Management of colorectal laterally spreading tumors: a systematic review and meta-analysis

Pedro Russo, Sandra Barbeiro, Halim Awadie, Diogo Libânio, Mario Dinis-Ribeiro, Michael Bourke, Pedro Russo, Sandra Barbeiro, Halim Awadie, Diogo Libânio, Mario Dinis-Ribeiro, Michael Bourke

Abstract

Objective and study aims To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST). Methods Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model. Results Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 - 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 - 92.9 %, I 2 = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 - 95.5 %, vs. 84 % 95 % CI 78.1 - 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 - 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 - 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 - 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 - 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 - 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 - 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 - 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST. Conclusions EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.

Conflict of interest statement

Competing interests None

Figures

Fig. 1
Fig. 1
Flow chart of the selection of studies eligible for data extraction and analysis.
Fig. 2a
Fig. 2a
Rate of en-bloc resection by technique.
Fig. 2b
Fig. 2b
Rate of complete endoscopic resection by technique.
Fig. 2c
Fig. 2c
Rate of complete endoscopic resection by type of lesion.
Fig. 2d
Fig. 2d
Rate of curative resection according to technique.
Fig. 2e
Fig. 2e
Submucosal invasion by technique.
Fig. 2f
Fig. 2f
Recurrence rate by technique.
Fig. 3a
Fig. 3a
Adverse events. Overall adverse events by technique.
Fig. 3b
Fig. 3b
Adverse events. Perforation by technique.
Fig. 3c
Fig. 3c
Adverse events. Bleeding rate by technique.
Fig. 4a
Fig. 4a
Follow-up and surgery. Overall surgery rate by technique.
Fig. 4b
Fig. 4b
Follow-up and surgery. Rate of surgery due to recurrence by technique.
Fig. 4c
Fig. 4c
Follow-up and surgery. Rate of surgery due to incomplete resection by technique.

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