Large non-pedunculated colonic polyps (≥ 20 mm) can be resected either by piecemeal endoscopic mucosal resection (pEMR) or endoscopic submucosal dissection (ESD). Macroscopic assessment of flat polyps for invasive cancer often has limited sensitivity, especially in borderline lesions. A universal ESD strategy in the colon offers high en bloc, and R0 resection rates with low recurrence rates. In contrast to pEMR, curative ESD obviates the need for endoscopic surveillance for benign lesions and surgical completion therapy for low-risk malignant polyps. On the other hand,  colorectal ESD is associated with higher complication rates and longer procedure times. This study aimed to perform a clinical and economic evaluation of a universal ESD strategy for non-pedunculated colonic polyps ≥ 20 mm at a tertiary referral center.

In a universal ESD approach, all non-pedunculated colonic polyps ≥ 20 mm resected between March and October 2025 were treated by ESD. All procedure- and hospital-related costs (materials, staff, length of stay, complications, surveillance colonoscopies, and additional treatments) were recorded and compared using propensity score matching with a historical pEMR cohort from previous years.

Forty patients with non-pedunculated colonic polyps ≥ 20 mm (range 22–112 mm) were treated within the universal ESD strategy. Lesions were located in the caecum (n=6), ascending colon (n=9), transverse colon (n=9), descending colon (n=2), and sigmoid colon (n=14). En bloc and R0 resection rates were 100% and 97.5%, respectively. Histology revealed 10 LGD, 24 HGD, five early cancers with low-risk features, and one cancer with high-risk features (L1, positive vertical margin). The overall complication rate was 2.5% (n=1; post-polypectomy syndrome). Mean procedure time was 113 minutes (range 43–430). In the initial cost analysis of the first 10 patients , immediate ESD costs were higher than those of pEMR (2,059.6 € vs. 1,469.2 €; Δ = +590.4 €). However, mandatory surveillance colonoscopies in the pEMR group generated additional costs of 886.4 €, resulting in higher 24‑month total costs for pEMR compared to ESD (2,355.6 € vs. 2,059.6 €; Δ = –296.0 €). Analysis of the full cohort is still ongoing. Potential costs which would be generated by additional surgery were not part of this evaluation but should also be taken into consideration.

This single-center analysis of a universal ESD strategy for non-pedunculated colonic polyps ≥ 20 mm demonstrates excellent clinical outcomes. The exploratory health-economic evaluation and the propensity score–based comparison with a historical pEMR cohort suggest that, due to required surveillance procedures, pEMR becomes more expensive than ESD over time. Final cost-effectiveness results, including avoided surgical treatment, are pending.