Cao Y, Liao C, Tan A, et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract

Department of Colorectal and Anal Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.
Endoscopy (Impact Factor: 5.05). 08/2009; 41(9):751-7. DOI: 10.1055/s-0029-1215053
Source: PubMed


Endoscopic submucosal dissection (ESD) has been developed to overcome the limitations of endoscopic mucosal resection (EMR). We aimed to compare the outcomes of these two methods.
Databases, including Pubmed, EMBASE, and The Cochrane Library, were searched to identify studies comparing ESD with EMR for premalignant and malignant lesions of the gastrointestinal tract. In a meta-analysis, primary end points were the en bloc resection rate and the curative resection rate; secondary end points were operation time, and rates of bleeding, perforation, and local recurrence.
15 nonrandomized studies (seven full-text and eight abstracts) were identified. Meta-analysis showed higher en bloc and curative resection rates (odds ratio [OR] 13.87, 95 %CI 10.12 - 18.99; OR 3.53, 95 %CI 2.57 - 4.84) irrespective of lesion size. Subgroup analysis showed higher en bloc and curative resection rates with ESD for esophageal, gastric, and colorectal neoplasms, and for lesions of size < 10 mm, 10 mm < 20 mm, and > 20 mm. Local recurrence was lower with ESD (OR 0.09, 95 %CI 0.04 - 0.18). But ESD was more time-consuming than EMR (weighted mean difference [WMD] 1.76; 95 %CI 0.60 - 2.92), and showed high procedure-related bleeding and perforation rates (OR 2.20, 95 %CI 1.58 - 3.07; OR 4.09, 95 %CI 2.47 - 6.80).
ESD showed better en bloc and curative resection rates and local recurrence compared with EMR, but was more time-consuming and had higher rates of bleeding and perforation complications. These results need to be confirmed by high quality trials and further studies in the west.

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    • "En bloc R0 resection rate of EMR was reported in up to 40% to 50% of cases for 2 to 3 cm lesions without ulcer scar,10-13 whereas for ESD in high volume centers en bloc rates were over 95%, even for lesions larger than 10 cm and those with ulcer scars.14-20 However, with ESD there is concern about technical difficulties, higher incidence of complications, and longer procedure time, besides which EMR is a relatively easy, safe, and swift procedure.17,19,21-25 The evaluation of curability is currently important because the criteria for endoscopic resection were expanded to large mucosal cancer with ulcer scar and slightly invasive submucosal cancer. "
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    ABSTRACT: Endoscopic submucosal dissection (ESD) has enabled en bloc resection of early stage gastrointestinal tumors with negligible risk of lymph node metastasis, regardless of tumor size, location, and shape. However, ESD is a relatively difficult technique compared with conventional endoscopic mucosal resection, requiring a longer procedure time and potentially causing more complications. For safe and reproducible procedure of ESD, the appropriate dissection of the ramified vascular network in the level of middle submucosal layer is required to reach the avascular stratum just above the muscle layer. The horizontal approach to maintain the appropriate depth for dissection beneath the vascular network enables treatment of difficult cases with large vessels and severe fibrosis. The most important aspect of ESD is the precise evaluation of curability. This approach can also secure the quality of the resected specimen with enough depth of the submucosal layer.
    Clinical Endoscopy 11/2012; 45(4):362-74. DOI:10.5946/ce.2012.45.4.362
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    • "Unfortunately, the treatment of relatively large lesions and lesions related to ulcers, ulcer scars, or fibrosis increases the ESD operation time, which subsequently also increases the risk of adverse events such as bleeding and gastrointestinal perforation [7] [8] [9] [10]. In fact, the incidence of procedurerelated bleeding is higher with ESD than with conventional EMR, meaning the control of bleeding during and after ESD "
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    ABSTRACT: Endoscopic submucosal dissection (ESD) is a novel endoscopic procedure first developed in the 1990s which enables en bloc resection of gastric neoplastic lesions that are difficult to resect via conventional endoscopic mucosal resection. However, given that ESD increases the risk of intra- and post-ESD delayed bleeding and that platelet aggregation and coagulation in artificial ulcers after ESD strongly depend on intragastric pH, faster and stronger acid inhibition via proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H 2 RAs) as well as endoscopic hemostasis by thermocoagulation during ESD have been used to prevent ESD-related bleeding. Because PPIs more potently inhibit acid secretion than H 2 RAs, they are often the first-line drugs employed in ESD treatment. However, acid inhibition after the initial infusion of a PPI is weaker in the early phase than that achievable with H 2 RAs; further, PPI effectiveness can vary depending on genetic differences in CYP2C19. Therefore, optimal acid inhibition may require tailored treatment based on CYP2C19 genotype when ESD is performed, with a concomitant infusion of PPI and H 2 RA possibly most effective for patients with the rapid metabolizer CYP2C19 genotype, while PPI alone may be sufficient for those with the intermediate or poor metabolizer genotypes.
    Diagnostic and Therapeutic Endoscopy 07/2012; 2012(32):791873. DOI:10.1155/2012/791873
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    ABSTRACT: This paper extends some basic results from the area of finite time and practical stability to linear, continuous, time invariant time-delay systems. Sufficient conditions of this kind of stability for a particular class of time-delay systems are derived
    Electrotechnical Conference, 1998. MELECON 98., 9th Mediterranean; 06/1998
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