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.

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.

Background: Biliary tract cancers (BTCs) carry a poor prognosis driven by frequent diagnosis at advanced or metastatic stages. Inadequate tissue sampling impedes biomarker-directed selection of therapy that could potentially improve outcomes over limited chemotherapeutic options. Plasma cell-free DNA (cfDNA) yields limited sensitivity. However, given its direct contact with the tumor, bile holds promise as a locally enriched source of tumor-derived cfDNA for evaluation. Methods: Following the PRISMA-ScR guidelines, we searched PubMed/MEDLINE and EMBASE without date restrictions. Seventeen primary studies of bile cfDNA in cholangiocarcinoma (CCA), gallbladder carcinoma (GBC), pancreatic ductal adenocarcinoma (PDAC), and primary sclerosing cholangitis (PSC) were synthesized narratively. Results: Compared to plasma cfDNA, Bile cfDNA was isolated at higher concentrations and in longer fragments than plasma cfDNA; bile cfDNA demonstrated higher concordance with matched tumor tissue, capturing more actionable alterations. Pairing it with serum CA19-9 or newer bile-derived markers improved performance. Emerging data suggest a role in early detection of CCA during PSC surveillance. Conclusions: Bile cfDNA as a liquid biopsy medium offers analytic advantages over plasma for detecting and profiling biliary malignancy. Standardized collection, extraction, and reporting protocols and prospective multicenter validation are needed before routine use.