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Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions

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Abstract

Background

For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive.

Methods

A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis.

Results

This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3–90.6) for the ESD patients versus 98.7 % (95 % CI 97.4–99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4–78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9–90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4–11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2–13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3–5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0–6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9–13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8–3.7 %) for the TEM patients (P < 0.001).

Conclusions

The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.

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Disclosures

Alberto Arezzo, Roberto Passera, Yutaka Saito, Taku Sakamoto, Nozomu Kobayashi, Naoto Sakamoto, Naohisa Yoshida, Yuji Naito, Mitsuhiro Fujishiro, Keiko Niimi, Tomohiko Ohya, Ken Ohata, Shinichi Okamura, Shinei Iizuka, Yoji Takeuchi, Noriya Uedo, Pietro Fusaroli, Marco Augusto Bonino, Mauro Verra, and Mario Morino have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy

    Alberto Arezzo, Marco Augusto Bonino, Mauro Verra & Mario Morino

  2. Division of Nuclear Medicine, San Giovanni Battista Hospital and University of Torino, Torino, Italy

    Roberto Passera

  3. GI Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

    Yutaka Saito, Taku Sakamoto & Nozomu Kobayashi

  4. Department of Gastroenterology, Juntendo University, Tokyo, Japan

    Naoto Sakamoto

  5. Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan

    Naohisa Yoshida & Yuji Naito

  6. Department of Endoscopy and Endoscopic Surgery, University of Tokyo, Tokyo, Japan

    Mitsuhiro Fujishiro & Keiko Niimi

  7. Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan

    Tomohiko Ohya

  8. Division of Gastroenterology, Kanto Medical Center NTT EC, Tokyo, Japan

    Ken Ohata

  9. Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan

    Shinichi Okamura & Shinei Iizuka

  10. Department of Gastrointestinal Oncology, Osaka Medical Centre for Cancer and Cardiovascular Diseases, Osaka, Japan

    Yoji Takeuchi & Noriya Uedo

  11. U.O. Gastroenterologia AUSL di Imola, Imola, Italy

    Pietro Fusaroli

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  1. Alberto Arezzo
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  2. Roberto Passera
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  3. Yutaka Saito
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  18. Marco Augusto Bonino
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  20. Mario Morino
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Correspondence to Alberto Arezzo.

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Arezzo, A., Passera, R., Saito, Y. et al. Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions. Surg Endosc 28, 427–438 (2014). https://doi.org/10.1007/s00464-013-3238-3

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  • DOI: https://doi.org/10.1007/s00464-013-3238-3

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