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.

Key Words: 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.

INTRODUCTION

Colorectal cancer (CRC) is the third most common malignancy and the second leading cause of cancer-related deaths worldwide[1]. Globocan 2022 estimated 1.93 million new cases and 904000 deaths, accounting for approximately 9.3% of all cancer deaths, with nearly half of the global burden originating from Asia[2-4]. This incidence is expected to rise to 3.2 million new cases and 1.6 million deaths by 2040[5]. The incidence has been declining in high-income countries over the past few decades, primarily due to the widespread implementation of population-based screening programs, such as colonoscopies and fecal immunochemical testing, as well as an increase in public health awareness, healthier lifestyles, and a decrease in smoking rates[6]. However, an increasing trend in CRC has been observed in younger populations (< 50 years), especially in Asia, owing to rapid changes in socioeconomic and lifestyle factors[7,8].

The etiology of CRC is multifactorial, involving complex interactions among genetic predisposition, environmental exposure, diet, lifestyle, and gut microbiota[9,10]. Despite this heterogeneity, the adenoma-carcinoma sequence remains the primary pathway for CRC development, and the prevention of CRC primarily involves the early detection and removal of precancerous lesions[11]. The risk of malignant transformation in precancerous colorectal lesions increases with the lesion size. Advanced adenomas, defined by size ≥ 10 mm, villous architecture, or high-grade dysplasia, are the strongest predictors of future CRC development[12]. Amid this rising disease burden, the ability to achieve curative, organ-preserving endoscopic treatment has redefined the therapeutic goals in colorectal oncology. The technical challenges and recurrence risks associated with lesions measuring ≥ 30 mm continue to drive the field toward advanced techniques. The evolution of techniques such as endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) represents not only technical progress but also a strategic shift toward precision and preservation, making the endoscopist a central figure in oncologic prevention. Endoscopic resection techniques, such as cold or hot snare polypectomy, are used for small and intermediate-sized lesions. In contrast, endoscopic mucosal resection (EMR), ESD, and EFTR are reserved for larger or high-risk polyps that require en bloc removal to ensure clear margins.

Zhu et al[13] published a study on this evolving landscape. Provides timely and clinically relevant evidence on the role of ESD and EFTR in the treatment of large colorectal lesions. The results were striking, with 102 patients and a mean lesion size of 38.4 ± 11.5 mm. The en bloc and R0 resection rates of 98% and 96.1%, respectively, demonstrate excellent oncological adequacy in the hands of experts. Conversion to surgery occurred in only 3.9% of cases, and no local recurrences were observed during short-term follow-up. These figures reaffirm that, in expert hands, endoscopic resection can achieve surgical-level curative outcomes while avoiding colectomy, a finding that should influence future triage algorithms for large colorectal lesions. These data reinforce the growing evidence, including large-scale meta-analyses, that ESD achieves superior en bloc resection compared with EMR, thereby improving histological accuracy and reducing the risk of recurrence. A significant contribution of Zhu et al[13] was the identification of the transverse colon location as an independent predictor of Post-Endoscopic Submucosal Dissection Electrocoagulation Syndrome. With an incidence of 23.5%, this complication highlights the importance of anatomical risk stratification. Beyond efficacy, the safety profiles of advanced endoscopic resection techniques merit careful consideration. Multiple meta-analyses have quantified the complication rates across modalities. A systematic review comparing 3424 ESD and 5122 EMR procedures reported perforation in 5.1% of ESD cases vs 1.7% with EMR and delayed bleeding in 4.3% and 3.6%, respectively, with ESD showing significantly higher procedural risk despite superior resection outcomes[14]. Similarly, a large pooled analysis of 98 studies, including 13291 colorectal ESD lesions, reported immediate and delayed perforation rates of 4.2% and 0.22%, respectively[15]. More recent data have reported overall adverse event rates of 5.3% for perforation and 7.7% for bleeding, underscoring that although ESD provides oncologically complete resections, it remains technically demanding with a non-negligible risk of complications[16]. These findings emphasize that “acceptable adverse event rates” are achievable primarily in high-volume expert centers with standardized preventive measures, such as clip closure, decompression, and meticulous dissection techniques. Hence, outcomes must always be interpreted in the context of operator expertise, lesion complexity, and institutional experience when comparing ESD, EMR, and EFTR for the management of large colorectal lesions. These findings emphasize the need for preventive strategies, including clip closure, decompression techniques, and emerging suturing methods, which have proven effective in reducing adverse events.

