Endoscopic eradication therapy (EET) is established as first-line management for dysplastic Barrett’s esophagus (BE) and early oesophageal adenocarcinoma. Although most patients respond to a combination of endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA), a proportion develop residual or non-lifting lesions that remain difficult to treat. Such cases are particularly challenging when patients are unsuitable for esophagectomy or chemoradiotherapy. The EndoRotor® non-thermal mechanical resection system has demonstrated feasibility in removing BE mucosa, including fibrotic or previously treated tissue¹, and early evidence supports its safety profile². We present a case illustrating its role as salvage therapy after failure of standard modalities.

A 76-year-old man with long-segment BE (C11M12) was diagnosed with moderately differentiated oesophageal adenocarcinoma, with no worrying features on PET-CT and EUS.. He had a history of two renal transplants for glomerulonephritis and was maintained on lifelong immunosuppression, as well as significant cardiac risk factors, rendering him high risk for surgery or chemoradiotherapy. Therefore, an endoscopic approach was favoured following multidisciplinary discussion.

He developed multi-focal neoplasia and required six EMR sessions with an excellent macroscopic response, eventually achieving Prague C0M0 status with only 2–3 residual Barrett’s islands. A persistent lesion at the 5 o’clock position exhibited a Paris IIa morphology and was non-lifting, making it unsuitable for further EMR or ESD. Biopsies demonstrated high-grade dysplasia (HGD). Hybrid APC was performed (selected due to preference to perform a “deeper ablation”, but dysplasia persisted, consistent with previously described RFA-refractory disease as described in the literature³⁻⁴. Subsequent repeat CT-scans demonstrated stable imaging without progression, EndoRotor® therapy was selected as salvage intervention.

Here we demonstrate EndoRotor® resection as technically successful technique, enabling non-thermal mechanical removal of previously treatment-resistant Barrett’s mucosa. Histopathology confirmed intramucosal carcinoma (IMCA). Follow-up endoscopy demonstrated further regression of the remaining Barrett’s island with improved appearance and reduced surface irregularity. Small areas of residual mucosa remained, and a repeat EndoRotor® session was planned. No immediate or delayed adverse events occurred, consistent with reported low complication rates². Repeat

radiological surveillance showed no local progression, nodal involvement, or distant metastasis.

This case highlights the value of EndoRotor® as a salvage modality for refractory Barrett’s neoplasia when Endoscopic resection modalities (EMR or ESD) and Ablation techniques (RFA or APC) are insufficient, particularly in patients unable to undergo surgery or oncologic therapy. Its non-thermal mode of action appears advantageous in previously ablated or fibrotic tissue, allowing targeted resection while limiting thermal injury. Emerging evidence supports its feasibility, safety, and potential utility in complex or treatment-resistant Barrett’s pathology¹–⁴. EndoRotor® may represent an important adjunct in the evolving management paradigm for advanced or refractory BE.