Controversies in technique selection for endoscopic resection of Barrett's neoplasia

Abstract

Barrett's esophagus-related neoplasia is now predominantly managed with endoscopic eradication therapy. This strategy combines endoscopic resection of visible lesions with ablation of residual Barrett's mucosa, offering excellent safety and long-term disease control. Two endoscopic resection techniques are used in current practice: endoscopic mucosal resection and endoscopic submucosal dissection. Existing guideline recommendations for technique selection vary but are largely based on the suspected depth of invasion and preference for R0 resection. However, the unique biological and clinical features of Barrett's challenge this framework. Neoplasia arises within a field of metaplastic change, and the ultimate goal is not simply complete resection but durable eradication of disease. The traditional oncologic endpoint, R0 resection, may be less meaningful in this context, while more clinically relevant outcomes, such as recurrence, disease-free survival, and patient-centred measures, remain inconsistently defined and reported. Furthermore, technical and procedural considerations, including histopathological accuracy, safety, and resource use, add further complexity to decision-making. This review explores the evolving evidence, highlights ongoing debates in technique selection for Barrett's neoplasia, and proposes considerations to inform patient-centred clinical decision-making and future research priorities.