Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal polyps: A meta-analysis and meta-regression with single arm analysis

Table 1 Pooled proportions and comparative meta-analysis of endoscopic submucosal dissection and endoscopic mucosal resection

	Total papers	Sample size (ESD)	Pooled proportions	Sample size (EMR)	Pooled proportions	RR (CI)	P value	Publication bias
En bloc resection	11	1641	89% (0.83-0.94)	1411	47% (0.36-0.59)	1.837 (1.464-2.305)	< 0.001	0.0025
Positive lateral margin	2	123	3% (0.01-0.06)	187	14% (0.09-0.19)	0.292 (0.089-0.995)	0.042	-
Positive vertical margin	1	38	5% (0.00-0.17)	83	1% (0.00-0.07)	4.368 (0.409-46.710)	0.223	-
Complete resection	8	918	82% (0.74-0.88)	1012	56% (0.34-0.77)	1.504 (1.041-2.174)	0.03	-
Lymphovsacular invasion	1	54	6% (0.03-0.13)	23	0% (0.00-0.04)	4.352 (0.248-76.483)	0.315	-
Mean procedural time	8	1087	-	838	-	72.709 (54.487-90.931)	< 0.001	-
Additional surgery	2	99	13% (0.07-0.21)	153	5% (0.02-0.09)	3.139 (1.360-7.243)	0.007	-
Perforation	18	19470	5% (0.03-0.09)	260901	0% (0.00-0.01)	7.597 (4.281-13.479)	< 0.001	0.301
Bleeding	14	20048	3% (0.02-0.05)	257065	3% (0.02-0.04)	1.277 (0.896-1.820)	0.175	0.139
Recurrences	12	1822	2% (0.01-0.03)	37721	10% (0.04-0.17)	0.269 (0.112-0.648)	0.003	0.725

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; CI: Confidence interval.

Table 2 Meta-regression

	En bloc resection			Complete resection			Perforation			Bleeding			Recurrence
	n	Beta (CI)	P value	n	Beta (CI)	P value	n	Beta (CI)	P value	n	Beta (CI)	P value	n	Beta (CI)	P value
Age	8	-0.017 (-0.168-0.133)	0.785	5	-0.010 (-0.426-0.406)	0.944	9	0.073 (-0.191-0.336)	0.535	8	-0.201 (-0.540-0.138)	0.197	8	0.254 (-0.039-0.547)	0.078
Gender	6	-6.023 (-23.152-11.106)	0.384	4	-20.662 (-108.758-67.434)	0.419	8	-7.868 (-22.078–6.342)	0.224	7	-4.446 (-27.915-19.022)	0.647	6	-9.096 (-62.174-43.982)	0.659
Polyp size	10	0.242 (-0.037-0.086)	0.390	6	-0.034 (-0.098-0.030)	0.217	10	-0.034 (-0.117-0.049)	0.378	9	-0.041 (-0.177-0.095)	0.498	8	0.077 (-0.118-0.272)	0.369
Lateral spreading tumor	10	1.262 (-1.072-3.596)	0.248	7	-0.481 (-4.655-3.693)	0.779	11	-2.324 (-5.536-0.888)	0.136	9	-0.680 (-5.586-4.226)	0.753	9	3.827 (-2.323-9.977)	0.185
Right colon	8	1.247 (-2.024-4.517)	0.387	5	2.373 (-0.881-5.626)	0.103	8	7.731 (4.965-10.497)	< 0.001	7	1.688 (-12.442-15.817)	0.771	6	-8.739 (-26.616-9.139)	0.246
Colon	7	-1.803 (-4.486-0.880)	0.145	4	-1.914 (-7.213-3.385)	0.26	8	0.759 (-3.184-4.701)	0.654	6	6.649 (-5.182-18.480)	0.194	7	-1.102 (-4.754-2.551)	0.473
Rectum	7	1.803 (-0.880-4.486)	0.145	4	1.914 (-3.385-7.213)	0.26	8	-0.759 (-4.701-3.184)	0.654	6	-6.649 (-18.480-5.182)	0.194	7	1.102 (-2.551-4.754)	0.473
Submucosal invasion	8	-0.004 (-0.014-0.007)	0.431	5	-0.006 (-0.020-0.008)	0.253	9	0.001 (-0.049-0.051)	0.956	8	-0.016 (-0.033-0.001)	0.061	7	-6.508 (-27.976-14.960)	0.471
Muscularis propria invasion	8	-5.870 (-17.738-5.998)	0.272	5	-0.157 (-21.715-21.401)	0.983	9	6.731 (-33.772-47.234)	0.706	8	-109.836 (-1040.943-821.272)	0.783	-	-	-

CI: Confidence interval.

