Performance of three major techniques for endoscopic submucosal dissection: a systematic review and network meta-analysis.

Endoscopic submucosal dissection (ESD) has been recognized as the standard treatment for early malignant lesions in the gastrointestinal tract. Limited evidence is synthesized on effectiveness of different techniques employed to facilitate ESD. We assessed the comparative efficacy of ESD techniques through a network meta-analysis.Randomized controlled trials (RCTs) comparing different techniques for ESD, including tunnel/pocket method (Tu-ESD), traction method (Tr-ESD), and conventional method (C-ESD) were identified. Study outcomes were en bloc resection, curative resection, procedure time, and adverse events. We performed network meta-analyses for all treatments and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence.18 RCTs involving 2677 patients were analyzed to evaluate the effectiveness of three major ESD techniques. Network meta-analysis results showed no inconsistencies across the network for all outcomes. According to surface under the cumulative ranking analysis, Tu-ESD achieved the highest ranking for curative resection (score 92.1), whereas Tr-ESD ranked highest for reducing procedure time (score 100). Tr-ESD demonstrated a significant reduction in procedure time compared with C-ESD (mean difference: -18.74 [95%CI -25.99 to -11.49]). Sensitivity and subgroup analyses (according to colorectal, gastric, and esophageal locations) showed that Tr-ESD was best for en bloc resection and procedure time, while Tu-ESD was best for curative resection and adverse events.Both Tu-ESD and Tr-ESD were effective and safe dissection methods compared with C-ESD. Given that different ESD techniques offer different advantages, the choice of technique should be tailored to the specific clinical scenario.