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.

Key Words: 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.

INTRODUCTION

Patients with ulcerative colitis (UC) are at an increased lifetime risk of developing colorectal dysplasia due to chronic mucosal inflammation. While colectomy was traditionally the default management for visible dysplastic lesions, a broad array of endoscopic resection techniques - ranging from simple polypectomy to advanced methods such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR) - now allow for organ-preserving treatment in appropriately selected patients. These techniques have expanded the therapeutic landscape, particularly with the aid of novel adjuncts and evolving procedural strategies. However, the timing of endoscopic intervention remains critical; resection is generally preferred in mucosal remission, as active inflammation increases procedural difficulty and the risk of adverse events.

Despite the growing adoption of EMR and ESD for UC-associated neoplasia (UCAN), considerable variation exists in clinical outcomes across studies. En bloc and R0 resection rates, curative resection outcomes, adverse events, and the risk of local or metachronous recurrence differ widely between single-center experiences and multicenter series. Submucosal fibrosis (SMF), a common challenge in UC, has prompted the development of several technique modifications - such as hybrid EMR-ESD, water pressure-assisted dissection, underwater resection, and novel lifting agents - but their comparative efficacy remains underexplored[1,2]. Moreover, guidance on when to choose EMR, ESD, or polypectomy remains empirically driven[3]. EFTR has emerged as a potential option for non-lifting or anatomically challenging lesions, but available data are limited to small series or case reports, and its safety profile in UC is not yet well defined[4].

This scoping review aims to serve as a practical and comprehensive reference for clinicians and researchers interested in the endoscopic management of UC-associated dysplasia. It incorporates evidence from multicenter studies, single-center cohorts, case series, and technical reports, highlighting both established practices and emerging innovations. By synthesizing data across lesion types, anatomical scenarios, and procedural modifications, this review provides both depth and breadth for those navigating this rapidly evolving field.

MATERIALS AND METHODS

Search strategy

This scoping review was conducted in accordance with the PRISMA-extension for Scoping Reviews 2020 guidelines. A comprehensive literature search of PubMed and EMBASE was performed from inception (1975) to May 2025 using the following search strategy: (“endoscopic submucosal dissection”/exp OR “endoscopic mucosal resection” OR “full thickness resection” OR “polypectomy”) AND (“ulcerative colitis”/exp OR “ulcerative colitis” OR “pouch”). Eligible studies included original articles, prospective or retrospective cohort studies, and novel case series or conference abstracts that reported outcomes or feasibility of polypectomy, EMR, ESD, or EFTR in patients with UC or post-surgical pouch anatomy. Only English-language articles were included. Animal studies, preclinical, and articles unrelated to endoscopic resection in UC were excluded. A total of 1075 records were identified (PubMed: 232; EMBASE: 843), and after removing 321 duplicates, 754 records underwent title and abstract screening. Of these, 345 were excluded, and 409 full-text articles were reviewed. Ultimately, 48 studies met inclusion criteria (Figure 1). Two independent reviewers (Partha Pal and Priyaranjan Kata) screened all titles, abstracts, and full-text articles for eligibility. In cases of uncertainty or disagreement, a third reviewer was consulted to reach consensus. Data were extracted on study design, patient population, lesion characteristics, resection technique, and outcomes including en bloc and R0 resection, adverse events, recurrence, and surgical conversion. Studies were categorized by technique and clinical context [e.g., SMF, post-ileal pouch-anal anastomosis (IPAA), subepithelial lesions (SELs)] and narratively synthesized. The PRISMA diagram was updated to reflect that 409 articles underwent full-text review, 361 were excluded (due to irrelevance, non-UC population, or language), and 48 were included in the final synthesis.

Figure 1  PRISMA 2020 checklist.

RESULTS

Polypectomy in UC

The traditional management of visible dysplastic lesions in patients with UC has been colectomy, particularly in cases earlier referred to as dysplasia-associated lesion or mass (DALM). However, a growing body of evidence supports the role of colonoscopic polypectomy followed by intensive surveillance in carefully selected patients (with mucosal remission and endoscopically resectable morphology) (Table 1).

Table 1 Summary of key studies on polypectomy in ulcerative colitis.

