Neoplastic recurrence after colorectal endoscopic submucosal dissection at scheduled endoscopic surveillance: a systematic review and meta-analysis

Background: Neoplastic recurrence risk at scheduled surveillance intervals after colorectal endoscopic submucosal dissection (ESD), as well as its association with histologic risk features, is unclear, resulting in uncertainty for post-ESD surveillance recommendations. We conducted a systematic review and meta-analysis of 1-, 3-, and 5-year post-ESD neoplastic recurrence with subgroup analyses. Method: A systematic search was performed up until October 2025. Eligible studies were assessed for neoplastic recurrence at or near the resection site at 1-, 3-, and 5-year scheduled surveillance colonoscopies. Rates of metachronous neoplastic lesions at the same time-intervals were also collected. Data were pooled using a random-effects model, and subgroup analyses were conducted for histology of the index lesion (low or high grade dysplasia, and T1 cancer) and resection quality (R0 vs. non-R0). Results: 10 studies encompassing 5306 lesions met the inclusion criteria. The pooled R0 resection rate was 82% (95%CI 79%-85%). Overall neoplastic recurrence rates were low and stable over time: 1.2% (95%CI 0.4%-2.6%), 1.4% (95%CI 1.0%-1.9%), and 1.9% (95%CI 0.9%-3.1%) at 1, 3, and 5 years, respectively. Malignant recurrence was rare (0.2%) and confined to noncurative resections or deep submucosal invasion. The pooled rate of metachronous lesions was 1.4% (95%CI 0.4%-3.0%). Limited time-stratified data suggest progressive accrual of metachronous neoplasia during follow-up rather than early post-ESD failure. Conclusions: Neoplastic recurrence is rare up to the 5-year endoscopic surveillance, especially in those with R0 resection and favorable histology. In low risk patients, an extended surveillance interval of up to 5 years can be considered, mostly because of an increased risk of metachronous lesions.