Clinical impact and environmental footprint of diagnostic endoscopic dissection versus first line surgery for colorectal lesions harboring focal deep invasive pattern

Aims Endoscopic submucosal dissection (ESD) can achieve curative resection for T1 colorectal cancers fulfilling low-risk histological criteria. However, optical diagnosis does not always accurately predict submucosal invasion depth, and lesions with focal deep invasive patterns (FDIP) are often referred directly to surgery. A first-line diagnostic ESD strategy, performing en bloc resection in these lesions to obtain definitive histopathology before deciding on surgery, may represent a safe and cost-effective alternative. This study compared the clinical, environmental, and economic impact of diagnostic ESD versus upfront surgery for FDIP lesions [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]. Methods This prospective multicenter study included patients with colorectal FDIP lesions (Connect IIC+/III, Kudo Vn or Sano IIIb;<10 mm in the colon or<20 mm in the rectum) from the FECCO database. We excluded patients with lesions without invasive patterns, ulcerated (Paris III) lesions, and with distant metastases, or stenosis. 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 other risk factors). Independent predictors of curative resection were identified by multivariable logistic regression. Carbon footprint (CO₂e) and economic analyses were based on life-cycle data for ESD, surgery, and hospitalization. Results Between January 2024 and May 2025, 190 patients (16 centers) underwent diagnostic ESD. Curative resection was achieved in 43% (n=86) of cases. In 16% (n=31) of cases the resection was considered at intermediate (expanded curative resection), and after multidisciplinary discussion only 6 patients underwent surgery. Seventy-three per cent (n=73) were considered at high risk (non-curative resection) and surgery was recommended. Overall, 107 patients (56%) avoided surgery and continued with endoscopic surveillance. CONNECT III classification (OR 0.42, 95% CI 0.18–0.98) and presence of retraction sign (OR 0.48, 95% CI 0.23–0.99) were independent negative predictors of curative resection. Compared with systematic upfront surgery, the diagnostic ESD strategy resulted in lower carbon emissions (222.2 vs 240.2 kg CO₂e per patient), reduced hospital stay (0.98 vs 3.5 days), and lower overall cost (€7,930 vs €12,960 per patient). Conclusions A diagnostic ESD-first strategy for FDIP colorectal lesions enables definitive staging while reducing the need for surgery, environmental impact, and healthcare costs, supporting its use as a sustainable alternative to upfront surgery in selected patients. Publication History Article published online: 05 June 2026 © 2026. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany