Large colorectal lesions: Expanding the boundaries of endoscopic management

Abstract

Large colorectal lesions (≥ 3 cm) present a significant therapeutic challenge due to their potential for malignancy and the technical difficulties they encounter. Endoscopic resection techniques, including endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection, have revolutionized the management of these lesions by offering organ-preserving alternatives to surgery with favorable outcomes. We read with great interest and commended Zhu et al for their valuable study on the endoscopic treatment of large colorectal lesions. Zhu et al’s study provides crucial real-world evidence regarding the safety and effectiveness of advanced endoscopic resection techniques in this challenging patient group. These findings support the possibility of achieving high rates of complete resection with acceptable adverse event profiles, reinforcing the role of endoscopic mucosal resection and submucosal dissection in routine practice. This editorial also offers a comprehensive review of the current literature, discusses its clinical implications, explores future directions, and compares endoscopic resection methods with surgical options. Zhu et al’s study findings not only validate the efficacy of advanced endoscopic resection but also signify a paradigm shift from surgical to organ-preserving strategies in colorectal oncology, a transformation that requires deliberate system-wide training and capacity building.

Keywords: Large colorectal lesion; Endoscopic management; Endoscopic mucosal resection; Endoscopic submucosal dissection; Endoscopic full thickness resection; Laterally spreading tumors

Core Tip: Large colorectal lesions constitute a distinct group with increased potential for malignancy, and their removal is technically challenging for endoscopists. Endoscopic mucosal resection is fundamental for many benign lesions; however, the risk of recurrence necessitates complete resection of lesion margins. Endoscopic submucosal dissection provides higher en bloc rates with oncological safety, whereas endoscopic full-thickness resection is beneficial for non-lifting or fibrotic lesions within the device’s limits. Consolidated evidence, including that of Zhu et al, emphasizes that tumor size alone should not dictate surgery; careful patient selection, expertise, and structured surveillance can improve endoscopic outcomes while maintaining bowel continuity.