A key limitation of Zhu et al’s study[13] is the heterogeneous nature of the included population, which complicates the interpretation of their outcomes. Lesion characteristics vary considerably, encompassing sessile polyps, laterally spreading tumors (LSTs), recurrent or fibrotic lesions, and non-lifting tumor subtypes, which differ markedly in terms of technical difficulty, recurrence risk, and complication. However, pooled outcome data may obscure clinically relevant distinctions. The anatomical locations of the lesions were also diverse, ranging from the rectum to the transverse colon. Rectal lesions are generally safer for ESD because of their accessibility and thicker walls, whereas transverse colon lesions are associated with higher rates of Post-Endoscopic Submucosal Dissection Electrocoagulation Syndrome because of thinner walls and greater mobility. However, the authors identified the location of the transverse colon as an independent risk factor, and the subgroup results were insufficiently detailed to guide clinical practice. Furthermore, treatment approaches were inconsistent; although ESD was the predominant modality, a small number of EFTR procedures were included, limiting comparative conclusions. Additionally, preventive strategies, such as clip closure or decompression tubes, were applied at the operator’s discretion, introducing variability in complication rates. Moreover, the uniform three-month follow-up period disregarded the differing recurrence patterns associated with EMR, ESD, and EFTR. Nonetheless, the findings of this study have broader implications for optimizing endoscopic management of large colorectal lesions. In this editorial, we examine the approach to colorectal lesions when detected and the potential methods for managing these lesions in the era of evolving techniques for complete endoscopic resection, including the drawbacks associated with these techniques and their comparison with standard surgical approaches. This editorial consolidates the current evidence and best practices for managing large colorectal lesions.

LARGE COLORECTAL LESIONS

Large colorectal lesions are generally defined as non-pedunculated polyps measuring ≥ 20 mm in diameter, a threshold consistently adopted by recent international guidelines, including those of the United States. Multi-Society Task Force, and the European Society of Gastrointestinal Endoscopy (ESGE)[17-19]. These large lesions carry an increased risk of advanced histology, submucosal and lymphatic invasion, incomplete resection, and recurrence, and they harbor carcinoma in 20%-50% of cases, making them technically challenging to manage[17]. While surgery has traditionally been the standard approach for large colorectal lesions, advancements in endoscopic techniques over the past decade have shifted the paradigm toward less invasive and organ-preserving treatment options for large colorectal lesions.

The evaluation of large colorectal lesions begins with a detailed endoscopic assessment using high-definition white light and image-enhanced methods, such as chromoendoscopy and narrow-band imaging, to determine the size, shape, surface pattern, and potential submucosal invasion. Colorectal lesions are typically classified according to the Paris classification by their morphology to assess cancer risk and guide management (Figure 1)[20,21]. LSTs are superficial colorectal neoplasms that extend mainly along the mucosal surface rather than into the submucosa, and usually measure ≥ 10 mm in diameter[22]. These LSTs represent a specific subset of lesions that can be classified according to the Paris classification, particularly flat lesions (0-II). LST can be categorized into granular or non-granular types, as morphology significantly impacts the resection approach and the risk of malignancy and recurrence (Figure 1). Granular LST can be further subdivided into a homogenous type and nodular mixed type, and non-granular-LST (LST-NG) into a flat elevated type and a pseudo-depressed type[23]. LSTs ≥ 20 mm have a 10%-15% risk of submucosal invasion, which increases to 30%-40% in patients with LSTs ≥ 30 mm[24]. Large LSTs often require advanced resection techniques, such as ESD or hybrid approaches, and surgery if unfavorable histologic features are present.

