927 Traction-Assisted Endoscopic Submucosal Dissection Reduces Procedure Time and Risk of Adverse Events: A Meta-Analysis

Abstract

INTRODUCTION: Endoscopic submucosal dissection (ESD) is superior to endoscopic mucosal resection (EMR) for treatment of superficial gastrointestinal neoplasia because it is associated with increased en bloc resection and lower rates of local recurrence. However, ESD is a technically demanding procedure with increased procedure time and has potential for serious adverse events. To overcome the procedural difficulty of ESD, Various traction methods such as clip-line method, clip and snare method and internal traction method, have been developed to provide countertraction to expose the dissection plane and allow safe and effective submucosal dissection. A number of studies have compared efficacy of traction-assisted ESD (T-ESD) and conventional ESD (C-ESD) but results are conflicting. We conducted a meta-analysis to assess the efficacy of T-ESD. METHODS: All clinical studies published up to April 2019 comparing the efficacy and safety of T-ESD and C-ESD were identified using electronic bibliographic searches of PubMed, Medline, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), and Web of Science (Science and Social Science Citation Index). Outcomes of interests included procedure time (minutes), rate of en bloc and R0 resections, and rates of adverse events (bleeding and perforation). Random effect model was used to calculate pooled mean difference (MD) for continuous variables and Odds ratios (ORs) for categorical variables. RESULTS: Of 621 articles identified, 18 studies [939 T-ESD and 963 C-ESD procedures] met inclusion criteria for final analysis [6 randomized controlled trials and 12 observational studies]. Overall, T-ESD significantly reduced procedure time (MD = - 16.63 min, 95% CI - 24.65 to - 8.60, P < 0.0001, I 2 = 68) and complication rates (OR = 0.56, 95% CI 0.36 - 0.87, P = 0.009, I 2 = 0) compared to C-ESD. En bloc resection and R0 resection rates were similar in both groups (OR = 2.36; 95% CI 0.58 - 9.55; P = 0.23, I 2 = 0 and OR = 1.45; 95% CI 0.76 - 2.77; P = 0.25, I 2 = 0; respectively). No publication bias was detected by funnel plot. CONCLUSION: Traction techniques facilitate submucosal dissection, reduce procedure time and improve its safety. These techniques are simple and can be performed using readily available accessories in the endoscopy unit. Application of traction method improves feasibility of ESD and may enable the widespread use of ESD in the West.