Emerging endoscopic resection strategies for organ preservation in early colorectal cancer

The management of early colorectal cancer (CRC) is increasingly debated among gastroenterologists and colorectal surgeons, driven by advances in endoscopic resection that enable curative organ-preserving treatment. Conventional endoscopic mucosal resection (EMR) remains the first-line small-to-moderate sized superficial lesions, although its application is limited for larger or fibrotic polyps, because of piecemeal resection and higher recurrence rates. Modified EMR techniques, including anchoring, precutting, and underwater EMR, are widely available and achieve superior technical outcomes without compromising safety, thus broadening the indications for endoscopic resection of low-risk neoplastic lesions. Endoscopic submucosal dissection (ESD) allows en bloc resection regardless of lesion size, and provides accurate histopathological evaluation even when curative criteria are not met, though its use is constrained by its technical complexity and limited availability. For rectal lesions exhibiting features suggestive of deep submucosal invasion, endoscopic intermuscular dissection may serve as an effective endoscopic therapeutic option, as it extends the resection plane into the intermuscular space, achieving clear vertical margins while facilitating organ preservation. Endoscopic full-thickness resection, alone or combined with EMR/ESD, addresses non-lifting, fibrotic or anatomically challenging lesions throughout the colon. Together, these modalities have reshaped the therapeutic landscape of endoscopy, allowing curative and organ-sparing management of early CRCs. This review summarizes organ-preserving endoscopic approaches for early CRC, and proposes a practical algorithm for technique selection while identifying key evidence gaps and future directions.