Figure 1  Morphological subtypes of superficial colorectal lesions and lateral spreading tumors as per Paris classification.

Furthermore, endoscopic features such as non-lifting signs, ulceration, or depressed components raise concerns for invasive carcinoma and help guide the choice between endoscopic and surgical management. Endoscopic ultrasound or cross-sectional imaging may be used for lesions suspected of deep invasion or those located at complex anatomical sites. Careful mapping, tattooing when surgery is planned, and multidisciplinary discussions are essential for optimal treatment planning. Overall, the goal of evaluation is to balance oncologic effectiveness with organ preservation by selecting the most appropriate resection technique, such as EMR, ESD, EFTR, or surgery, based on the lesion features, location, and patient factors. In clinical practice, however, lesion classification must extend beyond morphology to procedural planning, recognizing that the endoscopic strategy should be tailored not only to the lesion type but also to the available expertise and institutional readiness. A stepwise approach for the management of these lesions is shown in Figure 2.

Figure 2 Step-wise management of large colo-rectal lesions. EUS: Endoscopic ultrasound; ESD: Endoscopic submucosal dissection; PEECS: Post-endoscopic submucosal dissection electrocoagulation syndrome; EFTR: Endoscopic full-thickness resection; EMR: Endoscopic mucosal resection.

ENDOSCOPIC MANAGEMENT OF LARGE COLORECTAL LESION

EMR remains the first-line therapy for many large colorectal lesions, including those exceeding 2 cm, when performed by experienced endoscopists. Piecemeal EMR allows safe and effective removal, but recurrence rates may reach up to 20% compared with en bloc resection[25,26]. Piecemeal resection complicates pathological evaluation by fragmenting margins, limiting R0 confirmation, and increasing the risk of recurrence and interval cancer[27]. Although adjunctive techniques such as margin ablation, margin making, and enhanced imaging during surveillance help mitigate this risk[26,28,29]. The epinephrine volume reduction technique is a safe and effective method for treating giant polyps. The epinephrine volume reduction technique achieved a 25% reduction in diameter and a 60% reduction in volume. This volume reduction enables a more accurate assessment and decreases the bleeding rate[30]. A retrospective study of piecemeal EMR of colorectal lesions with a median size of 30 mm showed a complete resection rate of 97.4% and a high recurrence rate of 29%[31].

ESD enables the en bloc resection of very large lesions, ensuring accurate histopathologic staging and achieving lower recurrence rates than piecemeal EMR. The indications for ESD include en bloc resection not feasible with EMR, LST-NG, especially LST-NG (Pseudo depressed), Kudo VI-type pit pattern, shallow Sub mucosal invasion, large depressed tumors, large protruded lesions, mucosal tumors with submucosal fibrosis, sporadic localized tumors in conditions of chronic inflammation, such as ulcerative colitis, or residual or recurrent early carcinomas after endoscopic resection[32]. Multiple meta-analyses have demonstrated superior R0 and curative rates, particularly for LSTs[14,33-36]. However, ESD is technically demanding, time-consuming, and associated with a high risk of bleeding and perforation. Nonetheless, improvements in endoscopic devices, electrosurgical systems, procedural techniques, and closure methods have decreased the complexity of ESD. Comparative studies suggest that, for carefully selected patients without high-risk features, long-term survival and recurrence outcomes after curative ESD are comparable to those after surgery, with the added advantages of shorter recovery, fewer complications, and preserved bowel continuity[37,38]. A Japanese study on ESD for large colorectal lesions exceeding 30 mm showed an en bloc resection rate of 97% with a 5-year follow-up and a survival rate of 93.6%. The local resection rate was 0.5% and the patients were managed endoscopically[39]. A Korean multi-study on colorectal ESD showed that the en bloc resection rate was 89.6% for lesions 40-59 mm in diameter and 81.4% for those > 60 mm, with a local recurrence rate of 2.7%[40]. Arezzo et al[41] compared the outcomes of ESD and EMR in over 4000 colorectal lesions and found that en bloc resection rates ranged from 80% to 97% and R0 resection rates ranged from 70% to 90%, while perforation occurred more frequently with ESD up to 5% in some series, thus reflecting differences in lesion morphology, fibrosis, and operator experience.

