Comparison of long-term outcomes between endoscopic submucosal dissection and esophagectomy for superficial esophageal squamous cell carcinoma

Abstract Background Endoscopic submucosal dissection (ESD) is increasingly being performed as a less invasive alternative to esophagectomy for superficial esophageal squamous cell carcinoma (SESCC); however, comparative long-term outcome data, especially for non-curative resection (non-CR) cases and elderly patients, remain limited. This study aimed to compare the clinical outcomes of ESD and esophagectomy using a propensity score (PS)–matched cohort. Methods Patients with SESCC who underwent ESD or esophagectomy at a tertiary referral center between 2011 and 2021 were retrospectively reviewed. In the PS-matched cohort, overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), additional treatments, and adverse events were compared. Subgroup analyses were conducted for non-CR cases and elderly patients (≥70 years). Results Among the 63 PS-matched pairs, OS, DSS, and RFS were comparable between the ESD and esophagectomy groups. The 5-year OS, DSS, and RFS rates were 89.9% versus 79.2%, 95.7% versus 94.4%, and 90.6% versus 89.1%, respectively. The ESD group had significantly fewer adverse events (47.6% vs 68.3%, P 0.05) and a shorter median hospital stay (1.0 vs 10.0 days, P 0.001) than the esophagectomy group. Survival outcomes were also similar in the non-CR and elderly subgroups. Conclusions ESD is a safe and effective alternative to esophagectomy for SESCC, including in non-CR and elderly patients. Given the limitations of preprocedural depth assessment and the high risk of complications associated with esophagectomy, staging ESD for SESCC may represent a reasonable treatment option, particularly for elderly or high-risk patients.