Endoscopic Submucosal Dissection (ESD) illustration

Endoscopic Submucosal Dissection (ESD): Is This Advanced Polyp Removal Right for You?

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Kai Mendoza in Health & Wellness October 2026 • 4 min read.

"Explore how Endoscopic Submucosal Dissection (ESD) is revolutionizing the treatment of large colon polyps, offering a safer, cost-effective alternative to traditional surgery."


Colonoscopies are a routine part of preventative healthcare, designed to catch potential problems early. One of the most common findings during these screenings is the presence of polyps—small growths on the lining of the colon. While most polyps are harmless, some can develop into cancer if left untreated. Traditionally, large or complex polyps required surgical removal, but a new, less invasive technique called Endoscopic Submucosal Dissection (ESD) is changing the game.

Endoscopic Submucosal Dissection (ESD) is an advanced endoscopic technique used to remove large or complex polyps and early-stage cancers from the gastrointestinal tract. Unlike traditional polypectomy, which removes only the polyp itself, ESD allows for the removal of the entire lesion along with a layer of surrounding tissue. This en bloc resection ensures complete removal, reducing the risk of recurrence.

A recent study published in "Surgery" compared the outcomes of ESD to laparoscopic colectomy (surgical removal of a portion of the colon) for the treatment of large colorectal polyps. The study found that ESD was not only safe but also more cost-effective than surgery, offering a significant advantage for patients requiring advanced polyp removal.

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Current Role of ESD

Endoscopic submucosal dissection (ESD) is an advanced procedure used to remove selected gastrointestinal lesions through an endoscope. Its potential value is greatest when a lesion requires more precise removal than standard polypectomy may provide. Suitability depends on the lesion and the expertise available, so patients should discuss benefits, risks, and alternatives with a qualified clinician.

Approaches and Limits

Clinicians may use standard polypectomy, endoscopic mucosal resection (EMR), or ESD depending on the lesion's features. More advanced techniques can provide greater control but may require specialized expertise and resources. No single method is appropriate for every polyp, and treatment decisions generally balance complete removal against procedural risks.

Evolution of Treatment

The management of gastrointestinal polyps has developed from conventional endoscopic removal toward techniques designed to achieve more complete and precisely assessed resections. ESD represents one stage in that broader evolution. Its place in practice has continued to develop as clinicians refine patient selection, procedural methods, and follow-up.

What is Endoscopic Submucosal Dissection (ESD) and How Does It Work?

Endoscopic Submucosal Dissection (ESD) illustration

ESD is performed using a specialized endoscope equipped with a high-definition camera and various instruments for cutting, dissecting, and cauterizing tissue. The procedure is typically performed by a gastroenterologist with advanced training in endoscopic techniques.

Here’s a step-by-step overview of how Endoscopic Submucosal Dissection (ESD) works:

  • Preparation: The patient undergoes bowel preparation to ensure a clear view of the colon. They are also typically sedated to ensure comfort during the procedure.
  • Marking: The endoscopist uses the endoscope to visualize the polyp and then marks the area around the lesion with small dots using electrocautery.
  • Injection: A special solution is injected into the submucosal layer (the layer beneath the inner lining of the colon) to lift the polyp away from the deeper muscle layers. This creates a cushion of fluid that makes it easier to dissect the polyp.
  • Cutting: Using a specialized knife inserted through the endoscope, the endoscopist carefully cuts around the marked area, incising the inner lining of the colon.
  • Dissection: The endoscopist then uses the knife to dissect the submucosal layer, separating the polyp from the underlying tissue. This is a meticulous process that requires precision and expertise.
  • Removal: Once the polyp is completely dissected, it is removed through the endoscope.
  • Closure: In some cases, the area where the polyp was removed may be closed with clips or sutures to prevent bleeding or other complications.
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Current Evidence

Recent research continues to evaluate where ESD provides the greatest clinical value and how its risks can be managed. Studies commonly focus on complete resection, pathology assessment, complications, and the resources required for care. The evidence remains dependent on lesion characteristics, operator experience, and the clinical setting, so research findings may not apply uniformly to every patient.

