Comment on: “Performance of three major techniques for endoscopic submucosal dissection: a systematic review and network meta-analysis’ – more questions than answers?

10.1055/a-2643-7667

We read with interest the network meta-analysis by Ramai et al. comparing endoscopic submucosal dissection (ESD) techniques [1]. However, some methodological issues warrant discussion to enhance the study’s robustness and applicability.

First, the authors stated that they were motivated by the pressing need to analyze the efficacy of ESD techniques systematically. A network meta-analysis of randomized controlled trials (RCTs) comparing different ESD techniques in the colon has already been published by our group [2]. In contrast to our analysis, the authors also included RCTs pertaining to the upper gastrointestinal tract. However, combining ESD outcomes from both the upper and lower gastrointestinal tract is not appropriate because the choice of ESD technique may be biased by the anatomical site (e.g. tunneling is rarely performed in the colon) and the different characteristics of lesions (e.g. gastric vs. colonic lesions), which may impact the outcomes. Therefore, even if the authors performed a sensitivity analysis by location, the overall analysis is of limited utility due to the high risk of indirectness.

Additionally, categorizing tunnel and pocket ESD as a single entity is misleading due to their technical differences [3]. These techniques are often applied to different lesions and anatomical sites, making their unified evaluation of limited usefulness.

In the study, a significant imbalance exists in the focus of RCTs, with 15 studies on traction-assisted ESD and only 4 on the tunneling method. This disparity is likely to favor the technique with more supporting evidence, making the surface under the cumulative ranking scores of limited use in this context [4].

In conclusion, addressing these limitations is crucial for reducing inconsistencies and enhancing data comparability, thus ensuring better applicability of the study’s results in clinical practice.

Publikationsverlauf

Artikel online veröffentlicht:
28. Oktober 2025

• References

• 1 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;
• 2 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
• 3 Elkholy S, Awad A, Haggag H. et al. Different endoscopic submucosal dissection techniques: a tailored approach. VideoGIE 2024; 10: 277-284
• 4 Salanti G, Nikolakopoulou A, Efthimiou O. et al. Introducing the treatment hierarchy question in network meta-analysis. Am J Epidemiol 2022; 191: 930-938