Table 3 Subgroup analysis (Japan and rest of the world) of pooled proportions and comparative meta-analysis of endoscopic submucosal dissection and endoscopic mucosal resection

	Japan papers	Pooled proportions (ESD)	Pooled proportions (EMR)	RR (CI)	P value	Rest of the world papers	Pooled proportions (ESD)	Pooled proportions (EMR)	RR (CI)	P value
Overall results
En bloc resection	6	89% (0.77-0.97)	53% (0.38-0.67)	1.658 (1.270-2.165)	< 0.001	5	90% (0.85-0.94)	41% (0.22-0.61)	2.201 (1.411-3.433)	0.001
Positive lateral margin	2	3% (0.00-0.06)	14% (0.09-0.19)	0.292 (0.089-0.955)	0.042	-	-	-	-	-
Positive vertical margin	1	5% (0.01-0.17)	1% (0.00-0.05)	4.368 (0.409-46.710)	0.223	-	-	-	-	-
Complete resection	2	79% (0.73-0.84)	53% (0.48-0.58)	1.452 (1.303-1.618)	< 0.001	6	85% (0.78-0.91)	59% (0.27-0.88)	1.562 (0.921-2.650)	0.098
Lymphovsacular invasion	1	6% (0.03-0.13)	0% (0.00-0.04)	4.352 (0.248-76.483)	0.315	-	-	-	-	-
Mean procedural time	4	-	-	72.106 (48.831-95.382)	< 0.001	4	-	-	73.916 (36.075-111.757)	< 0.001
Additional surgery	2	13% (0.07-0.21)	5% (0.02-0.09)	3.139 (1.360-7.243)	0.007	-	-	-	-	-
Perforation	11	4% (0.01-0.07)	0.0002% (0.00-0.00081)	9.586 (4.425-20.768)	< 0.001	7	8% (0.05-0.12)	1% (0.00-0.02)	4.602 (2.729-7.759)	< 0.001
Bleeding	8	2.4% (0.01-0.04)	2.1% (0.01-0.03)	1.267 (1.174-1.367)	< 0.001	6	5% (0.02- 0.11)	3% (0.01-0.06)	1.986 (0.716-5.508)	0.188
Recurrences	7	1% (0.01-0.02)	7% (0.02-0.15)	0.274 (0.071-1.054)	0.06	5	3% (0.00-0.08)	16% (0.04-0.32)	0.245 (0.073-0.819)	0.022
Sensitivity analysis (≥ 20 mm only)
En bloc resection	4	82% (0.72-0.91)	50% (0.33-0.67)	1.645 (1.174-2.306)	0.004	2	91% (0.88-0.93)	33% (0.28-0.37)	2.668 (1.752-4.063)	< 0.001
Positive lateral margin	2	3% (0.00-0.06)	14% (0.09-0.19)	0.292 (0.089-0.955)	0.042	-	-	-	-	-
Positive vertical margin	1	5% (0.01-0.17)	1% (0.00-0.07)	4.368 (0.409-46.710)	0.223	-	-	-	-	-
Complete resection	2	79% (0.73-0.84)	53% (0.48-0.58)	1.452 (1.303-1.618)	< 0.001	2	90% (0.87-0.93)	77% (0.73-0.82)	1.613 (0.209-12.452)	0.647
Lymphovsacular invasion	2	6% (0.03-0.13)	0% (0.00-0.04)	4.352 (0.248-76.483)	0.315	-	-	-	-	-
Mean procedural time	2	-	-	69.167 (48.446-89.888)	< 0.001	1	-	-	82.700 (67.578-97.822)	< 0.001
Additional surgery	2	13% (0.07-0.21)	5% (0.02-0.09)	3.139 (1.360-7.243)	0.007	-	-	-	-	-
Perforation	5	4% (0.01-0.07)	0% (0.00-0.01)	5.235 (2.123-12.910)	< 0.001	3	7% (0.05-0.10)	1% (0.00-0.03)	4.546 (1.674-12.346)	0.003
Bleeding	4	3% (0.00-0.07)	3% (0.01-0.05)	0.895 (0.438-1.829)	0.762	3	3% (0.00-0.08)	1% (0.00-0.04)	2.233 (0.489-10.197)	0.300
Recurrences	5	1% (0.00-0.02)	7% (0.02-0.15)	0.204 (0.097-0.429)	< 0.001	3	3% (0.00-0.10)	27% (0.10-0.20)	0.179 (0.032-0.990)	0.049

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; RR: Relative risk; CI: Confidence interval.