Endoscopic submucosal dissection (ESD) offers compelling insights into managing T1 colorectal cancer (CRC), shaping surgical strategies.

• Of 383 T1 CRC patients, 3.6% had recurrences and 1.8% died in the high-risk group; none occurred in low-risk patients.
• In high-risk cases, local recurrence was 6.8% without surgery versus 0% with surgery (p < .001).

Consider ESD alone for low-risk T1 CRC, but opt for additional surgery in high-risk patients to minimize local recurrence.

• Five-year overall survival was significantly better with surgery (95.2%) compared to follow-up (79.7%) in high-risk patients (p < .001).