A selective resection algorithm for barrett’s neoplasia optimizes oncological outcomes

Aims Accepted oncological principles advise en-bloc, R0, excision of cancer to achieve a curative resection. In Barrett’s neoplasia, this includes T1a and superficial-T1b disease. While treatment options include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a mechanism for appropriate technique selection has not been described or validated.

Methods We conducted a prospective multi-centre observational study to evaluate the performance of a selective resection algorithm (SRA) for Barrett’s neoplasia. To achieve an en-bloc resection, ESD was selected if there was a suspicion for≥T1a disease and the lesion was>15 mm (January 2017 to April 2024). This was compared with a historical approach (HA), where ESD was only performed in cases suspicious for deep submucosal invasion (February 2013 to December 2016).

Results A total of 581 resections were performed in 542 patients. Median lesion size was 20 mm (IQR 10-30). EMR was performed in 354 (60.9%) and ESD in 227 (39.1%). The SRA cohort included 392 (67.5%) cases, and HA cohort 189 (32.5%). Histology was T1a adenocarcinoma in 177 (30.5%) and T1b in 94 (16.2%). For T1a disease, en-bloc resection (SRA 110 [83.3%] vs HA 22 [48.9%]; P<0.001), R0 excision (SRA 91 [68.9%] vs HA 17 [37.8%]; P<0.001) and curative resection (SRA 77 [58.3%] vs HA 14 [31.1%]; P=0.002) were higher in the SRA cohort. Lesions undergoing ESD were likely to be larger (29.9±17.6 mm vs 16.8±11.7 mm; P<0.001). The rates of en-bloc resection (ESD 94 [97.9%] vs EMR 38 [46.9%]; P<0.001), R0 excision (ESD 85 [88.5%] vs EMR 23 [28.4%], P<0.001) and curative resection (ESD 72 [75.0%] vs EMR 19 [23.5%]; P<0.001) were higher in the ESD group. Recurrence was lower in the ESD group (7 [7.3%] vs. 17 [20.9%], P=0.008). For T1b disease, en-bloc resection (SRA 70 [95.9%] vs. HA 9 [42.9%]; P<0.001), R0 excision (SRA 52 [71.2%] vs HA 2 [9.5%]; P<0.001) and curative resection (SRA 20 [27.4%] vs HA 0 [0%]; P=0.005) were higher in the SRA cohort. Lesions undergoing ESD were likely to be larger (33.5±18.0 mm vs 19.0±14.7 mm; P=0.007). The rates of en-bloc resection (ESD 76 [98.7%] vs EMR 3 [17.6%]; P<0.001), R0 excision (ESD 54 [70.1%] vs EMR 0 [0%], P<0.001) and curative resection (ESD 19 [24.7%] vs EMR 0 [0%]; P<0.001) were higher in the ESD group. Recurrence was lower in the ESD group (4 [5.2%] vs. EMR 4 [23.5%], P=0.014). Among all T1a and T1b-SM1 cases with favorable histology, which underwent ESD, 86/99 (86.9%) were curative resections.

Conclusions A selective resection algorithm optimizes oncologic outcomes for Barrett’s adenocarcinoma and mitigates the risk of piecemeal resection of cancers.

Conflicts of Interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
27 March 2025