Oesophagectomy following endoscopic resection for oesophageal carcinoma: A Dutch nationwide retrospective cohort study.

Abstract

Background: Endoscopic resection is the standard treatment for early-stage oesophageal carcinoma, but oesophagectomy is recommended when margins are involved or histopathological features suggest a high risk of lymph node metastasis. This study evaluated residual malignancy after endoscopic resection and the accuracy of postoperative risk stratification.

Methods: Data were extracted from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) for patients who underwent oesophagectomy after endoscopic resection between 2011 and 2019. Surgical decisions were guided by multidisciplinary team discussion based on endoscopic, radiological and histological risk factors. Outcomes included the presence of residual tumour, discrepancies between clinical and pathological staging, and surgical morbidity and mortality. Secondary outcomes were compared with those of patients undergoing oesophagectomy for locally advanced disease.

Results: A total of 146 patients were included, with a median age of 67 years. Residual tumour was identified in 67%, with 63% having intramural tumour and 18.5% lymph node metastases. Clinical-pathological stage discordance occurred in 63% of patients, comprising 24% upstaging and 39% downstaging. Postoperative complications occurred in 61% of patients, with 21.2% experiencing severe complications. The 30-day or in-hospital mortality rate was 1.4%, comparable to outcomes for patients with locally advanced disease.

Conclusion: Residual tumour was identified in two-thirds of patients undergoing oesophagectomy after endoscopic resection, with nearly one fifth demonstrating lymph node involvement. Clinical-pathological staging discrepancies were frequent, highlighting limitations in current post-endoscopic risk assessment. These findings apply to a selected subgroup of patients who proceeded to oesophagectomy after endoscopic resection and should not be interpreted as evidence that R0 endoscopic resection is generally non-curative for most early oesophageal cancers. Postoperative outcomes mirrored those of patients undergoing surgery for advanced disease, underscoring the importance of improved risk stratification to reduce overtreatment.