Challenges and Inconsistent Outcomes

Although ESD has become increasingly popular for complicated colorectal polyps, reported clinical outcomes have remained highly inconsistent worldwide. A 2022 single-centre retrospective study analyzed 220 colorectal polyps removed by ESD, reflecting efforts to identify factors that influence those outcomes. More recent reporting also notes that routine postprocedure admission can increase resource utilization, although an outpatient colorectal ESD protocol was adopted in 2022 as endoscopic wound closure improved. These limitations show why ESD requires careful patient selection, experienced operators, and appropriate postprocedure planning.

ESD Compared With EMR

EMR and ESD are both established endoscopic resection procedures for advanced gastrointestinal lesions, but they differ in technique, indications, and outcomes. Compared with standard polypectomy techniques, both can provide wider and deeper resection margins and enable en bloc removal for more detailed pathology, including evaluation for curative treatment of early neoplasia. ESD generally offers higher en bloc resection rates, but a 2026 systematic review and meta-analysis noted that its comparative efficacy and safety versus EMR remain uncertain, particularly in Western practice. The choice between ESD and EMR therefore requires individualized assessment rather than assuming that the more technically advanced procedure is always preferable.

The entire procedure typically takes 1 to 3 hours, depending on the size and complexity of the polyp. Patients are usually monitored for a few hours after the procedure and can often go home the same day.

Is Endoscopic Submucosal Dissection (ESD) Right for You?

If you've been diagnosed with a large or complex colon polyp, Endoscopic Submucosal Dissection (ESD) may be a viable alternative to surgery. Talk to your gastroenterologist to determine if you are a candidate for this advanced procedure. With its potential for reduced costs, faster recovery, and improved outcomes, ESD is transforming the landscape of polyp removal and offering new hope for patients seeking a safe and effective treatment option.

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When ESD Fits

ESD is particularly relevant for large colorectal lesions that cannot be removed en bloc using EMR or underwater EMR. Its ability to achieve en bloc resection can support precise histopathologic evaluation. However, determining appropriate indications for ESD in large colorectal lesions remains an important clinical judgment, so the technique should be considered selectively rather than automatically.

What Comes Next

Future progress in ESD will likely depend on improving technical consistency, patient selection, and care pathways. Research may also clarify which lesions benefit most from ESD and when less invasive alternatives are sufficient. Wider adoption should remain guided by outcomes, operator training, available resources, and evidence from different healthcare settings.

Technical and System Challenges

ESD is a valuable advanced approach for removing large colorectal polyps, but the procedure is technically challenging. The thickness of the colorectal wall, colonic folds, flexures, and peristalsis can make precise dissection more difficult. These anatomical and procedural demands help explain why access to experienced specialists and suitable facilities is an important part of evaluating ESD.

High-Risk Colorectal Lesions

High-risk colorectal colitis-associated neoplasia, including non-polypoid lesions and large non-pedunculated colon polyps, is often not amenable to conventional resection techniques. A study evaluated the effectiveness and safety of ESD for these high-risk lesions. For affected patients, ESD may therefore represent an important treatment option when conventional removal is unsuitable, while the decision still requires individualized specialist assessment.

ESD resection rates across the studies

  • 84.6 %Across 31 studies, pooled en bloc resection was 84.6%.[1]
  • 81.9 %The pooled curative resection rate was 81.9%.[1]

How ESD compares with EMR and varies by location

The right-colon procedures in a retrospective multicenter cohort had higher reported complication and perforation rates than procedures in the rectum or left colon. The excerpt reports these location differences but does not establish their cause.[2]

The pooled Western review estimates resection outcomes across multiple studies, while a randomized comparison and a retrospective cohort address different comparisons and outcomes. Their results therefore provide distinct pieces of evidence rather than a single directly comparable estimate.[1] [2] [3]

What remains uncertain about colorectal ESD

  • For lesions without high-risk features, what oncologic benefit, if any, does ESD provide over EMR beyond the rationale of en-bloc removal for diagnosis and curative resection?[4] [5]
  • Which lesion features make ESD preferable when sessile serrated lesions may be readily removed with other methods and may have low risk of low-risk submucosal invasive cancer?[5]

Questions about lesion selection and ESD

When might ESD be considered for a colorectal lesion?

The cited source says ESD should be considered for lesions with high suspicion of limited submucosal invasion, including depressed or irregular, nongranular lesions, particularly when larger than 20 mm.[6]

Can a biopsy always establish the diagnosis of a large superficial lesion?

