Endoscopic submucosal dissection (ESD) has revolutionized the management of superficial colorectal neoplasms, offering superior en bloc resection rates compared with conventional endoscopic mucosal resection (EMR). While ESD has been the standard of care in East Asian countries for over two decades, its adoption in Western countries has been considerably slower, hampered by the steep learning curve, prolonged procedural times, limited training infrastructure, and differences in disease epidemiology. However, recent years have witnessed a paradigm shift, with growing evidence from Western multicenter studies demonstrating outcomes that increasingly approach those reported from high-volume Eastern centers. The landmark RESECT-COLON randomized trial provided level-1 evidence supporting the superiority of ESD over piecemeal EMR for large colorectal polyps. Concurrently, novel training paradigms, technological innovations including traction-assisted devices and artificial intelligence (AI)-guided systems, and evolving societal guidelines from the American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), and European Society of Gastrointestinal Endoscopy (ESGE) are accelerating Western adoption. This state-of-the-art review comprehensively examines the current landscape of colorectal ESD in Western practice, highlighting the evolution of outcomes, training pathways, guideline recommendations, technological advances, and future directions. We provide a critical appraisal of the East–West outcome gap and discuss strategies to bridge this divide, positioning colorectal ESD as an increasingly viable first-line therapy for appropriate lesions in Western endoscopy centers.

Malignant biliary obstruction (MBO) represents a critical clinical challenge characterized by bile duct compromise leading to severe complications including intractable jaundice, recurrent cholangitis, biliary cirrhosis, and hepatic failure. Classification into distal MBO (DMBO) and hilar MBO (HMBO) guides therapeutic decision-making, with the former predominantly caused by pancreatic head adenocarcinoma and extrahepatic cholangiocarcinoma, while perihilar cholangiocarcinoma represents the principal etiology of the latter. The high morbidity and mortality associated with MBO necessitate prompt, expert intervention. While endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary biliary drainage (TBD) has traditionally served as the cornerstone of management for unresectable tumors, endoscopic ultrasound (EUS)-guided biliary drainage has emerged as a compelling alternative, particularly when conventional ERCP proves technically unsuccessful or anatomically unfeasible. This review comprehensively examines current endoscopic strategies for MBO, emphasizing the complementary roles of ERCP and EUS-based techniques. Optimal outcomes require intervention by experienced endoscopists at high-volume tertiary centers, with individualized treatment selection based on anatomical considerations, tumor characteristics, patient factors, and local expertise.