Operative, safety and economic outcomes of endoscopic submucosal dissection in older adults: a retrospective real-world analysis

BACKGROUND: Endoscopic submucosal dissection (ESD) is a cornerstone organ-preserving treatment for colorectal neoplasia; however, the impact of advanced age on procedural efficiency, safety, and economic burden remains controversial. This study aimed to comprehensively evaluate these outcomes in older adults within a real-world clinical setting. METHODS: We retrospectively reviewed 255 patients who underwent colorectal ESD between January 2022 and December 2023. Patients were divided into elderly (≥ 65 years, n = 119) and non-elderly (< 65 years, n = 136) groups. Operative outcomes (resection and wound-management speeds), safety (delayed bleeding and perforation), and economic metrics (hospital stay and costs) were evaluated. Multivariable regression, age-stratified models, and 1:1 propensity score matching (PSM) were utilized to rigorously adjust for baseline confounders. RESULTS: Elderly patients presented with significantly larger and morphologically more complex lesions. Nevertheless, multivariable analyses demonstrated no significant independent association between age and resection speed or wound-management speed, which was fully supported by subsequent PSM and restricted cubic spline (RCS) analyses. Complication rates were extremely low (2.0% for bleeding, 0.8% for perforation) with no descriptive differences between groups. Although initial regression models suggested a slight age-related increase in hospital costs and length of stay, these economic disparities were attenuated and lost significance after applying PSM to balance clinical drivers such as ASA physical status and anesthesia methods (matched hospital costs: 11.39k vs. 10.57k RMB, p = 0.249; identical median stay: 4 vs. 4 days). CONCLUSIONS: Appropriately selected elderly patients achieve operative and safety outcomes comparable to younger individuals during colorectal ESD. The initial economic variances observed are likely driven by underlying comorbidities and anesthetic requirements rather than chronological age itself. Clinical decisions should prioritize comprehensive, patient-centered assessments over strict age cutoffs.