Objectives. Endoscopic submucosal dissection (ESD) is an effective method for en bloc removal of large colorectal tumors in Japan, but this technique is not yet widely established in western countries. The purpose here was to report the experience of implementing colorectal ESD in Sweden. Methods. Twenty-nine patients with primarily nonmalignant and early colorectal neoplasms considered to be too difficult to remove en bloc with EMR underwent ESD. Five cases of invasive cancer underwent ESD due to high comorbidity excluding surgical intervention or as an unexpected finding. Results. The median age of the patients was 74 years. The median tumor size was 26？mm (range 11–89？mm). The median procedure time was 142？min (range 57–291？min). En bloc resection rate was 72% and the R0 resection rate was 69%. Two perforations occurred amounting to a perforation rate of 6.9%. Both patients with perforation could be managed conservatively. One bleeding occurred during ESD but no postoperative bleeding was observed. Conclusion. Our data confirms that ESD is an effective method for en bloc resection of large colorectal adenomas and early cancers. This study demonstrates that implementation of colorectal ESD is feasible in Sweden after proper training, careful patient selection, and standardization of the ESD procedure. 1. Introduction Colorectal cancer is one of the most frequent malignancies in the world and is the third leading cause of cancer-related death in Sweden. Neoplastic polyps (adenoma) are considered to be precursors of cancers in the colon and rectum. Stalked polyps can easily be removed by use of snare polypectomy. Sessile and flat adenomas can be eliminated efficiently using endoscopic mucosal resection (EMR) [1]. EMR is a relatively widespread and standardized method in western countries, but one problem is that large (>2？cm) sessile and flat adenomas are difficult to remove in one piece (“en bloc”) with EMR, and the endoscopist is usually forced to eliminate such tumors in multiple pieces (“piecemeal resection”). One disadvantage with fragmented polyps is that piecemeal resection makes it difficult for the pathologist to determine depth of invasion, lymphovascular infiltration, and lateral spread of the tumors in order to ensure radical removal. Uncertain radicality after EMR is a common reason for recommending surgical resection. Another disadvantage with piecemeal resection is that the rate of tumor recurrence is higher than that after en bloc resection [2, 3]. In order to avoid these problems associated with EMR, a new method referred to as
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