Colorectal ESD from basics to latest innovations!

Colorectal endoscopic submucosal dissection (ESD) is gaining adoption in Western practice because it outperforms endoscopic mucosal resection (EMR), with higher en bloc and R0 resection rates, lower local recurrence, and less need for surgery. Its main limitation is technical: colorectal ESD is long, complex, and complication-prone. Multiple recent advances aim to improve reproducibility and safety, including new dissection strategies (pocket-creation, tunneling, underwater ESD), traction systems (clip-band, adaptive and magnetic traction), advanced knives (a novel thin-needle knife with high-pressure waterjet) and closure platforms (reopenable clip with anchor prongs, through-the-scope helix tack-and-suture system and endoscopic hand suturing), stabilizing platforms, and robotic and AI assistance. Safe ESD still depends on fundamental skills: tip control, stable incision and trimming, efficient submucosal dissection, and immediate control of bleeding and perforation. This review aims to summarize current technical solutions, identify persistent limitations, and define priorities for training, case selection, cost-effectiveness, and environmental impact in Western practice.