EFTR, an en bloc endoscopic resection technique, is performed using a full-thickness resection device (Ovesco Endoscopy, Tübingen, Germany). It is useful for non-lifting lesions, fibrotic recurrences, and challenging areas, such as the para-appendiceal or diverticular regions. Although current device limitations restrict EFTR to < 30 mm, it can be useful in selected cases over 3 cm as part of hybrid strategies. The amount of tissue that can be aspirated into the cap is limited not only by the lesion size but also by the morphology and degree of fibrosis[42]. In a systematic review and meta-analysis by McKechnie et al[43], who evaluated the safety and efficacy of EFTR for colorectal lesions across 21 studies, including 1539 patients and 1551 procedures, a pooled technical success rate of 89% and an R0 resection rate of 79%, with a mean procedure time of 54 min and a mean specimen size of 17.5 mm, were reported. Thirty-day morbidity was 11%, with bleeding (5%) and perforation (2%) as the main adverse events. One-year recurrence occurred in 7.3% of the lesions[43]. In a meta-analysis by Singh et al[44], the authors compared EFTR and ESD in 530 patients with complex colorectal lesions across four studies. They demonstrated that both EFTR and ESD had similar en bloc [94% vs 91%, odds ratio = 1.73, 95% confidence interval (CI): 0.60-4.97, P = 0.31] and R0 resection rates (984% vs 80%, odds ratio = 1.52, 95%CI: 0.55-4.14, P = 0.42). EFTR is associated with shorter procedure times and fewer complications, perforations, and post-resection electrocoagulation syndromes[44]. However, EFTR had a higher rate of residual or recurrent lesions than ESD. The authors concluded that while EFTR offers a quicker and safer option for selected complex lesions, ESD remains superior for long-term curative resection, underscoring the need for individualized patient selection and close surveillance[44]. EFTR’s emergence should not be seen as competition to ESD, but as a complementary option bridging the gap between incomplete endoscopic resection and unnecessary colectomy.

Despite these advances, surgery remains indicated for lesions with deep submucosal invasion, unfavorable histology such as poor differentiation or lymphovascular invasion, or incomplete resection. It also plays a role when endoscopic resection is not feasible because of anatomical or technical limitations of the patient. A systematic review and meta-analysis comparing the long-term outcomes of endoscopic resection vs surgery for T1 CRC, involving 17 studies and over 19000 patients, found that five-year overall survival (79.6% vs 82.1%, hazard ratio = 1.10; 95%CI: 0.84-1.45) and recurrence-free survival (96.0% vs 96.7%, hazard ratio = 1.28; 95%CI: 0.87-1.88) were similar between surgery and endoscopic resection[45]. Adverse events were fewer in the endoscopic resection group than in the surgery group (2.3% vs 10.9%, P < 0.001). Lymph vascular invasion and rectal cancer, but not the depth of submucosal invasion, were independently associated with recurrence in all T1 CRCs[45]. Thus, EFTR is best reserved for non-lifting or recurrent lesions not amenable to EMR or ESD, whereas surgery remains the definitive option for non-curative resections or when a high-risk pathology is identified. A comparison of EMR, ESD, and EFTR for the management of large colorectal lesions is presented in Table 1.

Table 1 Comparison of endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection in the management of large colorectal lesions.

