Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis

Abstract

Background and study aims: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows en-bloc resection of gastrointestinal tumor. We systematically review the medical literature in order to evaluate the safety and efficacy of colorectal ESD. Patients and methods: We performed a comprehensive literature search of MEDLINE, EMBASE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of colorectal ESD. Results: Included in this study were 13833 tumors in 13603 patients (42 % female) who underwent colorectal ESD between 1998 and 2014. The R0 resection rate was 83 % (95 % CI, 80 - 86 %) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in continent (P = 0.004), study design (P = 0.04), duration of the procedure (P = 0.009), and, marginally, by average tumor size (P = 0.09). Endoscopic en bloc and curative resection rates were 92 % (95 % CI, 90 - 94 %) and 86 % (95 % CI, 80 - 90 %), respectively. The rates of immediate and delayed perforation were 4.2 % (95 % CI, 3.5 - 5.0 %) and 0.22 % (95 % CI, 0.11 - 0.46 %), respectively, while rates of immediate and delayed major bleeding were 0.75 % (95 % CI, 0.31 - 1.8 %) and 2.1 % (95 % CI, 1.6 - 2.6 %). After an average postoperative follow up of 19 months, the rate of tumor recurrence was 0.04 % (95 % CI, 0.01 - 0.31) among those with R0 resection and 3.6 % (95 % CI, 1.4 - 8.8 %) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 1.0 % (95 % CI, 0.42 - 2.1 %). Conclusions: Our meta-analysis, the largest and most comprehensive assessment of colorectal ESD to date, showed that colorectal ESD is safe and effective for colorectal tumors and warrants consideration as first-line therapy when an expert operator is available.

Fig. 1

Screening and selection process.

Fig. 2

Percentage distribution of 13 603 patients who underwent colorectal endoscopic submucosal dissection between 1998 and 2014 in 15 countries. Others include Taiwan, Australia, France, Poland, Sweden, Turkey, UK, Brazil, Colombia, and USA that contributed ≤ 1 % each.

Fig. 3

Meta-analysis of histologic en bloc (R0) resection rate in 60 studies involving 8312 tumors in 8111 patients that underwent colorectal endoscopic submucosal dissection. Each dot and the horizontal line through them correspond to the point estimate and confidence interval from each study respectively while the center and width of the diamond corresponds to the pooled estimate and its confidence interval respectively. Both within continent and overall pooled estimates are presented. Even though weighting (not shown) was done, it is not explicit because an iterative procedure was used in parameter estimation. ES indicates estimate.

Fig. S1

Funnel plot of histologically confirmed en bloc (R₀) resection rate in 60 studies involving 8312 tumors in 8111 patients that underwent colorectal endoscopic submucosal dissection. Each dot represents the R₀ resection rate. Lack of asymmetry in the distribution of study estimates around the center of the funnel suggests no publication bias. P value for egger’s test = 0.57. ES, estimate; se(ES), standard error of estimate.

Fig. S2

Meta-analysis of endoscopic en bloc resection rate in 86 studies involving 12 346 tumors in 12 151 patients that underwent colorectal endoscopic submucosal dissection. Each dot and the horizontal line through them correspond to the point estimate and confidence interval from each study respectively while the center and width of the diamond corresponds to the pooled estimate and its confidence interval respectively. Even though weighting (not shown) was done, it is not explicit because an iterative procedure was used in parameter estimation. ES, estimate.

Fig. S3

Meta-analysis of curative resection rate in 14 studies involving 1805 tumors in 1784 patients that underwent colorectal endoscopic submucosal dissection. Each dot and the horizontal line through them correspond to the point estimate and confidence interval from each study respectively while the center and width of the diamond corresponds to the pooled estimate and its confidence interval respectively. Even though weighting (not shown) was done, it is not explicit because an iterative procedure was used in parameter estimation. All studies except one (Emura 2014, Colombia) were from Asia. ES, estimate.