Colorectal ESD Perforation: Endoscopy | July 2026

Introduction:

Endoscopic submucosal dissection (ESD) enables en bloc resection of large colorectal neoplasms with excellent oncological outcomes. However, concerns about perforation have limited its widespread adoption. This large prospective multicenter study evaluated the incidence, risk factors, and clinical outcomes of colorectal ESD-related perforations.

Why was this study needed?

• Perforation is the most feared complication of colorectal ESD.
• Real-world Western data on perforation outcomes are limited.
• Predictors of perforation and need for surgery remain poorly defined.
• Better risk stratification can improve patient counseling and procedural planning.
• Understanding delayed perforation is essential for post-ESD surveillance.

Results:

• More than 90% of ESD-related perforations were successfully managed conservatively, particularly intraprocedural perforations, avoiding surgery in most patients.
• Delayed perforation was uncommon but carried a high likelihood of emergency surgery, making early recognition and close post-procedure monitoring critical.
• Large lesions, severe fibrosis, previous resection, poor endoscope maneuverability, and proximal colonic location significantly increased the risk of perforation.

Clinical Impact:

These findings reassure endoscopists that most intraprocedural perforations can be safely managed endoscopically without surgery. However, delayed perforation remains a serious complication requiring prompt diagnosis and surgical evaluation. Careful patient selection and recognition of high-risk lesions are essential to optimize ESD outcomes.

Bottom Line:

Colorectal ESD perforation is usually manageable without surgery, but delayed perforation remains the major clinical challenge. Patients with large, fibrotic, previously treated, or proximal colonic lesions require heightened procedural caution and close post-procedure surveillance.