S0903 Efficacy and Safety of Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection in Barrett’s Esophagus-Related Early Neoplasia: A Systematic Review and Pooled Comparative Analysis

Abstract

INTRODUCTION: Focal endoscopic mucosal resection (EMR) followed by radiofrequency ablation (EMR + RFA) and stepwise/complete EMR (s-EMR) have been used for management of Barrett’s esophagus related high grade dysplasia (HGD) and early adenocarcinoma (EAC). Recently, endoscopic submucosal dissection (ESD) has been utilized with good efficacy. A systematic review and meta-analysis to evaluate the cumulative & comparative efficacy and safety of different endoscopic therapies. METHODS: We searched several databases from inception through April 2020 for studies evaluating efficacy and safety of ESD, EMR + RFA and sEMR for management of Barrett’s related early neoplasia. Our primary outcomes of interest were recurrence of HGD or EAC, along with risk of strictures, perforation and bleeding. Secondary outcomes included enbloc and R0 resections for ESD, complete eradication of neoplasia for EMR-RFA and sEMR. Weighted pooled rates (WPR) were calculated for each outcome. Proportionate difference was calculated to compare different endoscopic modalities in terms of primary outcomes of interest. RESULTS: A total of 37 studies [14 ESD, 12 EMR + RFA, 11 sEMR], with 2377 patients [682 ESD, 872 EMR + RFA, 823 sEMR] were included in this systematic review and meta-analysis. 82.4% patients were males. WPR for recurrence with ESD, EMR + RFA and sEMR were 10.3% (6.6%, 15.8%), 5% (2.3%, 10%) & 7.4% (4.6%, 12%), respectively. No difference in recurrence with any endoscopic modality (P > 0.05). WPR for strictures during follow up with ESD, EMR + RFA & sEMR were 9.5% (3.6%, 23%), 11.5% (7.3%, 17.8%) & 29% (21%, 38%), respectively. ESD and EMR + RFA were associated with lower stricture formation as compared to sEMR (P < 0.05), while no difference in stricture formation between ESD and EMR + RFA. WPR for perforation with ESD, EMR + RFA and sEMR were 3.7% (2.2%, 6%), 1.6% (0.6%, 3.3%) & 2% (1%, 3.5%), respectively. EMR + RFA was associated with lower risk of perforation as compared to ESD (P = 0.01), while no difference in perforation risk between ESD and sEMR. WPR for bleeding with ESD, EMR + RFA & sEMR were 3.5% (2%, 5%), 3% (2%, 4.5%) & 6%(4%, 10%), respectively. Detailed comparative analysis and secondary outcomes outlined in Tables 1 and 2. CONCLUSION: There was no difference in recurrence of neoplasia with any endoscopic modality. However, EMR + RFA had best safety profile as it was associated with lower risk of perforation as compared to ESD and lower risk of stricture formation and bleeding as compared to sEMR.Figure 1.: Forest plots for recurrence of neoplasia.Table 1.: Comparative analysis; Table 2. Secondary outcomes of interest