Predictive Factors for Technical Difficulty During Endoscopic Submucosal Dissection of Superficial Barrett's Esophageal Adenocarcinoma

BACKGROUND AND AIM: Endoscopic submucosal dissection (ESD) is widely used to treat superficial Barrett's esophageal adenocarcinoma (sBEA) in Japan. However, ESD for sBEA remains technically challenging because of respiratory motion and esophageal peristalsis. No studies have reported predictive factors for technical difficulty during ESDs for sBEA. This study aimed to identify predictive factors for technical difficulty during ESDs for sBEA. METHODS: This retrospective single-center cohort study included patients who were diagnosed with sBEA and subsequently underwent ESDs between April 2006 and January 2025. Patients with previous esophagectomies, chemoradiotherapy, and who underwent staged circumferential ESDs or simultaneous resections of multiple lesions were excluded. Technical difficulty was defined as resection times ≥ 120 min, perforations, incomplete treatment, or piecemeal resections. Univariate and multivariate logistic regression analyses were performed to identify the predictive factors for technical difficulty. RESULTS: In total, 188 patients with 199 lesions were analyzed, and 33 (16.6%) lesions met the criteria for technical difficulty. Multivariate analysis identified long-segment Barrett's esophagus (LSBE) (adjusted odds ratio [OR]: 2.380; 95% confidence interval [CI]: 1.010-5.620; p = 0.048) and circumferential involvement of ≥ 1/2 of the esophagus (adjusted OR: 4.460; 95% CI: 1.290-15.400; p = 0.018) as independent predictive factors. These were also associated with lower R0 resection and negative horizontal margin rates and a higher incidence of post-ESD strictures. CONCLUSIONS: LSBE and circumferential involvement of ≥ 1/2 of the esophagus were identified as significant predictors of technical difficulty in ESDs for sBEA. Preoperative recognition of these factors may facilitate appropriate operator assignment and procedural strategies.