Endoscopic submucosal dissection versus endoscopic mucosal resection for rectal carcinoid tumor. A meta‐analysis and meta‐regression with single‐arm analysis

Abstract

Objective As there has been so far no consensus on the best endoscopic resection technique, a meta‐analysis was conducted to compare the efficacy and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for treating rectal carcinoid tumors. Methods MEDLINE and EMBASE databases were searched for articles on the treatment of rectal carcinoid tumors using ESD vs EMR published up to October 2020 for outcomes including en bloc and complete resection, margin involvement, procedure time, requirement for additional surgery, bleeding, perforation and recurrence. Risk ratio and weighted mean differences were used for a DerSimonian and Laird random effects pairwise meta‐analysis. Single‐arm meta‐analyses of proportions and random effects meta‐regression analysis were also conducted. Results Twenty‐two studies involving 1360 rectal carcinoid tumors were included, in which 655 and 705 rectal carcinoid tumors were resected with ESD and EMR, respectively. The resection efficacy of ESD was comparable to that of EMR for tumors <10 mm. However, there were a significantly higher complete resection rate, and lower rates of vertical margin involvement and requirement for additional surgery using ESD than using EMR for tumors ≤20 mm. ESD had a longer procedure time and an increased likelihood of bleeding than EMR. Conclusions ESD is more effective in providing a curative treatment for rectal carcinoid tumors ≤20 mm in size as ESD can achieve a higher complete resection rate with lower vertical margin involvement than EMR. While they are suitable for treating rectal carcinoid tumors <10 mm as both techniques provide similar efficacy.

Endoscopic treatment for rectal neuroendocrine tumor: which method is better?

“…However, ESD has the disadvantage that the technique is difficult to learn, the procedure time is long, and the risks of bleeding and perforation are higher than those of m-EMR. 27 , 29 , 40 , 43 , 45 , 46 Yong et al 41 reported a perforation rate of 2% and a bleeding rate of 7%. Incomplete resection and complications may occur if ESD is performed by an inexperienced operator.…”

“…Nevertheless, ESD is required if the lesion is too large, suctioning is not possible due to fibrosis in the lesion, or if the snaring for EMR does not work well. In a meta-analysis including 1,360 lesions, Yong et al 41 reported that ESD for rectal NETs >10 mm demonstrated a higher complete resection rate and lower vertical margin involvement than EMR.…”

“…Several studies have reported the complete resection rate of ESD as 87.1% to 100%. 29,31,38,[40][41][42][43] Hybrid ESD is an effective and safe endoscopic resection technique for rectal NETs as an alternative to conventional ESD. Hybrid ESD involves a circumferential incision after submucosal injection similar to ESD.…”

Clinical and Molecular Characteristics of Rare Malignant Tumors of Colon and Rectum

“…Rectal well-differentiated NETs smaller than 2 cm can be treated with endoscopic resection considering their very low metastatic potential and the tendency to be confined in the mucosa/submucosa. Tumors larger than 2 cm or those localized in other sites of the colon need to be treated with surgical excision similarly to adenocarcinomas [ 45 ]. The medical treatment of poly-metastatic disease overlaps with that of other gastrointestinal high-grade NETs [ 42 ].…”

Spannungsfeld endoskopische Resektionsverfahren bei GEP-NET // Endoscopic resection for GEP-NET

“…Die konventionell durchgeführte EMR (mit/ohne submukösem Flüssigkeitskissen) zeigte sich in vielen Studien immer wieder den modifizierten EMR-Techniken (Kappen-EMR, EMR nach Gummibandligatur, EMR nach zirkumferenzieller Inzision) und auch der ESD in Bezug auf die komplette Resektionsrate unterlegen [34,35,36], sodass sie beim Verdacht auf das Vorliegen eines NET keine Anwendung finden sollte. In allermeist retrospektiven Arbeiten konnten für die modifizierte EMR sowie die ESD absolut vergleichbare histologische R0-Resektionsraten von ≥ 90 % gezeigt werden, wobei das Risiko von Komplikationen niedrig war [36,37,38,39]. Eine endoskopische Alternative kann auch die Over-the-Scope-Vollwandresektion (FTRD "full thickness resection device") sein [40].…”