Post written by Kais Zakharia, MD, from the Division of Gastroenterology, University of Massachusetts Chan Medical School–Baystate Medical Center, Springfield, Massachusetts, USA.

Barrett’s esophagus (BE) remains the only known precursor to esophageal adenocarcinoma and, although the risk of progression varies with segment length and degree of dysplasia, endoscopic management has increasingly replaced surgery in well-selected patients.

In our recently published case in VideoGIE, we present, to our knowledge, the longest segment of BE ever resected via circumferential endoscopic submucosal dissection (ESD).

Our patient, a 72-year-old man, was found to have long-segment BE (C14M14) with multifocal high-grade dysplasia and early adenocarcinoma. After multidisciplinary review, circumferential ESD was chosen over esophagectomy or EMR plus ablation. The en bloc specimen measured 16 cm in length, representing a technical achievement but also a challenge in terms of stricture prevention and postprocedural management.

Key takeaways include:

• ESD feasibility in extensive disease—Even in very long BE segments with early cancer, ESD can provide complete resection with negative margins and accurate histology.
• Stricture management remains a major concern—Despite prophylactic stenting and steroid therapy, our patient developed a long stricture, ultimately requiring multiple dilations, triamcinolone injections, and systemic steroids. Stricture prevention strategies must continue to evolve.
• Multidisciplinary care is essential—Careful case selection, intraprocedural planning, and close post-ESD follow-up allowed this patient to avoid esophagectomy and remain recurrence-free at more than 1 year.
• Prophylactic stent size matters—Our observations suggest that larger stents may impair mucosal healing by causing localized ischemia, whereas smaller-caliber stents may be better tolerated.

Ultimately, this case illustrates both the potential and challenges of circumferential ESD in BE with early adenocarcinoma. With appropriate expertise and multidisciplinary collaboration, it can be a curative alternative to surgery, even in extreme cases. However, stricture prevention and postprocedural support remain critical to achieving good long-term outcomes.

We felt it was important to share this case because it demonstrates the feasibility and challenges of performing circumferential ESD in an extremely long segment of BE with early adenocarcinoma. To our knowledge, this represents the longest Barrett’s segment resected by ESD reported in the literature.

The video highlights several key teaching points: technical aspects of tunneling and specimen retrieval in long resections, strategies for minimizing stricture risk, and the importance of multidisciplinary decision-making when weighing ESD against esophagectomy. Although the procedure was technically successful with negative margins, the case also underscores the real-world challenges of post-ESD management, including stricture formation and patient quality of life.

By showcasing this video, we hope to encourage thoughtful discussion about the expanding role of ESD in complex BE cases and to share practical lessons for endoscopists managing these patients. Endoscopists can see that even in very long segments, en bloc resection is feasible and can achieve negative margins, offering an organ-sparing alternative to esophagectomy.

At the same time, our experience reinforces that stricture prevention remains a major challenge. Despite prophylactic stenting and steroids, our patient developed a significant stricture requiring multiple interventions. Careful choice of stent size, early use of intralesional and systemic steroids, and close follow-up were all key to achieving a good long-term outcome.

Finally, this case underlines the value of multidisciplinary decision-making and patient counseling. Setting expectations about possible adverse events and the need for intensive follow-up is as important as the technical success of the procedure.

A, Three incisions and tunnels were performed proximally. B, Submucosal dissection and connecting submucosal tunnels. C, Circumferential defect after endoscopic submucosal dissection. D, Esophageal circumferential specimen after completing the procedure (measuring approximately 16 cm).

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.