Ref.	Patients (n)	Lesion type	Polypectomy outcome	Cancer risk post-polypectomy	Recommendation
Rubin et al[5], 1999	48	Dysplastic polyps in UC	48% developed new polyps; no flat dysplasia or cancer in follow-up	2% (1 case within polyp)	Polypectomy with surveillance
Odze et al[6], 2004	34	Adenoma-like DALM	62.5% recurred; 1 case of adenocarcinoma	About 3%	Polypectomy if lesion well-circumscribed
Vieth et al[7], 2006	148	Sporadic adenomas	4.6% had distant neoplasia; 2.3% carcinoma	2.3%	Adequate if followed by endoscopic monitoring
Engelsgjerd et al[9], 1999	Case series	Adenoma-like DALMs	Similar profile to sporadic adenomas	Minimal	Supports conservative management
Kisiel et al[8], 2012	77	Polypoid dysplasia	13% developed cancer/flat dysplasia	13% over 5 years	Requires close follow-up
Schaus et al[10], 2007	23	Ileal pouch polyps	91.3% inflammatory; 8.7% dysplastic/malignant	8.7%	Polypectomy + symptom monitoring

DALM: Dysplasia-associated lesion or mass; UC: Ulcerative colitis.

Rubin et al[5] conducted a seminal study in 48 patients with UC or Crohn’s colitis who underwent resection of 70 dysplastic polyps in the absence of flat mucosal dysplasia. Over a mean follow-up of 4.1 years, while 48% developed additional polyps, there were no cases of flat dysplasia or carcinoma, supporting the feasibility of endoscopic management[5]. Similarly, Odze et al[6] reported long-term outcomes in 34 UC patients with adenoma-like DALMs and found that although 59% developed new adenoma-like lesions during a mean follow-up of 82 months, only one patient with concurrent primary sclerosing cholangitis developed adenocarcinoma.

Vieth et al[7] evaluated 148 patients with UC diagnosed with sporadic adenomas and observed that of the 87 who underwent complete endoscopic resection, only 2.3% developed carcinoma and 4.6% developed colitis-associated neoplasia in other colonic segments. In contrast, nearly half of the patients who did not undergo polypectomy progressed to dysplasia or cancer.

In a follow-up cohort study, Kisiel et al[8] observed a 13% five-year cumulative incidence of colorectal cancer or flat dysplasia in UC patients with polypoid dysplasia managed by polypectomy, emphasizing the importance of rigorous surveillance even after complete lesion removal. Their analysis found no significant difference in progression based on lesion location or baseline disease characteristics, indicating that neither adenoma-like dysplasia nor sporadic adenomas confer clearly differential risk profiles. Engelsgjerd et al[9] further supported these findings by showing that adenoma-like DALMs are histologically and molecularly similar to sporadic adenomas and may be managed endoscopically when carefully selected. Importantly, endoscopic resection was typically performed during quiescent disease to minimize technical difficulty and avoid confounding mucosal inflammation.

In the context of restorative proctocolectomy, Schaus et al[10] reported on 23 patients with ileal pouch polyps, the majority of which were inflammatory in nature. However, two patients (8.7%) had dysplastic or malignant lesions. Endoscopic polypectomy was both feasible and symptomatically beneficial, though these findings underscore the continued need for vigilance in surveillance strategies[10].

Taken together, these data suggest that in select patients with UC, especially those with endoscopically resectable polypoid lesions and no synchronous flat dysplasia, conservative management via polypectomy followed by scheduled surveillance may be a safe and effective alternative to immediate colectomy. Nonetheless, the risk of progression to high-grade dysplasia (HGD) or carcinoma remains non-trivial and mandates a structured follow-up approach.

EMR

EMR has increasingly gained acceptance as a minimally invasive strategy for managing visible dysplastic lesions in UC, especially when endoscopic resectability and lesion delineation are favorable. Historically, flat or complex lesions in UC were referred for colectomy, but accumulating evidence now supports EMR as a safe and effective alternative in selected patients. Importantly, EMR is generally performed during endoscopic remission to minimize the impact of inflammation on lesion detection, lifting quality, and procedural safety. Active colitis impairs lifting, increases bleeding risk, and may necessitate deferral or medical optimization prior to resection.

In a landmark prospective study, Hurlstone et al[11] demonstrated the feasibility of EMR for Paris class 0-II flat dysplastic lesions and class I adenoma-like masses in 712 UC patients (Table 2). Over a median follow-up of 4.1 years, 82 Paris 0-II lesions were resected with an en bloc approach in 93% of cases, achieving a recurrence rate of just 2.4%. Importantly, there were no perforations, and the histopathology confirmed complete resection with negative margins. These outcomes were comparable to those in non-UC controls, and recurrence of lateral spreading tumors (LSTs) was rare, albeit slightly higher in the UC cohort (14%) than controls (0%), likely due to SMF and chronic inflammation[11].

