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Endoscopy
DOI: 10.1055/a-2767-6165
Original article

Universal submucosal dissection outperforms selective mucosal resection in early esophageal adenocarcinoma

Authors

  • Fadi Younis 

    1   Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center and Tel-Aviv University, Tel Aviv, Israel
    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Thomas Rösch 

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Mario Anders

    3   Department of Gastroenterology and Interdisciplinary Endoscopy, Vivantes Wenckebach Hospital, Berlin, Germany

  • Hanno Ehlken

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Katharina Zimmermann-Fraedrich

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Philip Dautel

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Till Clauditz

    4   Institute for Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Michael Vieth

    5   Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
    6   Institute of Pathology, Klinikum-Bayreuth, and Bavarian Cancer Research Center (BZKF) Bayreuth, Bayreuth, Germany

  • Jocelyn de Heer

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Yuki Werner

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Tania Ruppenthal

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Oren Shibolet

    1   Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center and Tel-Aviv University, Tel Aviv, Israel

  • Oliver Mann

    7   Department of General, Abdominal and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Güllü Cataldegirmen

    8   Department of General and Abdominal Surgery, Vivantes Wenckebach Hospital, Berlin, Germany

  • Susanne Sehner

    9   Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

  • Michael J. Bourke

    10   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia

  • Guido Schachschal

    2   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Graphical Abstract

Referred to by:

Endoscopic resection in early Barrett’s esophagus-associated adenocarcinoma: does a universal endoscopic submucosal dissection approach make the cut?Endoscopy eFirst
DOI: 10.1055/a-2771-3598

Abstract

Background

In early esophageal adenocarcinoma (EAC), guidelines recommend endoscopic mucosal resection (EMR) for superficial (T1a) lesions and endoscopic submucosal dissection (ESD) for deeper (T1b) lesions based on visual assessment. We evaluated the outcomes of this targeted resection strategy.

Methods

In a retrospective bicentric study (2009–2023), 311 T1 EACs (235 T1a, 76 T1b) underwent endoscopic resection: EMR for presumed T1a and ESD for suspected T1b lesions. The primary outcome was complete (R0) resection stratified by tumor stage and resection technique. Secondary outcomes were rates of curative resection, adverse events, and surgery.

Results

EMR was appropriately applied in 63.0% of T1a cases, and ESD was correctly selected in 60.5% of T1b cases. R0 resection rates were higher with ESD than with EMR for both stages: T1a, 92.9% vs. 80.4%; T1b, 63.0% vs. 26.7%. Curative resection (ESD 60.9% vs. EMR 67.4%), surgery (19.5% vs. 14.0%), and adverse events (7.5% vs. 10.1%) were comparable. On multivariable analysis, ESD was the only independent predictor of complete resection. If surgery decisions had been based on R0 rather than curative outcomes, 20% of post-EMR and 50% of post-ESD esophagectomies could have been avoided

Conclusions

Endoscopic staging of early EAC is imperfect, leading to frequent mismatch between chosen and optimal resection techniques. ESD achieved higher complete resection rates for both T1a and T1b cancers without increased morbidity. ESD may therefore represent the preferred strategy for early EAC, potentially reducing unnecessary surgery.

Supplementary Material



Publication History

Received: 22 May 2025

Accepted after revision: 06 November 2025

Article published online:
13 January 2026

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