Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract

Background and study aims: Endoscopic submucosal dissection (ESD) has been developed to overcome the limitations of endoscopic mucosal resection (EMR). We aimed to compare the outcomes of these two methods. Methods: Databases, including Pubmed, EMBASE, and The Cochrane Library, were searched to identify studies comparing ESD with EMR for premalignant and malignant lesions of the gastrointestinal tract. In a meta-analysis, primary end points were the en bloc resection rate and the Curative resection rate; secondary end points were operation time, and rates of bleeding, perforation, and local recurrence. Results: 15 nonrandomized studies (seven full-text and eight abstracts) were identified. Meta-analysis showed higher en bloc and curative resection rates (odds ratio [OR] 13.87, 95%Cl 10.12-18.99: OR 3.53, 95%CI 2.57-4.84) irrespective of lesion size. Subgroup analysis showed higher en bloc and curative resection rates with ESD for esophageal, gastric, and colorectal neoplasms, and for lesions of size < 10 mm, 10 mm < 20 mm, and > 20 mm. Local recurrence was lower with ESD (OR 0.09, 95%Cl 0.04 - 0.118). But ESD was more time-consuming than EMR (weighted mean difference [WMD] 1.76; 95%Cl 0.60 - 2.92), and showed high procedure-related bleeding and perforation rates (OR 2.20, 95%Cl 1.58 - 3.07; OR 4.09, 95 %CI 2.47 - 6.80). Conclusions: ESD showed better en bloc and curative resection rates and local recurrence compared with EMR, but was more time-consuming and had higher rates of bleeding and perforation complications. These results need to be confirmed by high quality trials and further studies in the west.