909 Endoscopic Mucosal Resection versus Endoscopic Submucosal Dissection in the Treatment of Superficial Gastric Cancers - A Meta-Analysis Update

Abstract

INTRODUCTION: Early gastric cancer (EGC) is defined as a malignant tumor confined to the mucosa or the submucosa regardless of lymph node metastases. Endoscopic Mucosal Resection (EMR) is widely accepted as the treatment modality for EGC although it has some limitations. To overcome these and to facilitate resection of difficult lesions, Endoscopic Submucosal Dissection (ESD) was developed. ESD has a higher En-bloc and histological resection rate when compared to EMR. However, when compared to EMR, ESD has a higher complication rate, longer duration and is technically challenging. Despite its wide use in Eastern countries, the application of ESD is still being debated in the United States. We conducted a meta-analysis comparing the efficacy and safety of EMR and ESD in the management of EGC. METHODS: A literature search was done from electronic databases including PubMed, Cochrane, and Embase from inception until November 2018. A total of 13 relevant studies were isolated and included in the study. The relevant data were extracted, and meta-analysis with Random effects model was done using RevMan 5.3. RESULTS: We had a total of 3807 lesions in the EMR group and 4284 lesions in the ESD group. Patient characteristics were available for only 8 studies and were age-matched with a mean age of 67.15 years [Male-76.9%, Female-23.1%] and 67.52 years [Male-76.7%, Female-23.3%] in EMR and ESD groups respectively. Our primary outcomes were en-bloc resection rate (EBR) and curative resection rate (CRR). 2171 lesions were removed en-bloc by EMR versus 3949 lesions by ESD [OR 8.14, 95%CI (6.08, 10.91), P < 0.0001, I2 = 71%], favoring ESD over EMR. The CRR was achieved in 3194 lesions with ESD as compared to 1890 lesions with EMR [OR 4.23, 95%CI (2.61, 6.85), P < 0.00001, I2 = 91%]. Complications including bleeding [OR 0.65, 95%CI (0.43, 0.98), P = 0.04, I2 = 54%] and perforation [OR 0.40, 95%CI (0.24, 0.68), P = 0.0006, I2 = 50%] were significantly higher with ESD over EMR. CONCLUSION: This meta-analysis shows that EBR and CRR are better achieved with ESD over EMR, with higher rates of bleeding and perforation with ESD. ESD is a complex procedure requiring a high level of expertise, training, and its success depends on the performer’s skills. With careful selection of patients and advanced endoscopic skills, outcomes could be better with ESD than EMR. Our study has limitations; the data used for the analysis were non- randomized and were conducted in heterogeneous practice settings.