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Background and objective: Endoscopic submucosal dissection (ESD) is increasingly used for the treatment of early esophageal neoplasia. However, population-based data on clinical trends, complications and outcome associations in Germany are limited.

Method: We performed a nationwide retrospective analysis of esophageal ESD in Germany between 2010 and 2022 using standardized hospital discharge data form the Federal Statistical Office of Germany. Associations between patient characteristics, peri- and postinterventional complications, hospital case volume and hospital mortality were analyzed.

Result: A total of 5,640 esophageal ESD procedures were identified. Annual case numbers increased more than fivefold, from 152 in 2010 to 773 in 2022. Most patients were older than 50 years, and 74.6% were male. Malignant lesions accounted for 62.4% of cases. Overall hospital mortality was low at 0.48% and did not significantly differ by sex, age group, or lesion dignity. Procedure-related complications were significantly associated with hospital mortality, particularly sepsis (30%), need of prolonged mechanical ventilation (10.9%), and acute renal failure (9.7%), although these events were rare (< 3% each). Bleeding (8.49%) and perforation (2.18%) were the most frequent direct complications. Hospitals with a high annual ESD case volume (≥21/year:) had significantly lower rates of sepsis, bleeding, and mechanical ventilation, as well as a significantly lower hospital mortality of only 0.2% compared to 0.9% in low-volume centers (1–6/year).

Summary: In this nationwide analysis, the use of esophageal ESD increased substantially over time and was associated with low in-hospital mortality. Outcomes differed according to hospital case volume, supporting the high relevance of institutional experience in procedural safety. Although administrative data are well suited to describe temporal and structural patterns, they provide limited insight into causality and long-term oncologic outcomes.