Endoscopic resection versus esophagectomy for T1bN0M0 esophageal cancer: a systematic review and meta-analysis

Esophagectomy remains the standard of care for T1b esophageal cancer. Guidelines support the use of endoscopic resection (ER) including endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in carefully selected patients. We compared patients with T1b esophageal cancer who underwent ER or esophagectomy. We searched MEDLINE, EMBASE and CENTRAL from inception to November 2025 for studies comparing esophagectomy and ER for patients with T1b esophageal cancer. We excluded studies if patients received neoadjuvant or adjuvant treatment. Outcomes were 5-year overall survival (OS) and cancer specific survival (CSS), recurrence, and mortality. Meta-analysis (with propensity-matched data when available) was performed, with a subgroup analysis of ESD versus esophagectomy. Ten retrospective studies were identified comprising 2491 patients who underwent ER (n = 890) or esophagectomy (n = 1601). Mean age was 65.7 years with 16.1% female. Six studies grouped EMR and ESD together, three reported ESD alone, one examined EMR only. OS and CSS were available in seven and four studies, respectively. There was no significant difference between esophagectomy and ER regarding 5-year OS (HR 1.26; 95% CI 1.00-1.60; P = 0.05), 5-year CSS (HR 0.65; 95% CI 0.20-2.17; P = 0.49), and 30-day mortality (HR 0.39; 95% CI 0.13-1.16; P = 0.09). Recurrence was 18.1% after esophagectomy and 17.7% after ER. Subgroup analysis showed no difference in OS or mortality. Risk of bias was high in five studies. Available retrospective comparative evidence suggests no clear difference between ER and esophagectomy for patients with T1b esophageal cancer. Randomized controlled trials are needed to reduce patient heterogeneity.