Table 2 Studies evaluating endoscopic mucosal resection in ulcerative colitis.

Ref.	Patients (n)	EMR type	Lesion type	Key outcomes	Comments
Hurlstone et al[11], 2007	712	Conventional EMR	Paris 0-II, ALM, LST	93% en bloc; 2.4% recurrence; no perforations	Validated safety and efficacy in UC
Moyer et al[12], 2024	16	Distal cap EMR	Non-lifting dysplasia	75% complete resection; 0 SAEs; thermal margin ablation used	Ideal for fibrotic/adherent lesions
Hosotani et al[2], 2022	1	UEMR	Flat adenoma with fibrosis	Complete R0 resection; no complications	First UEMR case in UC with fibrosis
Takabayashi et al[13], 2022	1	UEMR	Lesion over ulcer/tattoo	En bloc resection; negative margins; safe in fibrotic UC	Demonstrates feasibility in scarred mucosa

EMR: Endoscopic mucosal resection; ALM: Adenoma-like mass; LST: Lateral spreading tumor; SAEs: Serious adverse events; UEMR: Underwater endoscopic mucosal resection; UC: Ulcerative colitis.

Distal cap-assisted EMR

One key challenge in EMR for inflammatory bowel disease (IBD) patients is the presence of SMF, which leads to a negative lift sign and complicates snaring. Moyer et al[12] addressed this by applying distal cap-assisted EMR in a multicenter retrospective study involving 16 IBD patients with non-lifting lesions. The study reported a complete resection rate of 75% with no serious adverse events within 30 days. The cap-assisted technique allowed successful resection in anatomically difficult or scarred locations, and most lesions were resolved by the second follow-up endoscopy. Notably, thermal margin ablation and adjuvant techniques such as hot avulsion enhanced completeness of resection and reduced recurrence[12].

Underwater EMR

Underwater EMR (UEMR) is another emerging approach, particularly effective for lesions in fibrotic or scarred mucosa where submucosal injection is unhelpful. Hosotani et al[2] reported a successful en bloc resection of a 15-mm flat lesion in the sigmoid colon of a UC patient with severe SMF using UEMR. This approach eliminated the need for submucosal lifting and leveraged the “floating effect” to safely isolate the lesion[2].

Similarly, Takabayashi et al[13] described UEMR in a UC patient with a polyp overlying longitudinal ulcer scars and adjacent tattoo. A 15-mm sporadic adenoma was removed en bloc without complications, demonstrating the utility of UEMR in anatomically complex and fibrotic terrain (Table 2)[13].

ESD

ESD has become an essential technique for achieving en bloc, margin-negative resection of dysplastic lesions in UC, particularly those that are large, non-polypoid, or fibrotic. Unlike EMR, ESD allows for complete resection regardless of lesion morphology or SMF, which is common in the inflamed mucosa. However, timing is critical - ESD should ideally be performed during endoscopic remission, as active disease may increase vascularity, impair lifting, and complicate margin assessment. In this section, we begin by reviewing multicenter data, followed by single-center series, selected case reports, and recent innovations in technique and training.

Multicentre studies on outcomes and safety of ESD

Several multicenter studies across Europe, Asia, and North America have established the technical feasibility and clinical safety of ESD in UC patients with visible dysplasia (Table 3). En bloc resection rates consistently exceed 88%, with R0 resection reported in 73%-96% of cases. For example, a large Endoscopic Resection Italian Network consortium study achieved 95.8% en bloc and 85.4% R0 resection rates in 96 patients, with curative outcomes in 83.3%, and a post-ESD surgery requirement in only 11.5% of cases[14]. Similarly, an Italian multicenter series by Geyl et al[15] reported slightly lower but comparable rates: En bloc 91%, R0 81.8%, and curative 79.5%, despite a high prevalence (75%) of SMF[15]. Another European pooled analysis by Manta et al[16] further supported the robustness of ESD outcomes in UC, with en bloc and R0 rates of 100% and 96.2% respectively in 53 patients, despite fibrosis in more than half the cohort[16].

Table 3 Multicentre studies evaluating outcomes of endoscopic submucosal dissection in ulcerative colitis.

