Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis of randomized clinical trials.

Abstract

Conventional endoscopic mucosal resection (CEMR) is the established method for the resection of non-pedunculated colorectal lesions (NPCRL) ≥ 10mm. In the last decade, underwater endoscopic mucosal resection (UEMR) has been introduced as a potential alternative. The aim of this systematic review with meta-analysis is to compare the recurrence and safety of UEMR and CEMR by analyzing only randomized controlled trials (RCTs). We systematically searched PubMed, Cochrane Library and EMBASE until April 2023. Studies met the following inclusion criteria: (1) RCTs, (2) comparing UEMR with CEMR, (3) NPCRL ≥ 10mm, and (4) reporting the outcomes of interest. Primary outcomes were recurrence and safety. Secondary outcomes were en bloc, R0, complete resection, clipping and adverse events per type. Five RCTs were included. UEMR was associated with a lower recurrence rate (OR: 0.56; 95% CI: 0.32-0.97). Thus, the RR of recurrence was 1.7 times higher in the CEMR group (95% CI, 1.04-2.77). There was no significant difference in the pooled safety analysis. UEMR showed better en bloc resection rates (OR: 1.54; 95% CI: 1.15-2.07), but subgroup analysis showed comparable rates in lesions ≥ 20mm. R0 resection was higher in UEMR (OR: 1.72; 95% CI: 1.23-2.41). Other outcomes were not different between the 2 groups. UEMR is as safe as CEMR, with a higher overall R0 rate and a higher en bloc resection rate for lesions < 20mm, leading to a lower overall recurrence rate. The results of this meta-analysis support the widespread use of UEMR.