To compare real-world procedural costs, resource utilization, and system-level implications of EMR versus ESD for complex colorectal polyps within a universal healthcare framework.

All consecutive patients undergoing EMR or ESD for complex colorectal polyps at St. Michael’s Hospital, Toronto, Canada, between 2019 and 2025 were included (n = 1,546; EMR = 1,364, ESD = 182). Cost analysis was conducted using institutional cost data expressed in Canadian dollars, encompassing consumables, closure devices, anesthesia, labor, hospitalization, and complication management. Endoscopist reimbursement fees were derived from the relevant billing codes within the publicly available Ontario Schedule of Benefits: Physician Services, a schedule under Regulation 552 of the Health Insurance Act.  A deterministic model using single-point estimates for both costs and effects was constructed to calculate the incremental cost-effectiveness ratio (ICER).

Procedural costs were markedly higher for ESD ($7,007) versus EMR ($1,348), driven by anesthesia ($750 vs. $14), consumables ($2376.47 vs $625.05), and greater labor time ($239 vs. $60). Closure devices were also more costly for ESD ($1,041 vs. $685). Hospital admissions occurred in 11.6% of all resections, most commonly following ESD-related perforations (n=3) or bleeding events (n=3), contributing an additional $2,600 per admission and $1,300 per inpatient day. Despite its higher cost, ESD achieved superior curative resection (93.4% vs. 91.6%) and significantly lower recurrence (3.1% vs. 9.6%, p = 0.018) compared to EMR. The estimated incremental cost per additional curative resection was approximately $89,000 per recurrence avoided. This means that, on average, for every 100 complex colorectal resections, replacing EMR with ESD would prevent 6.5 recurrences at an additional cost of $565,900, equating to $89,000 per recurrence avoided.

Within a publicly funded healthcare system, ESD confers superior long-term curative outcomes but at a procedural cost more than five times higher than EMR. Cost-effectiveness of ESD is maximized when selectively applied to high-risk rectal, non-granular, or advanced lesions harboring submucosal invasion, where en-bloc resection yields durable benefit. These findings underscore the importance of value-based remuneration frameworks that better align reimbursement with procedural complexity and outcome durability.