Upper gastrointestinal (GI) endoscopic submucosal dissection (ESD) is an increasingly adopted technique in the United Kingdom. This study presents a prospective analysis of clinical outcomes associated with the establishment of an ESD service at a single tertiary referral centre over four years. The findings aim to contribute to the growing national experience in advanced endoscopic resection.

A prospective cohort study was conducted of all patients who underwent upper GI ESD at Imperial College Healthcare NHS Trust between 2021 and 2025. The Trust serves as a regional referral centre for complex endoscopic resections in North West London and has provided an ESD service since December 2021. All referrals were discussed with a multidisciplinary team (MDT) involving gastroenterologists, surgeons, oncologists, radiologists, and pathologists. Treatment decisions followed ESGE guidance. ESDs were performed under general anaesthesia, and patients discharged the same day, unless clinically indicated otherwise. Data included procedure count, lesion type (epithelial vs subepithelial), site, histology, size, duration, R0 and curative rates, and complications. 

A total of 67 ESDs were performed, 86% epithelial and 14% subepithelial. Seventy percent were in males, mean age 69.6 years. Most resections were gastric (59.7%), followed by oesophageal (26.9%), gastro-oesophageal junction (9.0%) and duodenal (4.5%). Histology varied by site: among oesophageal lesions, 44% contained intramucosal carcinoma (IMC) and 56% high-grade squamous dysplasia; of gastro-oesophageal junction (GOJ) lesions, 83% were IMC, with half of IMC cases in the oesophagus or GOJ arising in Barrett’s oesophagus. Gastric lesions were heterogeneous—IMC (27%), low-grade dysplasia (23%), stromal tumours (12%)—with occasional lipomas, neuroendocrine tumours (NETs) and inflammatory polyps. Duodenal lesions comprised 66% NETs and 33% IMC. 

Mean lesion size was 21 mm. Oesophageal lesions were largest (23.5 mm), followed by gastric (21.9 mm) and duodenal (12 mm). Mean resected lesion size increased from 16.6 mm in 2022 to 26.4 mm in 2025. In the oesophagus, squamous HGD measured 27.8 mm on average, IMC with Barrett’s 18.5 mm, and IMC without Barrett’s 13.1 mm. Mean procedure time was 70.6 ± 38.3 minutes, increasing from 56 minutes in 2022 to 74 minutes in 2025; oesophageal ESDs were longest (77 minutes) and duodenal shortest (52 minutes). Mean resection time was 70 minutes for a 20mm lesion. 

Among epithelial lesions, the en bloc resection rate was 95%, R0 rate 88%, and curative rate 83%. Same-day discharge occurred in 78% of cases. The overall complication rate was 7% (n = 9): perforations (n = 5, mainly duodenal or gastric) and strictures (n = 2, all oesophageal). There were no ESD-related deaths. 

ESD is the gold-standard therapy for selected epithelial lesions of the upper GI tract. As per ESGE guidance (1), it is indicated for all T1 oesophageal squamous lesions without deep submucosal invasion (T1a M2), Barrett’s-related neoplasia > 2 cm or with submucosal invasion or fibrosis, and all dysplastic gastric lesions (T1a and limited T1b). Its capacity for en bloc resection reduces the need for surgery and enables accurate histological assessment. No definitive guidelines currently exist for subepithelial endoscopic resection. 

A dedicated Upper GI Endoscopy MDT was established to optimise case selection and accept regional referrals for endoscopic resection, leading to a marked increase in procedural volume. Challenges in expanding an ESD service include case volume, operator training, endoscopy capacity, anaesthetic support, and multidisciplinary availability. Our results demonstrate a correlation between experience, referral volume, and case complexity, reflected by increasing mean lesion size and procedure time. Between 2023 and 2025, mean procedure time rose 18 minutes and lesion size 10 mm. Despite this, high enbloc (> 90%) and R0 (87%) rates were maintained, with a stable curative rate (76%) and low complication rate. 

Our experience shows that a structured regional ESD service in the UK, supported by specialist MDT discussion, can achieve excellent outcomes comparable to international standards while safely managing increasingly complex cases.