Traction-assisted versus conventional endoscopic submucosal dissection for superficial gastrointestinal neoplasms: a systematic review and meta-analysis of randomized controlled trials

Aims A promising option called traction-assisted endoscopic submucosal dissection (T-ESD) has emerged to overcome the limitations of the conventional approach (C-ESD); thus, this systematic review and meta-analysis aimed to compare the procedure time, efficacy, and safety between T-ESD and C-ESD approach to superficial gastrointestinal (GI) neoplasms.

Methods MEDLINE, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing C-ESD with T-ESD in adults with superficial GI neoplasms, reporting at least one of the outcomes of interest. The primary outcome was procedure time. Secondary outcomes were complete and en bloc resection rates, as well as bleeding and perforation rates. The risk ratio (RR) and mean difference (MD) were applied with their 95% confidence intervals (95% CIs) for dichotomous and continuous outcomes, respectively, using a random-effects model. Sensitivity analyses were performed if I²≥50%. We performed subgroup analysis considering the lesion site (colorectum vs. esophagus vs. stomach). We deemed p<0.05 statistically significant. R statistical software was used for all statistical analyses.

Results We included 14 RCTs (2,166 patients). 69.7% of the included patients were male. The mean age in each study ranged from 53.4-74.9 years. In terms of lesion site, 26.1% patients had colorectal lesions, 16.3% esophageal lesions, and 57.6% stomach lesions. T-ESD was associated with a significantly shorter procedure time (MD -15.39 minutes; 95% CI -21.93, -8.86; p<0.01; I²=76%). Regarding complete resection, T-ESD showed statistically better rates (RR 1.02; 95% CI 1.00, 1.03; p=0.04; I²=0%); however, there was no significant difference in the risk of en bloc resection (RR 1.00; 95% CI 0.99, 1.02; p=0.52; I²=50%). There was no significant difference in the risk of bleeding (RR 1.00; 95% CI 0.63, 1.59; p=1.00; I²=0%); however, the risk of perforation was statistically lower with T-ESD (RR 0.31; 95% CI 0.15, 0.67; p<0.01; I²=0%), compared to C-ESD. The leave-one-out sensitivity analyses showed that results were not dependent on individual studies. The subgroup analysis by lesion site showed that there were significant differences between the subgroups only in terms of procedure time – where the duration of T-ESD was shorter than C-ESD only for colorectal (MD -24.74 minutes; 95% CI -36.22, -13.27; p<0.01; I²=72%) and esophageal (MD -17.77 minutes; 95% CI -22.81, -12.73; p<0.01; I²=0%) lesions; while the duration of stomach lesions dissection was similar between both techniques. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14]

Conclusions Compared to C-ESD, the use of T-ESD in the approach to superficial GI neoplasms showed a shorter duration, greater efficacy in terms of complete resection, and higher safety regarding perforation. Additionally, it is important to highlight that only the dissection of stomach lesions did not demonstrate advantages in terms of procedure time with T-ESD.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

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Publication History

Article published online:
15 April 2024