Efficacy Of Endoscopic Piecemeal Mucosal Resection Versus Endoscopic Submucosal Dissection For Laterally Spreading Tumors:A Meta-analysis

Objective:Laterally spreading tumors(LSTS)are usually larger than 10mm in diameter,which are prone to occur in the colon and rectum.The maximum diameter of lesions treated by endoscopic mucosal resection(EMR)is not more than 20mm.Study have shown that endoscopic piecemeal mucosal(EPMR)and endoscopic submucosal dissections(ESD)are effective treatment for large LST lesions.However,due to there are many types of LST,the efficacy and advantages of EPMR and ESD in different types of LST are still inconclusive.The aim of this study is to evaluate the efficacy and safety of EPMR and ESD in the treatment of LST by Meta-analysis.Methods:Two investigators systematically searched the English databases and Chinese databases from construction to December 2022,and literature were searched for all controlled trials comparing EPMR and ESD in the treatment of LST.Two researchers independently screened the retrieved literature,and evaluated the quality of the final included literature according to the New NOS scale,and then extracted the data of the general information of the literature and the variables such as the outcome indicators of the study.Rev Man5.3 software was used to draw the forest map and perform the Meta-analysis.The dichotomous variables(such as complication rate,tumor recurrence rate,etc.)were analyzed by odds ratio(OR)and 95%confidence interval(CI).The mean difference(MD)and 95%confidence interval(CI)were used to analyze the data of continuous variables(such as operation time and lesion diameter).MH method or Peto method can be used to calculate the effect value when the effect size of binary variables is combined with fixed effect.I~2and Q tests were used to determine the heterogeneity of the included literature,and random effect model or fixed effect model was selected for summary analysis according to the results.Sensitivity analyses were performed to assess the robustness of the results by removing individual studies and recombining effect sizes one by one.When more than 10 articles were included,a funnel plot could be drawn,and publication bias could be judged by observing whether the funnel plot was symmetrical.Results:A total of 11 articles with 1244 patients were initially included,including 407 patients in the EPMR group and 837 patients in the ESD group.Meta-analysis showed that:(1)In terms of operation time,the operation time of EPMR group was significantly shorter than that of ESD group,MD=-24.95,95%CI:-28.18～21.71,P<0.01.(2)The diameter of lesions resected by EPMR and ESD were similar(MD=-0.99,95%CI:-3.47～5.46,P=0.66).(3)The incidence of bleeding was 9.6%(26/271)in the EPMR group and 6.7%(27/401)in the ESD group,OR=0.87,95%CI:0.44～1.72,P=0.69.The incidence of bleeding was similar between the two groups.The incidence of postoperative perforation was 2.6%(6/227)in the EPMR group and 3.1%(12/393)in the ESD group,OR=1.19,95%CI:0.45～3.13,P=0.73.The incidence of postoperative perforation was similar between the EPMR and ESD.(4)For postoperative tumor recurrence,the recurrence rate of EPMR group was significantly higher than that of ESD group(21.3%vs.1.4%),OR=23.49,95%CI:10.01～55.13,P<0.01.(5)The type of LST in the two groups was similar.There were 89 cases(78.76%)of LST-G in the EPMR group and 69 cases(75.82%)of LST-G in the ESD group,OR=1.29,95%CI:0.64～2.58,P=0.48.(6)The proportion of lesions located in the colon was 0.57 in EPMR group and0.63 in ESD group,OR=1.98,95%CI:0.29～13.70,P=0.49.The location distribution of LST lesions in the colon and rectum was basically the same in the EPMR group and the ESD group.(7)Postoperative pathological results showed that the detection rate of submucosal invasion and cancer in EPMR group was 1.3%(3/231),and that in ESD group was 5.2%(17/326),OR=0.26,95%CI:0.09～0.77,P=0.01,indicating that the detection rate of submucosal invasion and cancer in the ESD group was higher than that in the EPMR group.Conclusion:(1)In the treatment of LST,there was no significant difference in lesion diameter between EPMR and ESD.The treatment time of EPMR was significantly shorter than that of ESD.(2)In terms of surgical safety,there was no difference in the incidence of adverse events such as bleeding and perforation between the two groups,indicating that ESD is equally safe and reliable in the treatment of LST.(3)The recurrence rate of EPMR group was significantly higher than that of ESD group.(4)The location distribution of LST lesions in the colon and rectum was basically the same in the EPMR group and the ESD group,and there was no significant difference in the type of LST lesions between the two groups.(5)The postoperative pathological results showed that the incidence of submucosal invasion and cancer in the ESD group was higher than that in the control group,indicating that ESD can be used for complete excision while the lesions are judged to be malignant.(6)In this study,there are still few subjects included in the two surgical procedures,and each independent study is a small sample study,which may have a large bias,and there is a lack of large sample studies to divide LST into different subtypes,so as to carry out subgroup studies in Meta-analysis.In the future,large sample experiments are still needed to verify the results.