A network meta-analysis of strategies for endoscopic submucosal dissection procedures from the perspectives of efficacy, duration and safety

BACKGROUND: Endoscopic submucosal dissection (ESD) is a well-accepted endoscopic resection modality for early-stage gastrointestinal tumors. Over the past decades, progressive refinements in instruments, traction methods, and closure techniques have enhanced the safety and efficacy of ESD, and ESD further evolves into conventional ESD (C-ESD), traction-assisted ESD (T-ESD), and underwater ESD (U-ESD). The three modalities have their distinct benefits and are complementary to each other in clinical practice. At the same time, they compete with one another, presenting a challenge to operators with respect to which to select in specific scenarios. OBJECTIVE: To conduct a network meta-analysis to make comparisons of the three approaches of ESD, with a focus on key endpoints including their operative duration, resection rate, R0 resection rate, and adverse event incidence. METHODS: A computerized search was conducted across PubMed, Embase, Web of Science, and Cochrane Library databases. The literature was evaluated using the PRISMA 2020 framework. The netmeta package was used for pairwise and network meta-analysis. Continuous outcomes were pooled as mean differences, and dichotomous outcomes were pooled as risk ratios. When continuous data were reported as medians with interquartile ranges or ranges, values were converted to approximate means and standard deviations before pooling. RESULTS: /min, respectively) and shorter median procedure times (55.02 and 58.51 vs. 70.20 min, respectively). For adverse events, the absolute rates were 7.8% for T-ESD, 6.3% for U-ESD, and 10.8% for C-ESD. For R0 resection, the corresponding rates were 92.0%, 92.0%, and 91.1%, and for en bloc resection they were 97.9%, 97.0%, and 96.0%. According to SUCRA ranking, T-ESD ranked highest for procedure speed (0.76), median procedure time (0.83), en bloc resection (0.87), and R0 resection (0.65), whereas U-ESD ranked highest for adverse events (0.78). These rankings were interpreted together with effect estimates and confidence intervals. CONCLUSION: Compared with C-ESD, U-ESD and T-ESD showed favorable trends for different procedural endpoints, but the certainty of superiority varied across outcomes. T-ESD ranked highest for procedure speed, median procedure time, en bloc resection, and R0 resection, whereas U-ESD ranked highest for adverse events. Because several dichotomous outcomes had confidence intervals crossing the null value, SUCRA-based rankings should be interpreted as comparative probability rankings rather than definitive proof of clinical superiority.