The cited guideline excerpt notes that biopsy may cause fibrosis in the submucosal layer, making later endoscopic treatment difficult, and that a simple biopsy may not provide an accurate qualitative diagnosis for some large lesions.[7]

Terms used in colorectal ESD evidence

Sessile serrated lesion
A lesion discussed as potentially not ideal for ESD because of its stated risk profile and availability of other removal methods.[5]

Sources

  1. Colorectal endoscopic submucosal dissection in the West: A systematic review and meta-analysis (pmc.ncbi.nlm.nih.gov)
  2. Resection of Early Colorectal Neoplasms Using Endoscopic Submucosal Dissection: A Retrospective Multicenter Cohort Study (pmc.ncbi.nlm.nih.gov)
  3. Rates of Cancer, Non-curative Resection, Adverse Event and Surgery After Colonic Endoscopic Submucosal Dissection (ESD)—Results from a Large International Multicenter Study (pmc.ncbi.nlm.nih.gov)
  4. Colorectal endoscopic submucosal dissection: patient selection and special considerations (pmc.ncbi.nlm.nih.gov)
  5. gi.org (gi.org)
  6. Management of colorectal laterally spreading tumors: a systematic review and meta-analysis (pmc.ncbi.nlm.nih.gov)
  7. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection (www.jges.net)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

Everything You Need To Know

1

What exactly is Endoscopic Submucosal Dissection (ESD), and when is it considered a better option than a traditional polypectomy?

Endoscopic Submucosal Dissection (ESD) is an advanced endoscopic technique designed to remove large or complex polyps, along with early-stage cancers, from the gastrointestinal tract. Unlike a traditional polypectomy, which only removes the polyp itself, ESD involves removing the entire lesion plus a layer of surrounding tissue, offering a complete en bloc resection that significantly reduces the risk of the polyp recurring. ESD is particularly advantageous for large or complex polyps that would typically require surgery.

2

A study mentions that Endoscopic Submucosal Dissection (ESD) is cost-effective. Can you elaborate on how the costs of ESD compare to traditional surgical options like laparoscopic colectomy for treating large colorectal polyps?

The study published in "Surgery" directly compared Endoscopic Submucosal Dissection (ESD) to laparoscopic colectomy for the treatment of large colorectal polyps. The findings indicated that ESD is not only a safe procedure but also more cost-effective than laparoscopic colectomy. While the specific cost savings would depend on factors, like hospital and insurance coverage, the reduced need for extensive hospital stays and recovery time contribute to the economic benefits of utilizing Endoscopic Submucosal Dissection.

3

Can you walk me through the steps of an Endoscopic Submucosal Dissection (ESD) procedure, detailing each stage from preparation to closure?

An Endoscopic Submucosal Dissection (ESD) involves several key steps. First, the patient undergoes bowel preparation to ensure clear visibility in the colon and is typically sedated for comfort. The endoscopist then uses the endoscope to visualize the polyp and marks the area around the lesion with electrocautery. A special solution is injected into the submucosal layer to lift the polyp away from deeper muscle layers. Using a specialized knife, the endoscopist cuts around the marked area, incising the inner lining of the colon, and dissects the submucosal layer to separate the polyp. Once completely dissected, the polyp is removed through the endoscope. Finally, the area may be closed with clips or sutures to prevent bleeding or complications.

4

Who is a good candidate for Endoscopic Submucosal Dissection (ESD)?

If you have been diagnosed with a large or complex colon polyp, Endoscopic Submucosal Dissection (ESD) may be a viable alternative to surgery. Typically a gastroenterologist would need to be consulted to determine if you are a candidate for this advanced procedure.

5

What are the advantages of using Endoscopic Submucosal Dissection (ESD) instead of traditional surgical removal methods?

Endoscopic Submucosal Dissection (ESD) offers several advantages over traditional surgical removal methods, such as laparoscopic colectomy, for treating large colon polyps. Key benefits include reduced costs, as demonstrated in a study, along with the potential for faster recovery times and improved patient outcomes. Additionally, ESD is a less invasive procedure, which typically translates to reduced risks and complications compared to surgical options. The complete removal of the lesion during ESD, also known as en bloc resection, decreases the risk of polyp recurrence, enhancing the long-term effectiveness of the treatment.

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