Endoscopic resection of colitis-associated neoplasia: A scoping review

Abstract

BACKGROUND

Ulcerative colitis (UC) increases the risk of colorectal dysplasia. While colectomy was once standard, advances in polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR) now allow organ-sparing management in selected cases.

AIM

To summarize current evidence on the feasibility, safety, and outcomes of these techniques in UC-associated neoplasia.

METHODS

A scoping review was conducted using PubMed and EMBASE (1975-May 2025) with the search: (“endoscopic submucosal dissection”/exp OR “endoscopic mucosal resection” OR “full thickness resection” OR “polypectomy”) AND (“ulcerative colitis”/exp OR “ulcerative colitis” OR “pouch”). Screening followed PRISMA guidelines. Eligible studies included those reporting outcomes, feasibility, or novel techniques in the endoscopic management of UC-associated dysplasia.

RESULTS

Of 1075 identified records, 754 were screened after duplicate removal, and 48 studies were included. Polypectomy was safe and effective for well-demarcated, lifting lesions without adjacent dysplasia. EMR has excellent outcomes for small, polypoid, or right-sided lesions that demonstrated adequate lifting. ESD is indicated for flat, large, non-polypoid, or fibrotic lesions, particularly in the left colon. ESD achieved en bloc resection in 88%-100% and R0 resection in 73%-96% of cases. The overall complication rate with ESD was approximately 2%-10%, primarily bleeding or perforation. Local recurrence occurred in 0%-6.8%, and metachronous lesions developed in up to 31% of cases over follow-up durations of up to 15 years. Surgical intervention after ESD was required in 10%-20% of patients, typically for non-curative resection or new lesions. Submucosal fibrosis, a common obstacle in UC, limited lifting and increased procedural difficulty. Adjunctive strategies - such as water pressure-assisted dissection, pocket-creation method, self-assembling peptide injectables, and traction systems - enhanced technical success. EFTR, though limited to case series, was effective for non-lifting or anatomically complex lesions, particularly in post-surgical or pouch anatomy, but carried higher procedural risk including rare but serious adverse events.

CONCLUSION

Endoscopic resection offers a spectrum of curative, minimally invasive options for managing dysplasia in UC. EMR remains appropriate for simple, lifting lesions, while ESD and EFTR broaden the therapeutic landscape for complex or fibrotic pathology. Lesion morphology, lifting characteristics, and operator experience should guide technique selection. Long-term outcomes are favorable with appropriate surveillance, though the risk of metachronous neoplasia necessitates continued monitoring.

Keywords: Ulcerative colitis; Ulcerative colitis-associated neoplasia; Endoscopic submucosal dissection; Endoscopic mucosal resection; Endoscopic full-thickness resection; Polypectomy; Dysplasia

Core Tip: Endoscopic resection techniques - polypectomy, mucosal resection, submucosal dissection, and full-thickness resection - offer organ-sparing options for dysplasia in ulcerative colitis. Technique selection should be guided by lesion morphology, location, response to lifting, and degree of fibrosis. Submucosal dissection is preferred for flat, fibrotic, or non-lifting lesions, while mucosal resection suits well-lifting, polypoid lesions. Adjuncts such as water pressure dissection, peptide-based injectables, and traction systems enhance technical success. Full-thickness resection is a valuable option for non-lifting or scarred lesions not amenable to conventional methods, though careful case selection is essential.