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IS ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) TRULY COMPARABLE TO TRANSANAL ENDOSCOPIC MICROSURGERY (TEM) FOR EARLY RECTAL EPITHELIAL AND SUBEPITHELIAL TUMORS? A META-ANALYSIS
Abdul-Rahman F. Diab
*1,2, Joseph Sujka
2, Salvatore Docimo
2, Christopher DuCoin
21University of Central Florida College of Medicine / HCA Healthcare GME Consortium, Ocala, FL; 2University of South Florida Morsani College of Medicine Department of Surgery, Tampa, FL
Background:Early rectal tumors can be effectively managed using Transanal Endoscopic Microsurgery (TEM) and Endoscopic Submucosal Dissection (ESD). This study aimed to compare ESD and TEM in the resection of early rectal tumors concerning en bloc resection rates, R0 resection rates, mean procedural times, perforation rates, bleeding rates, adverse events/complication rates, and mean length of stay (LOS).
Methods:We conducted a systematic literature review following PRISMA guidelines to identify studies directly comparing ESD with TEM for early rectal tumor resection. Using a random effects model, odds ratios were calculated for dichotomous outcomes, and mean differences were determined for continuous outcomes to assess effect sizes. Subgroup analyses were performed based on tumor origin (epithelial vs. subepithelial). The odds ratio (OR) and control event rate (CER) across studies were used to calculate the number needed to treat (NNT).
Results:No significant difference was observed in en bloc resection rates between ESD and TEM. The R0 resection rate was lower in the ESD group. Subgroup analysis indicated that the reduced R0 resection rate in ESD remained significant in the subepithelial subgroup but not in the epithelial subgroup, with the subgroup difference reaching statistical significance (p = 0.05). Although the result did not meet conventional statistical significance (p < 0.05), it was very close and thus holds practical significance. The NNT with ESD to result in one additional missed R0 resection (harmful event) compared to TEM was 10 (95% CI 4–162). The ESD group demonstrated significantly shorter mean procedural times and LOS, with no significant subgroup differences between epithelial and subepithelial tumors. Perforation, bleeding, and adverse event/complication rates did not significantly differ between ESD and TEM, with no notable subgroup differences.
Conclusions:This study suggests that endoscopic submucosal dissection (ESD) is associated with a lower R0 resection rate than transanal endoscopic microsurgery (TEM) but offers a shorter mean length of stay (LOS) and procedural time. To date, no randomized controlled trials have been published. Large-scale randomized controlled trials are needed to reach more definitive conclusions. Until then, TEM may be more suitable for otherwise healthy patients, while ESD may be preferable for high-risk patients with limited tolerance for anesthesia. Additionally, further studies are needed to assess whether tumor origin (epithelial vs. subepithelial) impacts the R0 resection rate in ESD.
Literature review flow diagram following the PRISMA guidelines. The diagram illustrates the study selection process for inclusion in the review.
PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Quality appraisal results of the studies using the ROBINS-I tool.
ROBINS-I, The Risk of Bias in Non-randomized Studies of Interventions.
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