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In response to Gupta and colleagues’ study on implementing an endoscopic submucosal dissection (ESD)-first algorithm for Barrett’s cancers >15 mm, we highlight critical concerns regarding selection bias, patient morbidity, and guideline adherence. We argue that the improved outcomes reported in the second study period may reflect a shift in case mix—diluted by morphologically favourable lesions—rather than the independent superiority of the strategy. Furthermore, from a risk–benefit perspective, the routine application of ESD exposes patients with dysplasia and T1a disease to a significantly higher risk of oesophageal strictures (22.6%) without demonstrating clear oncologic or survival superiority over endoscopic mucosal resection (EMR). We also raise concerns regarding the long-term oncological safety of patients with T1b diseasepatients who underwent non-curative resection without subsequent surgical salvage. Finally, we caution that lowering the ESD size threshold to 15 mm contradicts current international guidelines (typically >20 mm) and requires specific validation within this ‘“grey zone’.” We advocate for a more tailored approach that carefully balances oncologic clearance with the prevention of procedural morbidity.