Endoscopic submucosal dissection versus endoscopic mucosal resection for early esophageal neoplasia: A systematic review and meta-analysis

Abstract : Esophageal carcinoma (EC) is a primary global health concern, ranking as the eighth most common cancer and the sixth leading cause of cancer-related mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are widely used to manage early-stage EC and Barrett’s esophagus. However, their comparative efficacy and safety remain debated. This study aims to systematically compare the safety and efficacy of ESD and EMR in the treatment of early EC and Barrett’s esophagus. A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines. Databases including MEDLINE (via PubMed), Google Scholar, and Cochrane Library were searched for studies published up to October 2024. Twenty-two studies involving 3,309 patients (1425 ESD and 1884 EMR) met the inclusion criteria. Outcomes assessed included en bloc resection, R0 resection, curative resection, local recurrence, bleeding, perforation, and stricture formation. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model via RevMan 5.4. ESD significantly outperformed EMR in en bloc resection (RR = 2.22, 95% CI: 1.69–2.90; p < 0.001), R0 resection (RR = 1.93, 95% CI: 1.28–2.91; p = 0.002), and curative resection rates (RR = 2.29, 95% CI: 1.52–3.46; p < 0.001). ESD was associated with lower local recurrence in squamous cell carcinoma (SCC) (RR = 0.13, 95% CI: 0.06–0.30; p < 0.001), though recurrence was higher in Barrett’s esophagus (RR = 1.67, 95% CI: 1.30–2.14; p < 0.001). No significant difference was observed in bleeding rates; however, ESD carried a higher risk of perforation (RR = 2.94, 95% CI: 1.31–6.60; p = 0.009). ESD is more effective than EMR in achieving complete and curative resections for early EC and SCC, particularly for lesions >20 mm. However, it has a higher complication rate, especially perforation. Careful patient selection and procedural expertise are essential when choosing between the two techniques.