Clinical and environmental impact of diagnostic endoscopic dissection strategy versus first-line surgery for colorectal lesions with focal deep invasion

BACKGROUND: Endoscopic submucosal dissection (ESD) can achieve curative resection for selected T1 colorectal cancers, but optical diagnosis poorly predicts invasion depth. Consequently, focal deep invasive pattern (FDIP) lesions are often referred to surgery. A diagnostic endoscopic dissection approach may represent a cost-effective alternative. We evaluated the clinical impact of a diagnostic endoscopic dissection strategy and modeled its environmental and economic impact versus upfront surgery. METHODS: This multicenter study included patients with colorectal FDIP undergoing endoscopic dissection (ESD and intermuscular dissection for rectal lesions when appropriate). Surgery was recommended for high-risk lesions (>T1 or T1 with lymphovascular invasion, high-grade budding, or poor differentiation) and discussed for intermediate-risk cases (>1000 µm invasion without additional risk factors). Carbon and cost analyses were based on life-cycle data. RESULTS: Between January 2024 and May 2025, 190 patients underwent diagnostic endoscopic dissection. Low-risk histology was observed in 86/190 patients. Intermediate-risk resections were observed in 31/190 patients, while 73/190 were classified as high-risk resections. Overall, 109 patients (57%) avoided surgery. Compared with modeled upfront surgery, diagnostic endoscopic dissection was associated with lower carbon emissions (222.2 vs 240.2 kgCO₂e per patient), shorter hospital stay, and reduced overall costs (€7,930 vs €12,960 per patient). CONCLUSION: A diagnostic endoscopic dissection first strategy enables accurate staging while reducing surgery, environmental impact, and healthcare costs.