The Optimal Technique to Remove Visible Lesions in Barrett's Esophagus: When to Use Endoscopic Mucosal Resection or Endoscopic Submucosal Dissection?

BACKGROUND: The incidence of esophageal adenocarcinoma (EAC) has risen significantly in recent decades, with Barrett's esophagus (BE) as the most important precursor. When a visible lesion is identified within BE, endoscopic resection (ER) is the preferred treatment, providing both histologic staging and curative therapy for dysplasia and low-risk EAC.

SUMMARY: Two ER techniques are commonly used: cap-based endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is an extensively studied technique considered safe, effective, and easy to learn. However, due to the cap-based approach, lesions larger than 15-20 mm need to be removed by multiple adjacent resections, so-called piecemeal resection. This may result in remnant tissue in the resection field and may compromise histopathological assessment. In contrast, ESD enables en bloc removal regardless of lesion size. While ESD has also demonstrated safety and efficacy, it is technically more demanding and associated with longer procedure times. For some lesions, there is general agreement on treatment, with ESD preferred for lesions with suspected submucosal invasion, bulky morphology, or fibrosis. Conversely, EMR remains the standard for smaller, superficial lesions without these features.

KEY MESSAGE: A significant grey zone persists, clinical scenarios for which comparative evidence is lacking and consensus on the optimal treatment approach remains unclear.