Endoscopic surveillance of patients with Barrett's esophagus has identified a rather large number with high-grade dysplasia in the Barrett's segment. Most regard this finding as a threshold for intervention. The new technique of endoscopic mucosal ablation has allowed the treatment of high-grade dysplasia with preservation of the esophagus and a morbidity and mortality lower than an esophagectomy. The survival following either treatment is similar. This has reduced the use of surgical resection to treat these patients. Many, however, have visible lesions within the flat Barrett's segment such as a nodule or ulcer. Such lesions must be removed by endoscopic mucosal resection to determine the nature of the lesion and, if a cancer, its depth of penetration into the esophageal wall. If a cancerous lesion is limited to the lamina propria, ablation of the Barrett's segment can proceed. If a cancerous lesion extends beyond the muscularis mucosa, there is a significant increase in the probability of lymph node metastasis and an esophagectomy is required. Despite flawed statements to the contrary, there is no “safe” level of invasion into the submucosa that would extend the use of endoscopic resection. To manage these patients correctly requires that surgeons become adept at endoscopy and endoscopic mucosal resection. The opportunity for this training is limited and is an issue that must get the attention of the Residency Review Committee for Surgery and the American Board of Surgery. The new therapy is extremely work intensive and is associated with the risk of developing cancer during the treatment. Consequently a vigilant support staff is necessary to handle the patients. In our experience patients who have high-grade dysplasia in a long segment of Barrett's esophagus, or in an anatomically short esophagus with a large hiatal hernia, or in an esophagus with a severe motility problem, or have multifocal high-grade dysplasia or multiple failures of ablation therapy are not candidates for esophageal preservation therapy and are better off having a vagal sparing esophagectomy. This form of esophagectomy is associated with less perioperative morbidity and a shorter hospital stay than a standard transthoracic or transhiatal esophagectomy. Further, its late morbidity, including weight loss, dumping, and diarrhea, is significantly less.2