A Systematic Review Showing the Comparative Efficacy and Safety of Endoscopic Submucosal Dissection Versus Endoscopic Mucosal Resection in the Management of Colorectal Neoplasia

Colorectal neoplasia contributes substantially to the global burden of disease, and selecting the most appropriate endoscopic treatment is essential to reduce recurrence and avoid surgery. This systematic review focused exclusively on direct comparisons of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for colorectal neoplasia while excluding non-colorectal lesions, single-arm studies, rectal neuroendocrine tumors, and other non-comparable interventions (studies without direct EMR versus ESD comparison). A systematic search of PubMed, Embase, and Scopus from inception to June 2025 was performed in accordance with the PRISMA guidelines. Six reviewers independently screened studies, and 17 comparative studies involving 3790 lesions were included. Data were extracted for tumor size, procedure time, en bloc resection, complete RO resection, recurrence, and major complications, including perforation and delayed bleeding. Risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2 (RoB 2) tool for randomized trials. Across included studies, ESD was used for larger lesions, required longer procedure times, and achieved higher en bloc and R0 resection rates than EMR. ESD also demonstrated lower recurrence, whereas perforation and delayed bleeding were generally more frequent after ESD. EMR remained faster and was associated with a lower perforation risk, particularly in smaller and less complex lesions. Overall, ESD provides superior oncologic resection quality and lower recurrence but at the cost of greater technical burden and a higher complication profile.