Endoscopic submucosal dissection for early oesophageal adenocarcinoma

Endoscopic submucosal dissection (ESD) is an advanced, organ-preserving treatment for carefully selected early oesophageal adenocarcinomas. It removes a lesion in one piece, allowing the pathologist to assess its margins, depth and biological risk with greater confidence than piecemeal techniques.

The approach is especially relevant to cancers arising in Barrett’s oesophagus, where abnormal tissue can range from low-grade dysplasia to invasive adenocarcinoma. Early referral and precise staging are essential because an apparently small lesion may still contain features that require surgery or additional treatment.

For Australian clinicians and patients, decisions commonly pass through a specialist upper gastrointestinal team. A patient may begin with a GP in Brisbane, Melbourne or regional New South Wales, then move through a public hospital or private gastroenterology pathway before an expert centre considers ESD.

What the procedure involves

During ESD, an endoscopist marks the lesion, injects fluid beneath it and makes a controlled incision around the abnormal area. The diseased mucosa and part of the underlying submucosal layer are then dissected away from the deeper oesophageal wall.

The aim is an en bloc specimen with clear lateral and deep margins. This differs from endoscopic mucosal resection (EMR), which is often quicker and highly useful for small, clearly defined lesions but may remove larger or irregular areas in several pieces.

Who may be suitable

ESD is generally considered when adenocarcinoma appears limited to the mucosa or very superficial submucosa, with a low likelihood of lymph-node spread. Lesion size, ulceration, differentiation, lymphovascular invasion and the depth of submucosal penetration all influence suitability.

High-definition imaging, chromoendoscopy and sometimes magnification help define the lesion before treatment. Biopsies alone can underestimate the most advanced area, so the final ESD specimen frequently provides the information needed for definitive risk assessment.

ESD and other treatment pathways

Treatment is not selected by endoscopy findings alone. A multidisciplinary team may compare ESD with EMR, oesophagectomy, chemoradiotherapy or surveillance, taking account of the patient’s health, tumour biology and preferences. Barrett’s-related visible lesions are often treated alongside eradication of remaining abnormal Barrett’s mucosa.

An Australian patient may encounter different access arrangements depending on location and insurance status. Advanced ESD is concentrated in experienced tertiary services, so a referral from a local gastroenterologist to a centre in Sydney, Melbourne, Brisbane or another capital city may be appropriate. Medicare and public-hospital pathways can differ from private scheduling and out-of-pocket costs.

Benefits and technical risks

The principal benefit is organ preservation. Avoiding major surgery can reduce the effects associated with oesophagectomy, including altered eating patterns, prolonged recovery and surgical complications. ESD also gives the pathology team an intact specimen for detailed examination.

The procedure carries recognised risks. Bleeding may occur during or after treatment, and a full-thickness injury can cause perforation. Circumferential or extensive resections can heal with a scar-related narrowing called an oesophageal stricture, which may require balloon dilatation. Patients should promptly report chest pain, fever, vomiting blood or increasing difficulty swallowing after discharge.

Reading the pathology report

Pathology determines whether ESD was curative. Important findings include tumour differentiation, depth of invasion, vertical and horizontal margins, lymphovascular invasion and the presence of poor-risk features. A clear margin does not automatically eliminate the possibility of lymph-node disease.

If the lesion has favourable characteristics, endoscopic surveillance and Barrett’s eradication therapy may follow. If pathology shows deep submucosal invasion, involved margins or other high-risk features, the team may discuss additional surgery or oncological treatment. These decisions are individual and should be made before assuming that endoscopic removal is the final step.

Follow-up in Australian practice

Follow-up usually combines repeat endoscopy, inspection of the treatment scar and management of any remaining Barrett’s mucosa. Acid suppression is commonly used to support healing, while diet is advanced according to swallowing comfort and the treating team’s instructions.

The ISDE 2021 congress materials reflect the value of shared international education in this field, including research abstracts, expert presentations and discussion of evolving endoscopic techniques. In Australia, the practical next step after a suspicious early lesion is to arrange review by an upper gastrointestinal multidisciplinary team and provide the complete endoscopy images, biopsy results and relevant medical history.