Endoscopic Submucosal Dissection with Rubber Bands and Clips Compared to Conventional Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

Abstract

The rising number of gastrointestinal (GI) tumors, including esophageal, gastric, and colorectal tumors, makes it essential to develop more effective treatment methods. Endoscopic submucosal dissection (ESD) has become a popular intervention due to its ability to resect the tumor completely and prevent local recurrence. This study evaluates the safety and efficacy of ESD with rubber bands and clips (ESD-RBC) in the treatment of various GI tumors. We systematically searched Embase, Scopus, Web of Science, Medline/PubMed, and Cochrane databases until April 20, 2024. Eligible studies included clinical trials and observational studies focusing on ESD-RBC alone or compared to conventional ESD (C-ESD) in patients with gastrointestinal tumors. The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) tool. Statistical analyses were performed using RevMan and R software. ESD-RBC was superior to C-ESD in achieving R0 resection and en bloc resection (OR: 1.99 with 95% CI [1.17 to 3.36], P = 0.01, I² = 0%) and (OR: 5.98 with 95% CI [2.30 to 15.55]; P = 0.0002, I² = 0%), respectively. ESD-RBC enhanced the resection speed compared to C-ESD (MD: 8.48 mm²/min with 95% CI [3.12 to 13.83]; P < 0.00001, I² = 89%) and shortened the procedure duration (MD: - 11.94 min with 95% CI [- 21.98 to - 1.91]; P < 0.00001, I² = 7%). There was no statistically significant difference between both groups in terms of bleeding and delayed bleeding (OR: 1.08 with 95% CI [0.37 to 3.14]; P = 0.89, I² = 0%) and (OR: 0.69 with 95% CI [0.20 to 2.33]; P = 0.55, I² = 0%), respectively. The proportion of R0 resection using ESD-RBC was 90%, with 95% CI [65% to 98%] and I² = 78%. The en bloc resection rate was 96%, with 95% CI [95% to 97%], and I² = 0%. In addition, the raw mean (MRAW) of resection speed was 24.25 mm2/min, with 95% CI [13.48 to 35.02], and I² = 99.4%. ESD-RBC was superior to C-ESD in achieving en bloc resection and R0 resection with a comparable risk of bleeding and delayed bleeding. In addition, ESD-RBC enhanced the resection speed and shortened the procedure duration.

Keywords: Clips; ESD; En bloc resection; R0 resection; Rubber band; Systematic review.

Fig. 1

PRISMA flow diagram

Fig. 2

Forest plot of R0 resection in ESD-RBC versus C-ESD

Fig. 3

Forest plot of en bloc resection in ESD-RBC versus C-ESD

Fig. 4

Forest plot of procedure duration in ESD-RBC versus C-ESD