Is endoscopic submucosal tunnel dissection better than endoscopic submucosal dissection in treating large superficial esophageal neoplastic lesions? A systematic review and meta-analysis

Background: The resection of large superficial esophageal neoplastic lesions (SENLs) presents significant challenges for traditional endoscopic submucosal dissection (ESD). Endoscopic submucosal tunnel dissection (ESTD) has emerged as an alternative that potentially reduces resection difficulty. Objectives: We aimed to compare ESTD and ESD in the treatment of large SENLs. Design: Meta-analysis of randomized controlled trials (RCTs). Data sources and methods: We systematically searched MEDLINE, EMBASE, Cochrane Library, and Wanfang Data for RCTs comparing ESTD with ESD for large SENLs until July 1, 2024. The grading of recommendations assessment, development, and evaluation framework was used to assess the certainty of the evidence, whereas trial sequential analysis (TSA) was used to control for random errors and evaluate conclusion validity. Results: Four RCTs involving 315 patients were included. The pooled analysis showed that ESTD was significantly faster than ESD (mean differences 5.06, 95% confidence interval: 3.31-6.80; p < 0.01; I2 = 0%; low certainty of evidence). TSA indicated a desired sample size of 162, with the cumulative Z curve crossing the trial sequential monitoring boundary. ESTD also had lower rates of major complications and post-operation esophageal stricture (low certainty of evidence). No significant differences were found in en bloc and curative resection rates. Conclusion: With low certainty, ESTD appears superior to ESD for large SENLs, offering faster resection and fewer complications, with similar en bloc and curative resection rates.