Ref.	Country	n (lesions)	Mean size (mm)	En bloc (%)	R0 (%)	Curative (%)	Fibrosis (%)	Bleed (%)	Perforation (%)	Local recurrence (%)	Metachronous (%)	Surgery (%)
Maselli et al[14], 2024	Italy (ERIN)	96	35	95.8	85.4	83.3	About 73	4.2	8.3	3.1	3.1	11.5
Geyl et al[15], 2025	Italy (JCC)	88	40 (median)	91.0	81.8	79.5	75	8.0	14.8	6.8	Not reported	10.2
Kinoshita et al[17], 2018	Japan	25	22	100.0	76.0	Not stated	100	0.0	4.0	Not stated	Not stated	Indicated if non-curative
Manta et al[16], 2021	Italy	53	35 (median)	100.0	96.2	All R0	54.7 (F1 + F2)	13.2	5.6	0	3.7	3.8 (metachronous cases)
Ngamruengphong et al[18], 2022	United States	45	30 (median)	95.6	75.5	Not stated	73	8.8	2.2	2.6	31	2
Suzuki et al[19], 2017	United Kingdom/Japan	32	33 (median)	91.0	79.0	Not stated	97	3.0	0.0	3.1	9.3	4 (12.5%)

R0: Histologically clear margins; F1/F2: Fibrosis grading; ERIN: Endoscopic Resection Italian Network; JCC: Journak of Crohn’s Colitis.

In Japan, Kinoshita et al[17] demonstrated the technical excellence achievable in expert settings with 100% en bloc and 76% R0 resection across 25 patients, albeit with 20% requiring surgery due to non-curative pathology[17]. North American data from a nine-center cohort echoed these findings, with 96% en bloc and 75.5% R0 resection, despite a 73% rate of SMF. Local recurrence was rare (2.6%), though metachronous lesions occurred in 31% over 18 months[18]. Lastly, Suzuki et al[19] United Kingdom-Japan multicenter effort reported 91% en bloc and 79% R0 resections in 32 lesions, with fibrosis present in 97% - a technical barrier requiring expert-level dissection skills.

Together, these studies underscore that, in expert hands, ESD provides curative resections in the majority of patients with colitis-associated dysplasia and can potentially obviate the need for colectomy. However, extensive SMF - common in long-standing UC - even in remission, remains a major technical challenge. Therefore, patient selection, fibrosis severity, and post-resection surveillance remain key determinants of success.

Single center studies on outcomes and safety of ESD

Several single-center experiences have contributed important insights into the role of ESD for dysplastic lesions in UC (Table 4). In a Japanese series by Kasuga et al[20], 11 lesions ≥ 20 mm were resected in nine patients, with en bloc and curative resection rates of 91% and 82%, respectively. Scarring and SMF were associated with technical difficulty and piecemeal resection in one case[20]. Nishio et al[21] evaluated 102 lesions, comparing EMR and ESD across lesion morphology and size. They reported an R0 resection rate of 97% in the ESD group, including 100% for non-polypoid lesions, albeit with a 10% intraoperative perforation rate[21]. Yang et al[22] reported a resection rate of 93.3% and R0 achievement in 80% of 15 patients undergoing ESD, with no perforations or delayed bleeding; however, 14% experienced local recurrence and 14% metachronous dysplasia, underscoring the need for vigilant surveillance[22]. In a United States based series by Kochhar et al[23], seven IBD patients (five UC) underwent ESD with an en bloc resection rate of 86%, and no recurrences noted at 24 months. A subsequent broader series by the same group (Lightner et al[24] Cleveland Clinic, Cleveland, Ohio, United States of America) reported ESD outcomes in 25 patients with IBD (including 16 with UC), achieving R0 resection in 80% of cases and observing low recurrence over 19 months, but noting that 40% ultimately required colectomy due to medical refractoriness or neoplasia. These findings suggest that while ESD may achieve local control of dysplasia, long-term outcomes remain influenced by disease activity and systemic disease course.

Table 4 Single centre studies evaluating outcomes of endoscopic submucosal dissection in ulcerative colitis.

Ref.	n (lesions)	En bloc (%)	R0 (%)	Curative (%)	Perforation (%)	Local recurrence	Metachronous dysplasia	Notes
Kasuga et al[20], 2021	11	91	82	82	0	0	2 cases (≥ 20 mm)	All ≥ 20 mm lesions
Nishio et al[21], 2021	39	97	97	97	10	0	7% (HGD, LGD)	Compared to EMR
Yang et al[22], 2019	15	93	80	Not stated	0	14.3%	14.3%	Vaguely distinct lesions included
Kochhar et al[23], 2018	7 (5 UC)	86	Not stated	Not stated	0	0	0	United States single-center experience
Lightner et al[24], 2021	25 (16 UC)	Not reported	80	Not stated	4	2/15 (13.3%)	None	40% required surgery later

R0: Histologically clear margins; HGD: High-grade dysplasia; LGD: Low-grade dysplasia; UC: Ulcerative colitis; EMR: Endoscopic mucosal resection.

