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Colorectal stenosis after ESD is common but treatable endoscopically

The multicenter study analyzed data from 315 patients over a 6-year period.

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A new international study has shown that while the risk of narrowing of the colon or rectum (stenosis) is high after endoscopic removal of nearly fully circumferential colorectal lesions, the complication can be safely and effectively treated without surgery.
 
For the study, published in Gastrointestinal Endoscopy, first author Sandro Sferrazza, MD, of the Gastroenterology and Endoscopy Unit at ARNAS Civico-Di Cristina-Benfratelli, in Palermo, Italy, and colleagues analyzed data from 315 patients across 29 tertiary centers worldwide who underwent endoscopic submucosal dissection (ESD) for colorectal lesions involving 90% or more of the bowel circumference between June 2018 and September 2024.
 
“While ESD is increasingly used for very large and complex lesions, data on outcomes when ≥90% of the luminal circumference is resected — especially outside Japan — have been scarce and fragmented,” Dr. Sferrazza told GI & Hepatology News.
 
For the current analysis, 85% of the lesions studied were in the rectum, and the median lesion size was 95 mm, with 37% involving the entire circumference. Overall, the ESD procedure proved highly successful. Most patients had en bloc resection (removal in a single piece, 85%), complete tumor removal with clear margins (RO, 82%), and curative outcomes (80%). Only 9% of patients were referred for surgery.
 
However, post-procedure stenosis was common, occurring in 34% of cases. Risk was highest in rectal lesions, where nearly 4 in 10 patients developed narrowing, compared with about 1 in 10 for colonic lesions. Multivariable analysis confirmed that rectal location, complete circumferential resection, and larger lesion size were independent predictors of stenosis.
 
Importantly, all cases of stenosis were successfully treated with endoscopic interventions, restoring normal bowel function and avoiding the need for surgical correction.
 
Dr. Sferrazza characterized two findings as particularly striking. First, maintaining even a narrow band of healthy mucosa offers a strong protective effect. “Complete (100%) circumferential resection was independently associated with stenosis, suggesting that avoiding full circumferential resection whenever oncologically feasible may significantly reduce risk,” he said. “Second, despite a relatively high stenosis rate—especially in rectal lesions—all strictures were successfully treated endoscopically, with complete symptom resolution and no need for surgery. This reinforces the concept that stenosis, while frequent, is not necessarily a treatment failure if managed within an experienced endoscopic setting.”
 
According to Dr. Sferrazza, the results “support a more nuanced, anatomy-preserving approach to circumferential colorectal ESD,” he said. “When dealing with lesions involving 90–99% of the circumference, endoscopists should actively aim to preserve a small mucosal bridge if oncologically safe. In addition, the data provide reassurance that circumferential ESD — particularly in expert centers — remains a valid alternative to surgery, even in the rectum, as post-ESD stenosis can be anticipated, monitored, and managed endoscopically with high success rates.”
 
He acknowledged certain limitations of the study, including the fact that the role of prophylactic strategies such as steroid injection, topical or systemic therapies, or early dilation “could not be definitively assessed due to their heterogeneous and limited use,” he said. “Prospective, standardized studies are needed to evaluate whether and how these measures can truly reduce stenosis risk.”

Dr. Sferrazza reported having no relevant disclosures.

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