Procedural efficiency and safety of traction-assisted versus conventional endoscopic submucosal dissection for gastric tumors: a meta-analysis of randomized controlled trials

BACKGROUND: Endoscopic submucosal dissection (ESD) is an effective minimally invasive treatment for superficial gastric tumors. However, it is technically demanding and often associated with prolonged procedure time and a risk of adverse events. Traction-assisted ESD (TA-ESD) has been introduced to improve submucosal visualization and procedural efficiency; however, evidence regarding its benefit over conventional ESD (C-ESD) in gastric lesions remains inconsistent. This study aimed to compare procedural efficiency, resection quality, and safety between TA-ESD and C-ESD in patients with superficial gastric tumors. METHODS: We conducted a PRISMA-compliant systematic review and meta-analysis of randomized controlled trials comparing TA-ESD with C-ESD for gastric tumors. Five electronic databases were searched through November 8, 2025. Only trials reporting intention-to-treat or modified intention-to-treat analyses were included. The primary outcome was procedure time. Secondary outcomes included en bloc resection, R0 resection, perforation, delayed bleeding, and traction-related damage to the specimen. Pooled estimates were calculated using the mean difference (MD) and risk ratio (RR). Subgroup analyses were performed based on endoscopist experience, tumor location, and tumor size. RESULTS: Five randomized controlled trials comprising 463 patients (228 TA-ESD and 235 C-ESD) met the inclusion criteria. TA-ESD was associated with a shorter procedure time than C-ESD (mean difference [MD] = -12.45 min, 95% CI: -20.67 to -4.23; P = 0.003); however, this finding was sensitive to leave-one-out analyses, with statistical significance lost after exclusion of either the Bi 2024 or Nagata 2021 trial. Procedure time was lower for both upper/middle-third gastric lesions (MD = -21.21 min, 95% CI: -30.26 to -12.17; P < 0.0001) and lower-third lesions (MD = -10.72 min, 95% CI: -17.79 to -3.64; P = 0.003). En bloc resection rates (risk ratio [RR] = 1.00, 95% CI: 0.98-1.02; P = 0.98) and R0 resection rates (RR = 0.99, 95% CI: 0.93-1.06; P = 0.83) were comparable between groups. There were no differences in perforation (RR = 0.52, 95% CI: 0.07-3.97; P = 0.53) or delayed bleeding (RR = 0.78, 95% CI: 0.29-2.09; P = 0.61). Traction-related specimen damage was rare, with a pooled incidence of 1.3%. CONCLUSION: TA-ESD was associated with shorter procedure time than C-ESD, while maintaining comparable resection quality and safety. However, this association was sensitive to leave-one-out analyses and should therefore be interpreted cautiously. Furthermore, the overall certainty of evidence was limited, with three of five included trials judged to be at high risk of bias, and GRADE certainty for most secondary outcomes rated as low to very low. These limitations, together with the small number of available trials, underscore the need for further large, multicenter randomized studies using standardized traction techniques to better define the efficacy and safety of TA-ESD.