Case series and notable case reports

In addition to multicenter and single-center studies, various case series and notable reports have enriched the understanding of ESD in UCAN by highlighting unique technical challenges. Gupta et al[25] reported the successful use of ESD in a 35-year-old male with HGD in long-standing UC, emphasizing its diagnostic and curative utility in visible, non-polypoid lesions with p53 overexpression, even in challenging rectosigmoid locations. Pal et al[26] described a prospective Indian cohort, where ESD was performed for flat or non-lifting lesions and achieved R0 resection in most cases, despite frequent SMF. They also noted the utility of UEMR in managing fibrotic recurrences post initial resection[26].

A unique technical variant was presented by Alkhayyat et al[27], who encountered an unusual thickened submucosal adipose layer during ESD for sigmoid colonic dysplasia, necessitating liquid soap for visualization and traction assistance for complete resection - highlighting the anatomical adaptations required. Masuo et al[28] illustrated a critical diagnostic limitation in ESD: A superficially resected visible dysplastic lesion in UC harbored occult submucosal invasive carcinoma with lymphatic invasion, necessitating subsequent proctocolectomy despite initial curative intent. Similarly, Sakamoto et al[29] documented a flat rectal lesion with subtle discoloration that appeared endoscopically benign but demonstrated deep submucosal invasion upon histopathology, reinforcing the diagnostic staging value of ESD and its role in surgical decision-making. Finally, Tanaka et al[30] detailed a case of serrated adenoma in long-standing pancolitis UC where standard EMR was not feasible due to fibrosis, and ESD with a hook knife enabled en bloc resection, offering a precise histologic classification and a minimally invasive therapeutic approach. This case underscores how fibrosis from chronic inflammation may preclude conventional techniques and necessitate more advanced dissection strategies.

Studies including both EMR and ESD or hybrid ESD

A growing body of evidence supports the feasibility of combining EMR and ESD techniques to optimize resection outcomes in UCAN, especially in fibrotic or anatomically challenging lesions (Table 5). In a tertiary United States. cohort, Alipouriani et al[31] evaluated 50 IBD patients (38 ESD, 11 ESD + EMR, 1 EMR) and reported an en bloc resection rate of 68% and a recurrence rate of 18%, with no significant difference between ESD and hybrid groups. In a large multicenter Japanese registry, Hirai et al[32] compared 96 ESD and 142 EMR procedures across 14 institutions. While ESD was more frequently used for larger, flat, or left-sided lesions and had a higher perforation rate (6.3% vs 0%), recurrence and survival outcomes were similar, supporting morphology-guided modality selection. Complementing these data, Pal et al[26] described outcomes in six Indian patients in low-resource settings undergoing EMR (n = 5) or ESD (n = 1) for UCAN. R0 resection was achieved in 83.3%, with one case of residual lesion successfully treated with UEMR, illustrating the feasibility of hybrid and tailored resection strategies even in high-fibrosis environments[26].

Table 5 Summary of outcomes from studies using endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid techniques in ulcerative colitis-associated neoplasia.

	Alipouriani et al[31], 2025	Hirai et al[32], 2023	Smith et al[33], 2008	Pal et al[26], 2022
Setting	Tertiary United States center	14 Japanese centers	United Kingdom single center	Tertiary center, India
Patients (n)	50	336	67	6
Lesions	ESD (n = 38), ESD + EMR (n = 11), EMR (n = 1)	ESD (n = 96), EMR (n = 142)	Hybrid ESD-assisted EMR	EMR (n = 5), ESD (n = 1)
En bloc resection (%)	68%	ESD: 97%, EMR: 89%	ESD-EMR: 78%	83.3%
R0 resection (%)	Not specified	Not specified	94% (en bloc subset)	83.3%
Perforation rate	2%	ESD: 6.3%, EMR: 0%	3%	None
Recurrence (%)	18%	Local: 2.7%, metachronous: 6.1%	Local: 7%, metachronous: 0%	1 case residual, treated
Follow-up duration	3 years (median)	34.7 months (median)	18 months (median)	Short-term
Key Findings	ESD and hybrid feasible with minimal complications; recurrence similar across groups	Large multicenter validation of ER in UC; higher perforation with ESD; no difference in recurrence	Hybrid ESD-EMR enables resection in fibrotic ALMs; high R0 and low recurrence	Combined resection feasible in Indian setting; R0 achieved in 5/6; residual lesion managed endoscopically

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; UC: Ulcerative colitis; ALMs: Adenoma like mass; R0: Histologically complete resection.

