Neoplastic recurrence after colorectal endoscopic submucosal dissection at scheduled endoscopic surveillance: A systematic review and meta-analysis

Background Neoplastic recurrence after colorectal Endoscopic Submucosal Dissection (ESD) at scheduled surveillance intervals, as well as its association with histological risk features, is unclear, resulting in uncertainty on post-ESD surveillance recommendations. We conducted a systematic review and meta-analysis on 1-, 3-, and 5-year post-ESD neoplastic recurrence with subgroup analyses. Methods A systematic search was performed through October 2025. Eligible studies of neoplastic recurrence at or near 1, 3, and 5 year-scheduled surveillance colonoscopies. Rates of metachronous neoplastic lesions at the same time-intervals were also collected. Data were pooled using a random-effects model, and subgroup analyses were conducted for histology of the index lesion (low-or high-grade dysplasia and T1 cancer) and resection quality (R0 vs. non-R0). Results Ten studies encompassing 5,306 lesions met the inclusion criteria. The pooled R0 resection rate was 82% (95% CI, 79%-85%). Overall neoplastic recurrence rates were low and stable over time: 1.2% (95% CI 0.4%-2.6%, I2=87.7%, τ²=0.0033), 1.4% (95% CI 1%-1.9%, I2=0%, τ²=0, and 1.9% at 5 years (95% CI 0.9% - 3.1%, I2=84.8%, τ²=0.0028). Malignant recurrence was rare (0.2%) and confined to non-curative resections or deep submucosal invasion. The pooled rate of metachronous lesions was 1.4% (95% CI, 0.4%-3.0%). Limited time-stratified data suggest progressive accrual of metachronous neoplasia over follow-up rather than early post-ESD failure. Conclusions Neoplastic recurrence is rare up to 5-year endoscopic surveillance, especially in those with R0 resection and favorable histology. In low-risk patients, an extended 3-5-year surveillance interval should be considered, mostly based on an increased risk of metachronous lesions.