Endoscopic submucosal dissection: Challenges, innovations, and the road ahead

Endoscopic submucosal dissection (ESD) offers a curative, organ-preserving approach for early-stage gastrointestinal tumors, yet its global adoption remains inconsistent. This review examined the multifaceted challenges hindering wider use of ESD, including the steep technical learning curve, variability in training access, procedural time demands, and risk of complications. We explored recent innovations aimed at improving procedural outcomes and reducing operator dependency, such as enhanced dissection tools, traction techniques, and digital training platforms. In addition, emerging technologies, such as artificial intelligence, robotics, and image-guided systems, are reshaping the procedural landscape and may help streamline both decision-making and execution. Looking forward, addressing the current limitations of ESD will require technical refinement as well as broader investment in training infrastructure and system-level support. This article outlined key areas for development and provided a forward-looking perspective on how ESD may evolve into a more accessible and standardized therapeutic modality.