Smith et al[33] demonstrated in a United Kingdom series that hybrid ESD-assisted EMR achieved 78% en bloc and 94% R0 resection rates in fibrotic adenoma-like masses, with no metachronous recurrence during 18 months of follow-up. This approach was particularly useful in IBD-associated fibrosis when submucosal lifting was partial or segmental, but could still be leveraged using assisted traction and mucosal anchors.

When to choose EMR vs ESD in UCAN

Choosing between EMR and ESD for UC-associated dysplasia depends on lesion characteristics and fibrosis burden. EMR is appropriate for small, clearly demarcated, polypoid lesions that lift well and can be removed en bloc or piecemeal with low suspicion of submucosal invasion. In contrast, ESD is preferred for flat, large (typically > 20 mm), non-polypoid, or fibrotic lesions, especially those with Paris IIa/IIb morphology or LSTs, where en bloc resection is necessary for accurate histologic assessment and long-term cure. Dalal et al[3] reported that ESD, though more technically demanding, achieved significantly higher en bloc resection rates (100% vs 50%) and showed a trend toward reduced recurrence and surgical referrals compared to EMR, particularly in flat, left-sided lesions[3]. These findings align with other series demonstrating superior R0 resection and lower recurrence with ESD in high-risk lesions, while EMR remains a simpler, cost-effective option for well-lifting, benign-appearing polyps[26,31,33]. SMF - whether from prior inflammation or previous resection - favors ESD over EMR, provided adequate disease control has been achieved beforehand.

Long-term outcomes after ESD for UC-associated dysplasia

Matsumoto et al[34] conducted one of the first studies evaluating long-term outcomes following ESD for UCAN. In a retrospective cohort of 17 patients with 22 lesions, they compared ESD with total proctocolectomy and reported a median follow-up of nearly 15 years. ESD achieved en bloc resection in 83% and histologically complete resection in 67% of lesions, despite all cases exhibiting positive non-lifting signs due to SMF. No procedure-related adverse events or local recurrences were observed. However, metachronous neoplasia occurred in 71% (5 of 7) of patients undergoing ESD, and four ultimately required proctocolectomy. Importantly, no patients died of UCAN during follow-up. These findings highlight the role of ESD as an effective organ-preserving diagnostic and therapeutic tool in UCAD, while also underscoring the substantial risk of metachronous lesions and the need for strict long-term surveillance post-ESD[34].

Role of endoscopic ultrasound in assessing submucosal cushion for ESD feasibility

In a novel case series, Kim et al[35] explored the use of endoscopic ultrasonography (EUS) to evaluate the adequacy of the submucosal cushion following injection, as a preprocedural tool to determine ESD feasibility in UCAN. Among nine UC patients evaluated, a total of ten lesions underwent saline or hyaluronic acid injection followed by EUS mini-probe assessment. Lesions with diffuse SM cushion thickness < 2.0 mm were deemed unsuitable for ESD. Of the ten lesions, eight met eligibility criteria and were successfully resected by ESD, achieving 100% en bloc and 87.5% R0 resection rates without perforation. One case of delayed bleeding was reported.

This study demonstrates how EUS-guided assessment can serve as a practical adjunct to evaluate submucosal lift quality and fibrosis burden, especially in long-standing UC where deep fibrosis is common and lifting may be equivocal. This approach may offer an objective method to gauge lifting adequacy and fibrosis burden prior to ESD, particularly in fibrotic colonic segments in long-standing UC[35].

DISCUSSION

SMF and ESD outcomes

SMF presents a major technical challenge during colorectal ESD, especially in the context of UCAN (Table 6). In a Western cohort of 195 rectal ESDs, Félix et al[36] reported that lesions with severe fibrosis (23.1%) were associated with significantly reduced en bloc, R0, and curative resection rates and required more hybrid ESDs and longer dissection times. Predictive factors included prior EMR, UC, and deep submucosal invasion[36]. In a focused cohort of UC patients, Nishio et al[21] demonstrated that a longer disease duration (≥ 10 years) and scarring background mucosa were independently associated with severe SMF, which in turn significantly increased the risk of intraoperative perforation (30% vs 4%) despite comparable en bloc and R0 resection rates[37]. In a large series from Japan, Ozeki et al[1] showed that water pressure-assisted ESD (WP-ESD) significantly shortened procedure time in fibrotic lesions compared to conventional ESD, without increasing adverse events. WP-ESD allowed efficient submucosal entry and dissection by combining saline immersion with active pressure infusion, offering a promising technique for managing fibrotic colorectal lesions, including those in UC[1]. Additionally, Hayashi et al[38] identified severe fibrosis and poor endoscopic operability as independent predictors of both incomplete resection and perforation, reinforcing the need for preprocedural risk stratification in fibrotic colonic lesions. In this context, careful lesion evaluation - including prior treatment history, mucosal appearance, and disease duration - can help anticipate fibrosis grade and inform procedural planning (e.g., choice of WP-ESD, hybrid approach, or postponement until mucosal healing).

