodular BE lesion should be removed en bloc to allow optimal histopathological assessment of lateral and deep resection margins. However, this is not possible in the real world. The primary objective of our editorial was to highlight that true recurrence should only be determined once complete remission of intestinal metaplasia (CRIM) – the primary endpoint of endoscopic eradication therapy recommended by all gastrointestinal society guidelines – has been achieved. This distinction is essential for differentiation of true recurrence from residual disease after initial endoscopic resection. Without distinguishing residual disease from true recurrence, studies risk overestimating the recurrence burden and, consequently, overestimating the clinical benefits of ESD over EMR.

In real-world practice, the relevant clinical endpoint must take into account the fact that all patients with residual BE will undergo subsequent ablative therapy after endoscopic resection to eradicate all dysplastic and nondysplastic BE mucosa. Hence, we maintain that CRIM remains the most clinically meaningful endpoint for assessing recurrence in BE management and encourage future research to integrate both clinical and patient-centered outcomes to guide best treatment practices.

Publication History

Article published online:
22 April 2025