Skip to main content

Advertisement

Log in

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Endoscopic submucosal dissection (ESD) allows en bloc resection of the entire lesion, permitting a higher curative resection rate and increased quality of life by minimizing the resection size compared with that of endoscopic mucosal resection (EMR). Although ESD has been implemented at most university hospitals in Korea, potential complications of ESD such as bleeding and perforation raise doubts in the therapeutic decision on use of the ESD procedure for early gastric cancer patients and in reimbursement decision making. This systematic review aimed to address both the effectiveness and safety outcomes of ESD versus EMR for early gastric cancer.

Methods

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Koreamed were searched using the primary keywords “stomach neoplasm” AND “endoscopic submucosal dissection” AND “endoscopic mucosal resection.” To assess the quality of selected studies, the methodologic approach of the Scottish Intercollegiate Guidelines Network was used. Five effectiveness-relevant and three safety-relevant outcome measures were extracted. Bibliography management and metaanalysis for each outcome were conducted using Review Manager 5.0.

Results

Three nonconcurrent cohort studies and nine retrospective cohort studies were identified. Metaanalyses showed ESD to be significantly more effective than EMR for en bloc resection (odds ratio [OR], 8.43; 95% confidence interval [CI], 5.20–13.67), complete resection (OR, 14.11; 95% CI, 10.85–18.35), curative resection (OR, 3.28; 95% CI, 1.95–5.54), and local recurrence (risk ratio [RR], 0.13; 95% CI, 0.04–0.41). Whereas intraoperative bleeding (RR, 2.16; 95% CI, 1.14–4.09), perforation risk (RR, 3.58; 95% CI, 1.95–6.55), and operation time (standard mean difference [SMD], 1.55; 95% CI, 0.74–2.37) were significantly greater for ESD, overall bleeding risk (RR, 1.22; 95% CI, 0.76–1.98) and all-cause mortality (RR, 0.65; 95% CI, 0.08–5.38) did not differ significantly between ESD and EMR.

Conclusions

Considering that bleeding risk did not differ significantly between ESD and EMR and that perforation risk usually does not lead to life-threatening disease, the effectiveness benefit of ESD can outweigh the overall harm compared with EMR on the condition that ESD is performed by experienced practitioners.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Nakamura K, Ueyama T, Yao T, Xuan ZX, Ambe K, Adachi Y, Yakeishi Y, Matsukuma A, Enjoji M (1992) Pathology and prognosis of gastric carcinoma: findings in 10,000 patients who underwent primary gastrectomy. Cancer 70:1030–1037

    Article  PubMed  CAS  Google Scholar 

  2. Kang KJ, Lee JH (2010) Characteristics of gastric cancer in Korea—with an emphasis on the increase of the early gastric cancer (EGC). J Korean Med Assoc 53:283–289

    Article  Google Scholar 

  3. Ono H, Kondo H, Gotoda T, Shirao K, Yamaguchi H, Saito D, Hosokawa K, Shimoda T, Yoshida S (2001) Endoscopic mucosal resection for treatment of early gastric cancer. Gut 48:225–229

    Article  PubMed  CAS  Google Scholar 

  4. Jung HY (2008) Extended approach of EMR/ESD in stomach cancer. J Korean Gastric Cancer Assoc 8:5–8

    Google Scholar 

  5. Hotta K, Oyama T, Akamatsu T, Tomori A, Hasebe O, Nakamura N, Kojima E, Suga T, Miyabayashi H, Ohta H (2010) A comparison of outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasms between high-volume and low-volume centers: multicenter retrospective questionnaire study conducted by the Nagano ESD study group. Intern Med 49:253–259

    Article  PubMed  Google Scholar 

  6. Sumiyama K, Kaise M, Nakayoshi T, Kato M, Mashiko T, Uchiyama Y, Goda K, Hino S, Nakamura Y, Matsuda K, Mochizuki K, Kawamura M, Tajiri H (2004) Combined use of a magnifying endoscope with a narrow band imaging system and a multibending endoscope for en bloc EMR of early-stage gastric cancer. Gastrointest Endosc 60:79–84

    Article  PubMed  Google Scholar 

  7. Jang JS, Lee EJ, Lee SW, Lee JH, Roh MH, Han SY, Choi SR, Jeong JS (2007) Endoscopic submucosal dissection for early gastric cancer and gastric adenoma. Korean J Gastroenterol 49:356–363

    PubMed  Google Scholar 

  8. Chung IK, Lee JH, Lee SH, Kim SJ, Cho JY, Cho WY, Hwangbo Y, Keum BR, Park JJ, Chun HJ, Kim HJ, Kim JJ, Ji SR, Seol SY (2009) Therapeutic outcomes in 1,000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD study group multicenter study. Gastrointest Endosc 69:1228–1235