	EMR	ESD	EFTR
Indication	First-line for most non-malignant polyps; en-bloc best ≤ 20 mm; piecemeal EMR for ≥ 20 mm lesions	En bloc resection is not feasible with EMR; LST-NG; Kudo VI-type pit pattern; shallow SM invasion; large depressed tumors; large protruded lesions; mucosal tumors with submucosal fibrosis; sporadic localized tumors in conditions of chronic inflammation, such as ulcerative colitis; residual or recurrent early carcinomas after endoscopic resection	Best for difficult non-lifting lesions; fibrotic lesions; residual or recurrent adenoma; small subepithelial lesions. Ideal for lesions up to 30 mm
En-bloc resection rate	Low for large lesions; en bloc resection is rare in lesions ≥ 20 mm, most are piecemeal	High: 89%-97%	High: 94%
R0 (complete) resection	Lower; hard to assess after piecemeal	Higher in expert hands; pooled: 75%-85%	Good (84%) if the lesion is fully captured within the cap
Local recurrence	Historically, 10%-30%; decreased (5%) with margin thermal ablation techniques	< 2%-5% when R0 is achieved	Very low when complete EFTR is achieved
Perforation risk	Low: 0.5%-3%	Higher: Approximately 4% (up to 7%-10% in some series)	Intrinsic to the technique, but closed OTSC simultaneously
Procedure time/resources	Shorter, outpatient; widely available	Longer, technically complex; limited to expert centers	Faster than ESD; however, device-specific training is needed
Limitations	Piecemeal, higher recurrence, and poor margin assessment	Steep learning curve, higher perforation risk, limited availability	Size limits ≤ 20-25 mm; not ideal for > 3 cm; evidence mostly observational

EFTR: Endoscopic full-thickness resection; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; LST-NG: Laterally spreading tumor, non-granular type; OTSC: Over-the-scope clip; R0 resection: Histologically complete resection with tumor-free margins; SM: Submucosal.

CURRENT GUIDELINES ON ENDOSCOPIC MANAGEMENT OF LARGE COLORECTAL LESIONS

Endoscopic guidelines highlight the importance of thorough lesion assessment, multidisciplinary evaluation, organ preservation, referral to expert endoscopists, and avoidance of overtreatment, which remain the key goals. Accurate preoperative diagnosis using magnifying endoscopy, narrow-band imaging, or pit-pattern analysis is emphasized to distinguish adenomas from carcinomas and assess invasion depth. The American Society of Gastrointestinal Endoscopy and the United States Multi-Society Task Force recommend EMR as the preferred method for large (≥ 20 mm) non-pedunculated lesions[19]. They also suggested prophylactic closure for lesions in the right colon and adjunctive thermal ablation of the post-EMR margin when no residual adenoma is visible. They recommend ESD only for lesions with a high risk of submucosal invasion, such as large depressed lesions or pseudo depressed LST-NG lesions, mucosal lesions with fibrosis, local residual early carcinoma after endoscopic resection, and non-polypoid colorectal dysplasia in patients with inflammatory bowel disease.

The 2024 update of the ESGE guidelines for colorectal polypectomy and EMR provides the most comprehensive and up-to-date recommendations for the management of large non-pedunculated colorectal polyps and complex lesions[18]. The guidelines reinforce hot EMR as the first-line treatment for most large non-pedunculated colorectal polyps ≥ 20 mm, emphasizing en bloc resection when feasible and advocating piecemeal EMR. It also introduces underwater EMR as an acceptable alternative for non-lifting or scarred lesions by experienced hands. The ESGE now recommends ESD primarily for lesions at high risk of superficial submucosal invasion, such as large depressed or pseudo-depressed LST-NG lesions, mucosal lesions with fibrosis, or local residual carcinoma after incomplete resection, provided that the procedure is performed by trained experts in high-volume centers with surgical backup. Furthermore, the guideline offers graded recommendations on EFTR, suggesting its role in non-lifting or fibrotic lesions < 30 mm, particularly in anatomically challenging sites such as the appendiceal or diverticular orifice. A significant addition in the 2024 document is the emphasis on competency-based training, peri-procedural management of antithrombotic therapy, documentation standards, and structured post-EMR/ESD surveillance intervals (3-6 months for piecemeal EMR and 12 months for ESD). Compared with the previous ESGE statements, the recent update places a stronger focus on standardization, quality indicators (e.g., en bloc resection ≥ 90%, adverse event rate < 10%), and dissemination of expertise across European centers.

