Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions

Table 1 Study characteristics comparing outcomes of colorectal endoscopic mucosal resection vs endoscopic submucosal dissection

Ref.	Year	Study site	Publication type	Total sample size	EMR			ESD
					Sample size	Male (%)	Age [mean ± SD (range)]	Sample size	Male (%)	Age [mean/median ± SD (range)]
Tajika et al[22]	2011	Japan	Full paper	189	104	61	59.9 ± 10.6	85	58	64.3 ± 9.2
Lee et al[23]	2012	South Korea	Full paper	454	140	64	63 (23-90)	314	55	61 (25-85)
Kobayashi et al[24]	2012	Japan	Full paper	84	56	68	65.9 ± 9.9	28	68	65.1 ± 9.7
Saito et al[25]	2010	Japan	Full paper	373	228	-	64 ± 4	145	-	64 ± 11
Kim et al[26]	2009	South Korea	Abstract	121	76	-	-	45	-	-
Tamegai et al[19]	2007	Japan	Full paper	103	32	-	-	71	54	63.4

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.

Table 2 Colorectal lesion characteristics

Ref.	Lesion size [mean ± SD (range) mm]		Operating time [mean or median ± SD (range) min]		Lesion location (EMR: ESD cases)			Lesion type (EMR:ESD cases)
	EMR	ESD	EMR	ESD	Left colon	Right colon	Rectum	Sessile	Depressed	Protruding	LST-G	LST-NG	LST-F	Recurrence
Tajika et al[22]	25.5 ± 6.8 (20-55)	31.6 ± 9 (20-54)	29.4 ± 26.1 (3-115)	87.2 ± 49.7 (19-256)	41:13	35:41	28:31		0:1	68:10	28:33	7:38		1:3
Lee et al[23]	21.7 ± 3.5 (20-40)	28.9 ± 12.7 (20-145)	-	54.73 ± 40.9 (6-321)	41:82	82:172	0.75	36:73			49:129	55:112
Kobayashi et al[24]	25 ± 9	27.1 ± 10.1	11 (2-280)	140 (45-400)	26:14	15:6	15:8			12:0	22:6	22:20		0:6
Saito et al[25]	28 ± 8 (20-95)	37 ± 14 (20-140)	29 ± 25 (3-120)	108 ± 7 (15-360)	52:28	89:44	110:73	80:5	0:2		114:62	34:71
Kim et al[26]	-	-	-	-	-	-	-				28:48	6:16	22:2
Tamegai et al[19]	28.7 (20-60)	32.1 (13-75)	-	61.1 (7-164)	-:28	-:26	-:17		0:2	12:19

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; LST-G: Laterally spreading tumour granular type; LST-NG: Laterally spreading tumour nodular granular type; LST-F: Laterally spreading tumour flat type.

Table 3 The outcomes of endoscopic mucosal resection and endoscopic submucosal dissection of colorectal lesions

Ref.	En-bloc resection rate (%)		Piecemeal resection rate (%)		R0 lesion margins (%)		Endoscopic completeness rate (%)		Bleeding rate EMR:ESD (%)	Perforation rate EMR:ESD (%)	Total complication rate (%)	Surgery post EMR/ESD (EMR:ESD cases)
	EMR	ESD	EMR	ESD	EMR	ESD	EMR	ESD				Due to perfor-ation	Due to deep invasion
Tajika et al[22]	48.1	83.5	52.9	16.5	39.4	83.5	97	98.8	2.9:2.4	0:5.9	2.9:8.2	0:3	0
Lee et al[23]	42.9	92.7	57.1	7.3	32.9	87.6	99.1	90.8	0:0.6	0:8	5.7:11.5	0:2	9:26
Kobayashi et al[24]	37.5	92.9	62.5	7.1	-	-	98.2	100	1.8:7.1	0:10.7	1.8:17.9	0	0
Saito et al[25]	33	84	67	16	-	-	98.7	100	3.1:1.4	1.3:6.2	4.4:7.6	0	0
Kim et al[26]	72.4	80	27.6	20	-	-	100	100	-	-	3.9:6.7	-	-
Tamegai et al[19]	0	98.6	100	1.4	-	95.6	100	90.1	-:0	-:1.4	-:1.4	-	-:7

NB total complication rate includes coagulation syndrome. EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.

Table 4 Recurrent lesion characteristics

Ref.	Follow-up time (mean or median ± SD, range) (mo)		Recurrence rate (%)		Piecemeal resection rate of recurrent lesions (%)		Recurrent lesion histology (EMR:ESD cases)				Treatment of recurrent lesion (EMR:ESD cases)
	EMR	ESD	EMR	ESD	EMR	ESD	Adenoma	Non-inv cancer	Sm1	Invasive cancer	APC	EMR	Surgery
Tajika et al[22]	53.8 ± 44.6 (3-191	14.3 ± 13.4 (3-53)	15.4	1.2	94	100	13/16:0	3/16:0	0:1/1	0:0	7/16:0	8/16:0	1/16:1/1
Lee et al[23]	26 (IQ range 13-41)	17 (IQ range 10-23)	25.7	0.8	90	50	-:2/2 (serrated)	-	-	-	0:0	28/29:2/2	1/29:0
Kobayashi et al[24]	38 (2.8-112.5)	19.9 (6.4-43.9)	21.4	0	92	n/a	8/12:0	3/12:0	0	1/12:0	0:0	11/12:0	1/12:0
Saito et al[25]	26 ± 17 (6-68)	20 ± 13 (6-61)	14	2	94	100	-:3/3	-	-	2/33:0	0:0	30/33:	3/33:0
												3/33
Kim et al[26]	12 (6-12)	12 (6-12)	11.8	4.8	-	0	-	1/1:0	0	0:0	-	-	-
Tamegai et al[19]	19.2 (3-34)	12.2 (3-34)	6.3	0	100	-	-	-	-	-	-:0	2/2:0	0:0

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; APC: Argon photocoagulation.

Table 5 Criteria for modified newcastle ottawa scoring system

Quality Checklist
Selection
1	Assignment for treatment-any criteria reported (if yes, 1-star)?
2	How representative was the reference group (EMR group) in comparison to the general population for colorectal lesions? (If yes, 1-star, no stars if the patients were selected or selection of group was not described)
3	How representative was the treatment group (ESD group) in comparison to the general population for colorectal lesions? (If drawn from the same community as the reference group, 1-star, no stars if drawn from a different source or selection of group was not described)
Comparability
Comparability variables	(1) Age; (2) gender; (3) lesion size; (4) LST; (5) lesion location; (6) LGD; (7) HGD; (8) submucosal tumor; (9)non-invasive cancer; (10) cancer
4	Groups comparable for 1, 2, 3, 4, 5 (If yes, 1-star was assigned for each of these. No star was assigned if the two groups differed)
5	Groups comparable for 6, 7, 8, 9, 10 (If yes, 1-star was assigned for each of these. No star was assigned if the two groups differed)
Outcome assessment
6	Clearly defined outcome of interest (if yes, 1-star)
7	Follow-up (1-star if described)

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; LST: Lateral spreading tumor; LGD: Low grade dysplasia; HGD: High grade dysplasia.

Table 6 Sub-group analysis of the four highest quality studies[22-25]

	I2(%)	P value	95%CI	Effect size
En-bloc resection rate	82.3	< 0.0001	0.14-0.81	0.476
Piecemeal resection rate	51.7	0.102	-0.76-0.19	-0.472
Endoscopic completeness rate	93.1	< 0.0001	0.19-0.17	-0.008
Recurrence rate	82.1	< 0.0001	0.13-0.82	0.476