Superficial non-ampullary duodenal epithelial tumors≥20 mm may represent a superior treatment option compared to EMR: A systematic review and meta-analysis by lesion size

Aims The indications for endoscopic submucosal dissection (ESD) in treating superficial non-ampullary duodenal epithelial tumors (SNADETs) remains controversial. Previous studies have indicated that clinical outcomes of duodenal endoscopic resection, including ESD and endoscopic mucosal resection (EMR), vary based on lesion size. However, no meta-analysis has specifically evaluated outcomes by lesion size. This study aimed to elucidate the indications for ESD in treating SNADETs based on lesion size.

Methods A meta-analysis was conducted to compare the outcomes of ESD and endoscopic mucosal resection (EMR) for SNADETs. A systematic search of PubMed, the Cochrane Library, and the Japan Medical Abstracts Society database was conducted. For studies with duplicate publications, the study with the largest sample size was selected. The rates of en bloc resection, intraoperative perforation, and delayed adverse events which included bleeding and perforation were selected as the outcomes. We contacted to corresponding authors of the studies included in the meta-analysis to request the additional data which were the outcomes according to the lesion size (< 20 mm or≥20 mm), and then compered the outcomes.

Results Fifteen retrospective observational studies were included in the meta-analysis. In the overall analysis, without considering lesion size, the en bloc resection rate (OR: 3.26 [95% CI: 1.60-6.63], p<0.05), intraoperative perforation rate (OR: 9.32 [95% CI: 5.71-15.21], p<0.05), and delayed adverse events rates (OR: 3.70 [95% CI: 2.38-5.75], p<0.05) were significantly higher for the ESD group. The size-specific analysis was conducted using data from nine studies where authors responded. For lesions<20 mm, there was no significant difference in en bloc resection rates between the ESD and EMR groups (OR: 1.18 [95% CI: 0.50-2.77], p=0.7); however, both the incidence of intraoperative perforation (OR: 10.94 [95% CI: 5.87-20.39], p<0.05) and delayed adverse events (OR: 3.70 [95% CI: 2.38-5.75], p<0.05) were significantly higher for the ESD group. Conversely, for lesions≥20 mm, en bloc resection rate was significantly higher for the ESD group (OR: 6.25 [95% CI: 3.05-12.82], p<0.05). The incidence of intraoperative perforation rates was significantly higher for the ESD group (OR: 5.67 [95% CI: 2.37-13.57], p<0.05), while the OR became smaller compare to it in overall analysis. And the incidence of delayed adverse events did not reveal significant difference (OR: 1.26 [95% CI: 0.55-2.88], p=0.58).

Conclusions For SNADETs≥20 mm, ESD appears to offer advantages over EMR by providing higher en bloc resection rates with equivalent rates of delayed adverse events. Therefore, large SNADETs as over 20 mm may be a good indication for ESD.

Publication History

Article published online:
27 March 2025