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

 

 Buy Article Permissions and Reprints

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 %CI 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 %CI 0.04 – 0.18). But ESD was more time-consuming than EMR (weighted mean difference [WMD] 1.76; 95 %CI 0.60 – 2.92), and showed high procedure-related bleeding and perforation rates (OR 2.20, 95 %CI 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.

References

• 1 Larghi A, Waxman I. State of the art on endoscopic mucosal resection and endoscopic submucosal dissection.  Gastrointest Endosc Clin N Am. 2007;  17 441-469
  PubMedSearch in Google Scholar
• 2 Kantsevoy S V, Adler D G. ASGE Technology Committee, . Endoscopic mucosal resection and endoscopic submucosal dissection.  Gastrointest Endosc. 2008;  68 11-18
  CrossrefPubMedSearch in Google Scholar
• 3 Ishihara R, Iishi H, Uedo N. et al . Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan.  Gastrointest Endosc. 2008;  68 1066-1072
  CrossrefPubMedSearch in Google Scholar
• 4 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
  CrossrefPubMedSearch in Google Scholar
• 5 Hirasaki S, Tanimizu M, Moriwaki T. et al . Efficacy of clinical pathway for the management of mucosal gastric carcinoma treated with endoscopic submucosal dissection using an insulated-tip diathermic knife.  Intern Med. 2004;  43 1120-1125
  CrossrefPubMedSearch in Google Scholar
• 6 Yamamoto H, Kawata H, Sunada K. et al . Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate.  Gastrointest Endosc. 2002;  56 507-512
  CrossrefPubMedSearch in Google Scholar
• 7 Deeks J J, Dannes J, D’Amico R. et al . Evaluating non-randomised intervention studies.  Health Technol Assess. 2003;  27 23-42
  PubMedSearch in Google Scholar
• 8 Oda I, Saito D, Tada M. et al . A multicenter retrospective study of endoscopic resection for early gastric cancer.  Gastric Cancer. 2006;  9 262-270
  CrossrefPubMedSearch in Google Scholar
• 9 Odashima M, Otaka M, Jin M. et al . Improved curative resection rates of early gastric cancers by endoscopic mucosal resection (EMR) using endoscopic submucosal dissection method (ESD).  Gastrointest Endosc. 2006;  63 AB187
  PubMedSearch in Google Scholar
• 10 Oka S, Tanaka S, Kaneko I. et al . Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer.  Gastrointest Endosc. 2006;  64 877-883
  CrossrefPubMedSearch in Google Scholar
• 11 Shimura T, Sasaki M, Kataoka H. et al . Advantages of endoscopic submucosal dissection over conventional endoscopic mucosal resection.  J Gastroenterol Hepatol. 2007;  22 821-826
  CrossrefPubMedSearch in Google Scholar
• 12 Watanabe K, Ogata S, Kawazoe S. et al . Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection.  Gastrointest Endosc. 2006;  63 776-782
  CrossrefPubMedSearch in Google Scholar
• 13 Hoteya S, Iizuka T, Hashimoto M. et al . The safety and efficacy of the endoscopic submucosal dissection for early gastric cancers, compared with conventional endoscopic mucosal resection.  Gastrointest Endosc. 2007;  65 AB358
  PubMedSearch in Google Scholar
• 14 Kim W J, Cho J Y, Choi I S. et al . The result of endoscopic mucosal resection and endoscopic submucosal dissection of gastric tumors over 15 years.  Gastrointest Endosc. 2007;  65 AB97
  PubMedSearch in Google Scholar
• 15 Saito Y, Mashimo Y, Kikuchi T. et al . Endoscopic submucosal dissection resulted in higher en-bloc resection rates and reduced lower recurrence for LSTS ≥ 20 mm compared to conventional EMR.  Gastrointest Endosc. 2007;  65 AB273
  PubMedSearch in Google Scholar
• 16 Tamegai Y, Saito Y, Masaki N. et al . Endoscopic submucosal dissection: a safe technique for colorectal tumors.  Endoscopy. 2007;  39 418-422
  Thieme ConnectPubMedSearch in Google Scholar
• 17 Hoteya S, Iizuka T, Yahagi N. Feasibility of endoscopic submucosal dissection for early gastric cancer arising from remnant stomach, compared with conventional endoscopic mucosal resection.  Gastrointest Endosc. 2008;  67 AB277
  PubMedSearch in Google Scholar
• 18 Jung H, Choi K, Song H. et al . Endoscopic resection for superficial esophageal cancer: comparison between EMR and ESD method.  Ann Oncol. 2008;  19 (Suppl 6) vi45
  PubMedSearch in Google Scholar
• 19 Min B H, Lee J H, Kim J J. et al . Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: Comparison with endoscopic mucosal resection after circumferential precutting (EMR-P).  Dig Liver Dis. 2009;  41 201-219
  CrossrefPubMedSearch in Google Scholar
• 20 Nonaka K, Nishimura M, Yoshinaga S. et al . Comparison of endoscopic submucosal dissection using sodium hyaluronate and needle-knife versus endoscopic mucosal resection for colonic laterally spreading tumors.  Gastrointest Endosc. 2008;  67 AB282
  PubMedSearch in Google Scholar
• 21 Teoh A Y, Cheung F K, Chiu P W. et al . Endoscopic submucosal dissection versus endoscopic mucosal resection in management of superficial squamous esophageal neoplasms.  Gastrointest Endosc. 2008;  67 AB188
  PubMedSearch in Google Scholar
• 22 Yamaguchi Y, Katusmi N, Aoki K. et al . Resection area of 15 mm as dividing line for choosing strip biopsy or endoscopic submucosal dissection for mucosal gastric neoplasm.  J Clin Gastroenterol. 2007;  41 472-476
  CrossrefPubMedSearch in Google Scholar
• 23 Conio M, Ponchon T, Blanchi S. et al . Endoscopic mucosal resection.  Am J Gastroenterol. 2006;  101 653-663
  CrossrefPubMedSearch in Google Scholar
• 24 Jeon S W, Jung M K, Cho C M. et al . Predictors of immediate bleeding during endoscopic submucosal dissection in gastric lesions.  Surg Endosc. 2008;  Jun 14 [Epub ahead of print]
  PubMedSearch in Google Scholar
• 25 Lee S Y, Kim J J, Lee J H. et al . Healing rate of EMR-induced ulcer in relation to the duration of treatment with omeprazole.  Gastrointest Endosc. 2004;  60 213-217
  CrossrefPubMedSearch in Google Scholar
• 26 Fujishiro M, Yahagi N, Nakamura M. et al . Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar.  Gastrointest Endosc. 2006;  63 243-249
  CrossrefPubMedSearch in Google Scholar

Feng GaoPhD 

Department of Colorectal and Anal Surgery
First Affiliated Hospital, Guangxi Medical University

Nanning, Guangxi
People’s Republic of China

Fax: +86-771-5356529

Email: doctorgao0771@hotmail.com