To reduce recurrence, ESGE recommends thermal ablation of the margins using snare-tip soft coagulation, following piecemeal EMR. This adjunctive therapy decreased the recurrence rate to 5% from 15%-20% following piecemeal EMR. A careful assessment of residual neoplasia must be performed after EMR. If residual tissue persists, removal should be attempted using a snare or cold or hot avulsion combined with the split-thickness skin graft. Argon plasma coagulation is discouraged because of its high recurrence rate. They recommend en bloc resection techniques as the technique of choice in selected cases, such as suspected superficial invasive carcinoma, which cannot otherwise be removed en bloc by standard polypectomy or EMR. Japanese Guidelines suggest that the choice between piecemeal EMR and ESD depends on the subtype of LST, as determined by magnifying endoscopy or endoscopic ultrasound when appropriate[46]. According to the American Society of Gastrointestinal Endoscopy, ESGE, and the United States Multi-Society Task Force on Colorectal Cancer, the indications for EFTR include lesions < 30 mm, particularly non-lifting lesions or those involving the diverticulum or appendicular orifice. Complications such as perforation and bleeding require prompt endoscopic treatment to prevent further complications. The guidelines also emphasize perioperative care, management of antithrombotic drugs, assessment of curability, and structured follow-up to identify recurrences or metachronous lesions.

CONCLUSION

Colorectal lesions larger than 3 cm require a tailored and evidence-based management approach. Although EMR remains fundamental, ESD and EFTR expand treatment options for complex lesions, especially in expert centers. Importantly, these advanced endoscopic techniques align with the principles of organ preservation, offering curative treatment without the need for colectomy, thereby promoting minimally invasive and patient-centered care. Looking ahead, multicenter prospective trials with extended follow-up are necessary to confirm long-term oncological safety, assess recurrence risk, and refine the indications for EFTR and ESD. Careful patient selection and stratification remain essential, and both the ESGE and Japan Gastroenterological Endoscopy Society guidelines emphasize that colorectal ESD should be concentrated in high-volume centers with established expertise to optimize safety and outcomes. Lim et al[47] conducted a comprehensive meta-analysis and meta-regression that confirmed these disparities and demonstrated that results from Japanese centers were consistently superior to those from other regions, emphasizing how regional expertise, case selection, and institutional volume shape the reported outcomes. Emerging techniques, such as underwater EMR, cold-snare EMR, and advanced suturing, aim to improve safety and reduce the risk of recurrence. Additionally, technological innovations, such as artificial intelligence for lesion characterization and robot-assisted endoscopic platforms, hold promise for further expansion of the therapeutic frontier of endoscopic resection. As technology, training, and preventive strategies evolve, the challenge ahead will be to standardize these techniques and expand access beyond tertiary centers, ensuring equitable organ-preserving care for patients with large colorectal lesions. To ensure that organ-sparing endoscopic approaches for large colorectal lesions can be safely and widely delivered, a comprehensive ecosystem of training, simulation, and monitoring is essential. The recommended pathway starts with a structured curriculum and progresses through simulation-based skill acquisition using animal models, virtual reality, or ex vivo systems[48]. A recent study of a simulation training course with telementoring for ESD demonstrated 100% en bloc resections without perforations when trainees were supervised remotely by expert mentors via live video, underscoring the value of telesupervision in bridging geographical or resource gaps[49]. Similarly, simulation-based training (including virtual reality/augmented reality platforms) has been shown to accelerate the learning curve in gastrointestinal endoscopy, offering risk-free practices and objective performance metrics[50]. Subsequently, performance monitoring via national or regional registries and dashboards tracking en bloc/R0 rates, adverse event incidence, and learning-curve milestones permits benchmarking of low-volume centers against high-volume referral units. Together, these strategies-structured curricula, simulation (physical, virtual, or telementored), and systematic outcome monitoring - are foundational to translating advanced techniques such as ESD and EFTR beyond expert centers, ensuring both accessibility and safety. As technology and expertise evolve, the challenge is no longer how to perform advanced endoscopic resections but how to deliver them safely, equitably, and reproducibly across healthcare systems. The future of CRC prevention will depend on how effectively we transform this technical excellence into accessible, standardized care.