Chinzon Miriam, Boghossian Mateus Bond, de Oliveira Veras Matheus, Dos Santos Evellin Souza Valentim, Ramai Daryl, de Assis Larissa Mercadante, Lopes Vitor Hernandes, Miyajima Nelson, Bernardo Wanderley Marques, de Moura Eduardo Guimarães Hourneaux
Gastrointestinal Endoscopy Unit, Division of Gastroenterology, Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo - HC/FMUSP, Sao Paulo, Brazil.
Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Surg Endosc. 2025 Jul 21. doi: 10.1007/s00464-025-11981-1.
Early-stage colorectal lesions are traditionally managed with conventional endoscopic mucosal resection (EMR-C). Endoscopic submucosal dissection (ESD), though technically demanding, enables en bloc resection with negative margins. Precut mucosectomy (EMR-P) was developed to enhance en bloc resection rates by minimizing the risk of snare slippage during procedures.
A systematic review and meta-analysis of cohort studies and randomized controlled trials (RCTs) compared EMR-P with EMR-C, ESD, and Hybrid ESD (ESD-H). Databases were queried for studies reporting en bloc resection rate and complete histological resection rate (R0), as well outcomes including procedure time, recurrence rate, and adverse events. Risk ratios (RRs) and weighted mean differences with 95% confidence intervals (CIs) were calculated using random or fixed-effects models based on heterogeneity.
Twelve studies, including 2.575 lesions (921 EMR-P, 615 EMR-C, 955 ESD, 84 ESD-H), were analyzed. EMR-P outperformed EMR-C in en bloc resection rates (RR 1.17, 95% CI: 1.03-1.33; P = 0.01) and R0 resection rates (RR 1.34, 95% CI: 1.15-1.57; P = 0.0002), particularly for flat lesions in the right colon. However, EMR-P was associated with a higher rate of adverse events. Compared to ESD, EMR-P demonstrated lower en bloc resection rate (RR 0.85; 95% CI; 0.75-0.97, P = 0.02) but showed no significant difference R0 resection rate (RR 0.95, 95% CI, 0.88-1.02, P = 0.15). In head-to-head comparisons between EMR-P and ESD-H, no significant differences were observed in en bloc or complete resection rates.
EMR-P emerges as a promising technique for resecting flat colorectal lesions > 10 mm, particularly those in the right colon, by reducing the risk of snare slippage. Future RCTs are essential to establish EMR-P's role in managing large colorectal neoplasms and optimizing recurrence prevention strategies.
早期结直肠病变传统上采用常规内镜黏膜切除术（EMR-C）进行治疗。内镜黏膜下剥离术（ESD）虽然技术要求较高，但能够实现整块切除且切缘阴性。预切开黏膜切除术（EMR-P）的开发是为了通过将手术过程中圈套器滑脱的风险降至最低来提高整块切除率。
对队列研究和随机对照试验（RCT）进行系统评价和荟萃分析，比较EMR-P与EMR-C、ESD和杂交ESD（ESD-H）。在数据库中查询报告整块切除率和完整组织学切除率（R0）的研究，以及包括手术时间、复发率和不良事件在内的结果。根据异质性，使用随机或固定效应模型计算风险比（RRs）和95%置信区间（CIs）的加权平均差。
分析了12项研究，包括2575个病变（921个EMR-P、615个EMR-C、955个ESD、84个ESD-H）。EMR-P在整块切除率（RR 1.17，95%CI：1.03-1.33；P = 0.01）和R0切除率（RR 1.34，95%CI：1.15-1.57；P = 0.0002）方面优于EMR-C，特别是对于右半结肠的扁平病变。然而，EMR-P与较高的不良事件发生率相关。与ESD相比，EMR-P的整块切除率较低（RR 0.85；95%CI；0.75-0.97，P = 0.02），但在R0切除率方面无显著差异（RR 0.95，95%CI，0.88-1.02，P = 0.15）。在EMR-P与ESD-H的直接比较中，整块或完整切除率未观察到显著差异。
EMR-P作为一种有前景的技术，可用于切除直径>10 mm的扁平结直肠病变，特别是右半结肠的病变，通过降低圈套器滑脱的风险。未来的RCT对于确定EMR-P在处理大肠大肿瘤和优化复发预防策略中的作用至关重要。
