Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
Surg Endosc. 2020 Apr;34(4):1688-1695. doi: 10.1007/s00464-019-06945-1. Epub 2019 Jul 10.
While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors.
Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I statistics, and publication bias by funnel plot using Egger and Begg tests.
Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43 cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35 min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94 days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I = 0.00%] and R resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I = 0.00%].
ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.
虽然多项研究已经评估了内镜黏膜下剥离术（ESD）和经肛门内镜微创手术（TEM）用于切除大型直肠肿瘤，但仍缺乏比较这两种方法疗效和安全性的数据。本研究的主要目的是进行系统评价和荟萃分析，以比较 ESD 和 TEM 治疗直肠肿瘤的疗效和安全性。
根据 PRISMA 指南，从开始到 2018 年 11 月制定个体化的搜索策略。测量的结果包括整块切除率、边缘阴性（R）切除率、与手术相关的不良事件和复发率。这是一项累积荟萃分析，通过计算汇总比例来进行。使用 Cochran Q 检验和 I 统计量评估异质性，并使用 Egger 和 Begg 检验通过漏斗图评估发表偏倚。
本荟萃分析纳入了 3 项研究（n=158 例患者；55.22%为男性）。与 TEM 相比，ESD 组患者的年龄（P=0.090）、直肠肿瘤大小（P=0.108）和腺瘤与癌症的诊断率（P=0.53）相似。ESD 病变比 TEM 更靠近近端（距肛门缘 8.41±3.49cm 比 5.11±1.43cm；P<0.001）。ESD 的手术时间和住院时间均短于 TEM[（79.78±24.45 比 116.61±19.35 分钟；P<0.001）和（3.99±0.32 比 5.83±0.94 天；P<0.001）]。ESD 和 TEM 的整块切除率[比值比（OR）0.98（95%置信区间 0.22-4.33）；P=0.98；I=0.00%]和 R 切除率[OR 1.16（95%置信区间 0.36-3.76）；P=0.80；I=0.00%]之间无显著差异。ESD 和 TEM 报告的不良事件[OR 1.15（95%置信区间 0.47-2.77）；P=0.80；I=0.00%]和复发率[OR 0.46（95%置信区间 0.07-3.14）；P=0.43；I=0.00%]相似。
对于大型直肠肿瘤患者，ESD 和 TEM 的切除率、不良事件和复发率相似；然而，ESD 与明显更短的手术时间和住院时间相关。需要进一步研究来评估这两种策略的医疗保健利用情况。
