Abstract
Background and study aims Colorectal endoscopic submucosal dissection (ESD) is increasingly used for treating early-stage colorectal cancer, including large, protruded lesions (LPL). However, the challenges posed by LPLs, especially those accompanied by severe fibrosis or muscle-retracting sign (MRS), remain unclear. This study aims to investigate ESD outcomes for LPL, focusing on factors such as tumor size and, submucosal fibrosis. Patients and methods In a multicenter retrospective study (June 2012 to May 2023), data from 526 patients with 542 LPL lesions (≥ 2 cm) were analyzed. Parameters included lesion size, procedure time, dissection speed, physician experience, submucosal fibrosis, and adverse events. The tunnel method, including the double tunnel method, was used for cases with severe fibrosis or MRS. Multivariate analysis assessed factors affecting procedure difficulty, particularly LPLs ≥ 4 cm. Results The study revealed an impressive en bloc resection rate of 97.8% and a curative resection rate of 78.6% for LPLs. Notably, fibrosis and MRS were present in 25% and 18% of 4-cm LPLs, respectively, and their frequency tended to increase as the tumor diameter increased. One treatment strategy for LPLs was the tunneling method, which was used most frequently (41 cases, 7.6%). Factors affecting dissection speed included larger tumor size, submucosal fibrosis, MRS, and physician experience. Conclusions Treating LPLs through colorectal ESD presents significant challenges, especially in patients with fibrosis and MRS. This study highlights the importance of recognizing these complexities, and that more reliable resection strategy must be established for accurate pathological evaluation.