Reply to Maida et al.

10.1055/a-2667-7586

We appreciate the opportunity to respond to the letter by Maida et al. [1] regarding our study [2], and address their concerns below.

Maida et al. referenced their network meta-analysis comparing five colorectal endoscopic submucosal dissection (ESD) techniques [3]. However, their results were statistically nonsignificant and did not report procedure time – a key metric for assessing clinical efficiency. In contrast, our study evaluated efficacy, efficiency (including procedure time), and safety. We demonstrated that traction-assisted ESD significantly reduces procedure time and improves en bloc resection rates without increasing adverse events, offering practical value for clinicians practicing or learning ESD.

Concerns regarding indirectness and study imbalance are inherent in network meta-analyses. We addressed these through a Bayesian framework, sensitivity analyses, and careful interpretation of surface under the cumulative ranking (SUCRA) scores as indicators of relative trends – not definitive rankings. Limitations, including the uneven number of randomized controlled trials, were clearly acknowledged.

Their critique of the tunnel method’s rarity in colorectal ESD is surprising and likely reflects regional practice differences. Given the conceptual similarity between tunnel and pocket techniques – the main distinction being the absence of a distal mucosal incision in the latter –we grouped them to improve generalizability across upper and lower gastrointestinal ESD. This decision was informed by clinical expertise.

Hybrid ESD was excluded from our analysis as it is typically used by less experienced operators or in salvage settings, often resulting in piecemeal resection. Including it would not align with the primary objective of ESD: en bloc resection. While Maida et al. included hybrid ESD in their study, it has little relevance for clinicians whose goals are aligned with the objectives of ESD, further distinguishing our work.

We maintain that technique selection should be individualized based on lesion characteristics and operator expertise. We underscore that these different techniques are complementary to each other in the right clinical context.

Publikationsverlauf

Artikel online veröffentlicht:
28. Oktober 2025

• References

• 1 Maida M, Facciorusso A, Sferrazza S. Comment on: “Performance of three major techniques for endoscopic submucosal dissection: a systematic review and network meta-analysis’ – more questions than answers?. Endoscopy 2025; 57
• 2 Ramai D, Qatomah A, Chun M. et al. Performance of three major techniques for endoscopic submucosal dissection: a systematic review and network meta-analysis. Endoscopy 2025;
• 3 Maida M, Facciorusso A, Marasco G. et al. Comparative efficacy of different techniques for colonic endoscopic submucosal dissection: a network meta-analysis of randomized controlled trials. Dig Liver Dis 2025; 57: 527-534