Comparative efficacy of different techniques for colonic endoscopic submucosal dissection: A network meta-analysis of randomized controlled trials

Background: Endoscopic submucosal dissection (ESD) is an advanced technique that can provide successful ‘en-bloc’ and R0 resection rate for large gastrointestinal lesions. To date, several ESD techniques have been proposed, but their comparative efficacy is still unclear. Methods: Major databases were systematically searched for RCTs comparing the efficacy and safety of different ESD techniques for the resection of colonic lesions. The primary outcomes were ‘en-bloc’ and R0 resection rates. The secondary outcome was the incidence of procedure-related AEs. Results: After selection of studies, 9 RCTs were included in the systematic review. On network meta-analysis for ‘en-bloc’ resection, pocked with traction ESD (PT-ESD) (RR=1.02; 95%CI=0.96–1.07) and pocket ESD (P-ESD) (RR=1.02; 95%CI=0.98–1.05) showed higher efficacy, whereas hybrid ESD (H-ESD) (RR=0.94; 95%CI=0.87–1.02) lower efficacy compared to conventional ESD (C-ESD). With regard to R0 resection, PT-ESD (RR=1.05; 95%CI=0.96–1.16) showed higher efficacy, and H-ESD (RR=0.97; 95%CI=0.84–1.13) lower efficacy compared to C-ESD. Concerning safety PT-ESD (RR=0.35; 95%CI=0.05–2.48) was associated with lower incidence of AEs, and H-ESD (RR=1.22; 95%CI=0.30–5.01) with higher incidence of AEs, compared to C-ESD. Conclusions: The results of this network meta-analysis show a trend towards greater effectiveness and safety of PT-ESD for the removal of colonic lesions. H-ESD was associated with worse results and should be reserved as a rescue treatment, preferring other techniques.