Universal submucosal dissection outperforms selective mucosal resection in early esophageal adenocarcinoma

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.