Endoscopic Submucosal Dissection for Early Colorectal Carcinoma with High-risk Criteria: Long-term Follow-up from the German Multicenter Registry.

Background and Study Aim Endoscopic submucosal dissection (ESD) is recommended for selected colorectal lesions, especially those with superficial submucosal invasion, enabling en-bloc resection and accurate histopathologic assessment. However, the management of high-risk lesions following ESD, especially regarding additional surgery versus surveillance, remains debated. This study evaluated outcomes after ESD for pT1 colorectal carcinoma, comparing surgical versus conservative management. Patients/Materials and Methods This retrospective multicenter study included 92 patients with pT1 colorectal carcinoma treated by ESD at 14 German referral centers (January 2017-December 2020). Patients were classified as low-risk ( n = 34) or high-risk ( n = 58) based on histopathologic criteria. Long-term outcomes were compared between low- and high-risk patients, as well as between high-risk patients undergoing additional surgery versus conservative management. Results The overall three-year disease-free survival was 82.6%, without a significant difference between the low-risk (88.2%) and high-risk groups (79.3%; p = 0.276). Among high-risk patients, 56.9% received additional surgery and 43.1% were managed conservatively. Recurrences occurred exclusively in the high-risk group (5.2%). The R0 resection rate after ESD was higher in patients managed without additional surgery than in those who subsequently underwent surgery (76.0% vs. 45.5%; p = 0.019). Conclusion ESD is effective for curative management of selected early colorectal cancers (pT1), particularly in low-risk cases. In high-risk patients, surgery remains the standard, with no recurrences observed after additional surgery in our cohort. A substantial proportion of high-risk patients did not undergo surgery in clinical practice and showed a recurrence rate of 12% (3/25). These findings support current recommendations while reflecting real-world treatment patterns.