Efficacy and safety of traction-assisted endoscopic submucosal dissection: a meta-regression of randomized clinical trials

Abstract

Background Endoscopic submucosal dissection (ESD) is widely used to treat gastrointestinal lesions. A traction-assisted (TA) strategy has been recently developed for ESD. In this study, we evaluated the safety and efficacy of TA-ESD compared with conventional ESD (C-ESD). Methods We searched PubMed, Embase, Web of Science, and the China National Knowledge Infrastructure to identify randomized clinical trials that compared TA-ESD and C-ESD. No filters for language or date of publication were used. Outcomes included complete resection rate, resected specimen size, procedure time, hemostasis usage (frequency), overall complication rate, perforation rate, and delayed bleeding rate. We used the mean difference (MD) for continuous outcomes in a random-effects model and Peto odds ratio (POR) for binary outcomes where any zero cell existed. Effect sizes and their 95 % confidence intervals (CIs) were determined. Results 12 out of 929 identified articles, including 1499 patients, were analyzed. According to pooled results, TA-ESD produced similar R0 resections to C-ESD, but its procedure time (minutes) was shorter than that of C-ESD (MD – 16.02, 95 %CI – 22.71 to – 9.33). Moreover, TA-ESD had a lower complication rate (POR 0.47, 95 %CI 0.29 to 0.76) and perforation rate (POR 0.24, 95 %CI 0.10 to 0.56) than C-ESD. A nonsignificant difference in delayed bleeding rate was observed, although there was a trend toward this being lower in TA-ESD than C-ESD (POR 0.90, 95 %CI 0.46 to 1.75, I 2 = 12 %). Conclusions The traction-assisted strategy improves safety and efficacy in the treatment of patients with ESD. However, we observed different effect sizes in the esophagus, stomach, and colorectum.

Traction is most important for the widespread use of endoscopic submucosal dissection, especially in procedures presenting particular difficulty

“…Regarding safety in this meta-analysis [1] the subset analyses of the esophagus and colorectum yielded similar results, namely that TA-ESD had a lower complication rate than C-ESD, with statistical significance; that for the stomach showed a lower complication rate with TA-ESD with, however, only marginal significance.…”

The future of endoscopic resection for early gastric cancer

“…Also, there was a trend for lower delayed bleeding in traction-assisted ESD, but without statistical significance (95% CI: 0.46-1.75). 47 In summary, recent evidence suggest that traction methods can improve ESD outcomes, and although it is not routinely recommended it is a readily available option if difficulties are encountered during ESD.…”

Endoscopic Submucosal Dissection of Pseudo-polyps in the Right Colon Using a Flexible Grasper With Articulating Distal Tip and Elbow-Like Bending

“…[10] A traction device can increase the e ciency and safety of ESD procedures by maintaining visualization of the submucosal dissection layer. [11] Various traction devices have been proposed to reduce procedure times and complication rates. [12] [13] However, most of devices are limited in their ability to navigate to the right colon or maintain dexterity of the instruments once situated in the right colon.…”