Large colorectal lesions: Expanding the boundaries of endoscopic management

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.