Endoscopic Submucosal Dissection (ESD) enables en bloc resection of large colorectal lesions [1], yet evidence on its efficacy and safety in elderly patients remains limited in Western countries, with most data originating from Asia [2-4]. The definition of “elderly” varies, although individuals aged 65 years or older are commonly included [5]. This study aimed to evaluate the efficacy and safety of colorectal ESD in patients aged ≥65 years, stratified by age group, compared with younger controls (<65 years).

This retrospective multicenter study included consecutive patients who underwent colorectal ESD across 19 European referral centers (2010–2025). Patients were grouped as <65 or ≥65 years, with elderly patients further divided into 65–74, 75–84, and ≥85 years. Demographic, endoscopic, and histologic data were collected. Primary outcomes included successful, en bloc, R0 resection, adverse events (bleeding, perforation, delayed events) rates, and need for surgery. 

A total of 3.493 ESDs were analyzed (≥65: 2.273; <65: 1.220). Overall success (89.2% vs 89.5%; p=0.81), R0 resection rates (76.6% vs 78.2%; p=0.42), and en bloc rates (89.1% vs 90.9%; p = 0.1059) were comparable between elderly and younger patients. Lesion size, fibrosis, morphology, JNET classification, lesion site, and resection time did not differ significantly. Adverse events (perforation, bleeding, delayed bleeding, delayed perforation, and other delayed events such as strictures) occurred in 9.3% of elderly patients and 8.8% of younger patients (p=0.51). Most were managed conservatively, with the need for surgery due to complications being 0.3% and 0.6% respectively (p=0.18). Within elderly subgroups, patients aged 75–84 had higher rates of perforation (OR 1.6; p=0.014) and delayed bleeding (OR 1.8; p=0.037) than those aged 65–74, while ≥85 showed no significant difference, likely due to limited sample size. Complication odds increased by 3.1% per year of age (OR 1.031; p=0.009). The need for surgery due to complications or malignancy did not differ by age (p=0.123). The distribution of submucosal invasive cancer was also similar (p=0.357).

Colorectal ESD in elderly patients is effective and curative, maintaining high en-bloc, successful, and R0 resection rates. While age independently increases the risk of procedural complications, most events were endoscopically manageable, resulting in low surgical conversion rates. These findings, derived from one of the largest Western elderly ESD cohorts, confirm and expand prior Asian data, supporting the use of ESD as a curative, minimally invasive option in selected elderly patients, with appropriate risk stratification. Future studies incorporating comorbidity and frailty are warranted to refine patient selection beyond biological age.