    Article  PubMed  Google Scholar 

  9. Cao Y, Liao C, Tan A, Gao Y, Mo Z, Gao F (2009) Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 41:751–757

    Article  PubMed  CAS  Google Scholar 

  10. Hirasaki S, Kanzaki H, Matsubara M, Fujita K, Matsumura S, Suzuki S (2008) Treatment of gastric remnant cancer postdistal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife. World J Gastroenterol 14:2550–2555

    Article  PubMed  Google Scholar 

  11. Hoteya S, Iizuka T, Kikuchi D, Yahagi N (2010) Clinical advantages of endoscopic submucosal dissection for gastric cancers in remnant stomach surpass conventional endoscopic mucosal resection. Dig Endosc 22:17–20

    Article  PubMed  Google Scholar 

  12. Oda I, Saito D, Tada M, Iishi H, Tanabe S, Oyama T, Doi T, Otani Y, Fujisaki J, Ajioka Y, Hamada T, Inoue H, Gotoda T, Yoshida S (2006) A multicenter retrospective study of endoscopic resection for early gastric cancer. Gastric Cancer 9:262–270

    Article  PubMed  Google Scholar 

  13. Min BH, Lee JH, Kim JJ, Shim SG, Chang DK, Kim YH, Rhee PL, Kim KM, Park CK, Rhee JC (2009) Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: comparison with endoscopic mucosal resection after circumferential precutting (EMR-P). Dig Liver Dis 41:201–209

    Article  PubMed  Google Scholar 

  14. Catalano F, Trecca A, Rodella L, Lombardo F, Tomezzoli A, Battista S, Silano M, Gaj F, de Manzoni G (2009) The modern treatment of early gastric cancer: our experience in an Italian cohort. Surg Endosc 23:1581–1586

    Article  PubMed  Google Scholar 

  15. Yokoi C, Gotoda T, Hamanaka H, Oda I (2006) Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection. Gastrointest Endosc 64:212–218

    Article  PubMed  Google Scholar 

  16. Hoteya S, Iizuka T, Kikuchi D, Yahagi N (2009) Benefits of endoscopic submucosal dissection according to size and location of gastric neoplasm, compared with conventional mucosal resection. J Gastroenterol Hepatol 24:1102–1106

    Article  PubMed  Google Scholar 

  17. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558

    Article  PubMed  Google Scholar 

  18. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188

    Article  PubMed  Google Scholar 

  19. Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634

    PubMed  CAS  Google Scholar 

  20. Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, Yoshihara M, Chayama K (2006) Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 64:877–883

    Article  PubMed  Google Scholar 

  21. Watanabe K, Ogata S, Kawazoe S, Koyama T, Kajiwara T, Shimoda Y, Takase Y, Irie K, Mizuguchi M, Tsunada S, Iwakiri R, Fujimoto K (2006) Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection. Gastrointest Endosc 63:776–782

    Article  PubMed  Google Scholar 

  22. Choi KS, Jung HY, Choi KD, Chung JW, Oh TH, Jo JY, Song HJ, Lee GH, Byeon JS, Myung SJ, Yang SK, Kim JH (2006) Endoscopic submucosal dissection for gastric tumors: complete resection rate, resection time, and complications in comparison with endoscopic mucosal resection after circumferential mucosal incision with a needle knife. Korean J Gastrointest Endosc 32:326–332

    Google Scholar 

  23. Shimura T, Sasaki M, Kataoka H, Tanida S, Oshima T, Ogasawara N, Wada T, Kubota E, Yamada T, Mori Y, Fujita F, Nakao H, Ohara H, Inukai M, Kasugai K, Joh T (2007) Advantages of endoscopic submucosal dissection over conventional endoscopic mucosal resection. J Gastroenterol Hepatol 22:821–826

    Article  PubMed  Google Scholar 

  24. Nakamoto S, Sakai Y, Kasanuki J, Kondo F, Ooka Y, Kato K, Arai M, Suzuki T, Matsumura T, Bekku D, Ito K, Tanaka T, Yokosuka O (2009) Indications for the use of endoscopic mucosal resection for early gastric cancer in Japan: a comparative study with endoscopic submucosal dissection. Endoscopy 41:746–750

    Article  PubMed  CAS  Google Scholar 

  25. Yamaguchi Y, Katusmi N, Aoki K, Toki M, Nakamura K, Abe N, Morozumi K, Sugiyama M, Ishida H, Takahashi S (2007) Resection area of 15 mm as dividing line for choosing strip biopsy or endoscopic submucosal dissection for mucosal gastric neoplasm. J Clin Gastroenterol 41:472–476

    Article  PubMed  Google Scholar 

  26. Ohkuwa M, Hosokawa K, Boku N, Ohtu A, Tajiri H, Yoshida S (2001) New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife. Endoscopy 33:221–226

    Article  PubMed  CAS  Google Scholar 

Download references

Disclosures

Young-Mi Park, Eun Cho, Hye-Young Kang, Jong-Mann Kim have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Eun Cho.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Park, YM., Cho, E., Kang, HY. et al. The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc 25, 2666–2677 (2011). https://doi.org/10.1007/s00464-011-1627-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-011-1627-z

Keywords

Navigation