Table 6 Studies evaluating impact of submucosal fibrosis in endoscopic submucosal dissection on ulcerative colitis associated neopalsia.

Parameter	Félix et al[36], 2023	Nishio et al[37], 2024	Ozeki et al[1], 2021	Hayashi et al[38], 2014
Setting	Western center, rectal ESD	UC patients, colonic ESD	Colorectal tumors with fibrosis	Japanese academic center
Sample size	195 lesions	55 lesions	133 lesions	267 lesions
Severe fibrosis (%)	23.1%	49%	72.2%	F2 = 34%
Impact on R0/curative (%)	R0: 61.4%, curative: 54.5%	R0: 93%, Curative: 93%	Shorter procedure time with WP-ESD	En bloc: 95.9%, incomplete: 4.1%
Key predictors	UC, prior EMR, deep SM invasion	UC duration ≥ 10 years, scarring mucosa	Prior treatment, UC	Severe fibrosis, poor operability, SM deep invasion
Comments	Lower resection speed, more hybrid ESD needed	Higher perforation in F2 fibrosis (30%)	WP-ESD reduced time; safety comparable to C-ESD	Severe fibrosis and poor operability independently predicted perforation

UC: Ulcerative colitis; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; R0: Histologically clear margins; C-ESD: Conventional endoscopic submucosal dissection; WP-ESD: Water pressure-assisted endoscopic submucosal dissection; SM: Submucosal.

Lifting and traction strategies in ESD for UC-associated dysplasia

Given the high prevalence of SMF in UC, adequate submucosal lifting and traction are crucial to the safety and efficacy of ESD. PuraLift, a novel self-assembling peptide solution, has shown comparable mucosal lifting to hyaluronic acid (MucoUp) but with significantly lower injection resistance across esophagus, stomach, and colon, offering smoother submucosal entry and potentially better tactile control during injection - a key feature in fibrotic settings (Table 7)[39]. Use of such agents is particularly valuable in UC patients with prior inflammation, where the submucosa may be fibrotic, scarred, or fragmented, limiting the performance of conventional lifting solutions.

Table 7 Lifting and traction techniques in endoscopic submucosal dissection for ulcerative colitis associated neoplasias.

Technique	Key feature	Application context	Advantage
PuraLift[39]	Self-assembling peptide lifting agent	All GI segments, excluded fibrosis cases	Low injection resistance, sustained lift
Multitraction[40]	3-looped clip system for recurrent lesion	UC recurrence with fibrosis	Enables re-entry and dissection in fibrotic bed
Triangulated “Wallet”[41]	Rubber band traction with 3-point clip fixation	Fibrotic rectal lesions in UC	Strong, adaptive perpendicular traction
Double-tunneling[42]	Bilateral flaps with preserved septum (“butterfly”)	Extensive rectal LSTs in UC	Maintains orientation, avoids flap rolling
PCM[43]	Submucosal pocket dissection under fibrosis	Residual dysplasia post-EMR + inflammation	Isolates fibrotic layer; good for UC mucosa

UC: Ulcerative colitis; EMR: Endoscopic mucosal resection; GI: Gastrointestinal; LSTs: Laterally spreading tumors; PCM: Pocket creation method.

For fibrotic or recurrent lesions, traction methods such as multiloop and triangulated clip-band systems have demonstrated improved visualization and dissection planes. Yzet et al[40] reported a successful resection of recurrent HGD using a multitraction system composed of three looped clips to expose a fibrotic bed and enable en bloc resection. Lupu et al[41] described the “wallet” strategy, a triangulated rubber band-clip technique that stretches both proximal and distal mucosal flaps to provide perpendicular traction, allowing efficient dissection in severely fibrotic UC mucosa. Additional innovations include the double-tunneling butterfly method, described by Stasinos et al[42], which preserves a central submucosal septum between two tunnels to maintain orientation and traction during resection of extensive rectal neoplasms with > 60% luminal involvement. The pocket-creation method has also been adapted for UC, as illustrated by Fujinuma et al[43], where complete en bloc resection of residual dysplasia was achieved despite prior EMR and extensive fibrosis. Together, these techniques address the dual challenge of poor lifting and obscured dissection planes in inflamed or previously treated colonic segments.

