Comparative efficacy of different techniques for colonic endoscopic submucosal dissection: A network meta-analysis of randomized controlled trials

Background

Endoscopic submucosal dissection (ESD) is an advanced technique that can provide successful ‘en-bloc’ and R0 resection rate for large gastrointestinal lesions. To date, several ESD techniques have been proposed, but their comparative efficacy is still unclear.

Methods

Major databases were systematically searched for RCTs comparing the efficacy and safety of different ESD techniques for the resection of colonic lesions. The primary outcomes were ‘en-bloc’ and R0 resection rates. The secondary outcome was the incidence of procedure-related AEs.

Results

After selection of studies, 9 RCTs were included in the systematic review.

On network meta-analysis for ‘en-bloc’ resection, pocked with traction ESD (PT-ESD) (RR=1.02; 95%CI=0.96–1.07) and pocket ESD (P-ESD) (RR=1.02; 95%CI=0.98–1.05) showed higher efficacy, whereas hybrid ESD (H-ESD) (RR=0.94; 95%CI=0.87–1.02) lower efficacy compared to conventional ESD (C-ESD).

With regard to R0 resection, PT-ESD (RR=1.05; 95%CI=0.96–1.16) showed higher efficacy, and H-ESD (RR=0.97; 95%CI=0.84–1.13) lower efficacy compared to C-ESD.

Concerning safety PT-ESD (RR=0.35; 95%CI=0.05–2.48) was associated with lower incidence of AEs, and H-ESD (RR=1.22; 95%CI=0.30–5.01) with higher incidence of AEs, compared to C-ESD.

Conclusions

The results of this network meta-analysis show a trend towards greater effectiveness and safety of PT-ESD for the removal of colonic lesions. H-ESD was associated with worse results and should be reserved as a rescue treatment, preferring other techniques.