This study evaluates the efficacy, safety, and oncologic outcomes of colorectal Endoscopic Submucosal Dissection (ESD) at two tertiary care centers in Saudi Arabia.

We conducted a retrospective observational cohort study of patients undergoing colorectal ESD from January 2024 up to November 2025 at King Fahad Medical City and Security Forces Hospital. Inclusion criteria comprised all patients with colorectal neoplasms resected via ESD. The primary outcome was the en bloc resection rate. Secondary outcomes included R0 resection (negative lateral/vertical margins), curative resection, adverse events (bleeding, perforation), and local recurrence. Statistical analysis was performed using the R statistical programming language.

A total of 47 patients (mean age 59.5±15.6 years; 52.2% male) underwent ESD. The cohort had a moderate comorbidity burden (ASA Class II: 70.2%). Lesions were mostly located in the rectum (46.8%) and sigmoid colon (17.0%), with a mean tumor size of 37.6±17.1 mm. Preoperative imaging was performed in 60.9% of cases. The classic ESD technique was employed in 89.4% of cases, frequently using a Dual Knife (31.9%). En bloc resection was achieved in 93.6% (44/47) of patients. Histopathology revealed adenomas in 71.7% and early carcinomas (Tis/T1) in 10.9%. R0 resection was confirmed in 91.3% for lateral margins and 89.1% for deep margins. Among evaluable cases, 93.3% achieved curative resection. The safety profile was favorable, with 95.7% of patients experiencing no adverse events. Complications occurred in 4.3% (2/47), comprising one intra-procedural bleeding event managed conservatively and one delayed perforation requiring surgical intervention. Over the follow-up period, surveillance colonoscopy identified local recurrence in 6.4% (3/47) of patients.

Colorectal ESD is a safe and effective modality in Saudi tertiary care settings,

achieving high en bloc rates (93.6%) and low recurrence (6.4%) comparable to international

benchmarks, supporting broader regional implementation.