Use of accessory tools for scope stabilization

A recent report from highlighted the utility of a rigidizing overtube in complex colonic ESD, including a case of UC with severe fibrosis. By improving scope stability and tip control in the proximal colon, the overtube facilitated precise dissection through fibrotic submucosa and enabled safe en bloc resection[44].

Special scenarios: ESD in pouch and SELs

While ESD is primarily applied to conventional dysplastic lesions in long-standing UC, its use in special clinical scenarios is expanding. In patients who have undergone restorative proctocolectomy with IPAA, neoplasia can still arise in the rectal cuff, especially when a longer residual cuff remains. Barrett et al[45] described two such cases where HGD and early adenocarcinoma were detected via surveillance pouchoscopy and successfully managed with ESD. These cases underscore both the potential for curative endoscopic resection in high-risk post-surgical settings and the need for standardized surveillance protocols in IPAA patients with prior dysplasia[45]. Similarly, Yoshii et al[46] reported a technically complex ESD of a 40-mm lesion arising from the remnant rectal mucosa after IPAA. Despite severe fibrosis and anatomical constraints due to prior anastomosis, en bloc resection was achieved using a retroflexed, multi-bending scope, demonstrating that ESD remains feasible in anatomically altered postoperative rectums[46].

An even rarer but challenging context is the appearance of dysplasia presenting as SELs in UC. Park et al[47] detailed a case where a hypoechoic lesion, initially appearing as an SEL on EUS in the proximal rectum, was ultimately diagnosed as well-differentiated adenocarcinoma. ESD facilitated complete resection of the lesion with clear margins; however, a synchronous adenocarcinoma was found near the ESD site, necessitating proctocolectomy. This case illustrates how deeply invasive or crypt-originating dysplasia may masquerade as SELs, and highlights the importance of thorough histological evaluation of any atypical mucosal elevation in UC surveillance, even in the absence of classical dysplastic features[47].

EFTR in UCAN

EFTR is an evolving technique for managing difficult colonic lesions, including non-lifting adenomas, subepithelial tumors, and scarred recurrences - situations where conventional EMR or ESD may fail. While its safety and efficacy are established in the general population, reports in IBD, particularly UCAN, remain limited. Kochhar et al[23] described the first use of EFTR in a UC patient with a large, fibrotic, non-lifting adenoma in the descending colon. Using the Ovesco full thickness resection device , R0 resection was achieved without complications, demonstrating the feasibility of EFTR in scarred UC segments[4]. However, caution is warranted: Oliviero et al[48] described a fatal entero-colonic fistula after EFTR of a LST in a patient with a prior hemicolectomy, underscoring the risks of deep wall resection in chronically inflamed or surgically altered colons. This case highlights that while EFTR may be technically successful, the presence of transmural inflammation may increase the risk of severe adverse events. Therefore, EFTR in UCAN should be reserved for highly selected cases with stable disease, no active inflammation, and clear procedural indication.

CONCLUSION

Endoscopic resection has become a central organ-preserving strategy in the management of UCAN. Polypectomy remains effective for small, well-demarcated lesions with no adjacent flat dysplasia. EMR is appropriate for polypoid or lifting lesions, primarily in the right colon, while ESD is preferred for flat, fibrotic, or non-lifting lesions - achieving en bloc resection in 88%-100% and R0 resection in 73%-96% of cases. Complication rates with ESD range from 2%-10%, with local recurrence in 0%-6.8% and metachronous lesions developing in up to 31% over long-term follow-up. Surgical intervention was needed in 10%-20% of patients, largely for non-curative histology or new lesions. SMF remains a major technical challenge but can be mitigated with innovations such as water pressure-assisted dissection, peptide-based injectables, traction systems, and hybrid techniques. Crucially, timing of resection is essential - procedures should be performed during endoscopic and clinical remission whenever possible to reduce complications and improve resection success. Active inflammation impairs lifting, increases bleeding risk, and may obscure dysplasia. While EFTR offers promise for scarred or anatomically complex lesions, current data are limited and its safety profile in UC is not yet well-defined. Therefore, EFTR should be cautiously applied in select patients with no ongoing inflammation or transmural disease. These findings support a tailored, morphology-guided approach to endoscopic resection in UC, informed by disease activity, fibrosis burden, and lesion accessibility, reinforced by long-term surveillance.