Comparative Clinical Outcomes of Various Colorectal Endoscopic Submucosal Dissection Techniques: A Systematic Review and Network Meta-Analysis.

BACKGROUND/AIMS: Traction-assisted endoscopic submucosal dissection (T-ESD), hybrid ESD (H-ESD), pocket-creation method ESD (P-ESD), and underwater ESD (U-ESD) were introduced to overcome the limitations of conventional ESD (C-ESD). We conducted a systematic review and network meta-analysis to compare the clinical outcomes of different colorectal ESD techniques. METHODS: Randomized controlled trials (RCTs) comparing various ESD techniques (C-ESD, T-ESD, H-ESD, P-ESD, U-ESD) were included. Procedure time, dissection speed, en bloc resection, complete resection, perforation, and delayed bleeding were compared using network meta-analysis. RESULTS: Sixteen RCTs involving 1,536 patients were included. T-ESD had a shorter procedure time (mean difference [MD], -25.17; 95% confidence interval [CI], -34.09 to -16.24). Dissection speed was faster with T-ESD (MD, 6.19; 95% CI, 2.12 to 10.26; surface under the cumulative ranking curve [SUCRA], 74.6) and H-ESD had a high SUCRA (73.0) for dissection speed. Based on the SUCRA rankings, T-ESD (81.4) and P-ESD (55.8) ranked higher for en bloc resection, while U-ESD (74.5) and T-ESD (65.2) ranked higher for complete resection. H-ESD consistently ranked lower than C-ESD for en bloc resection (6.5), complete resection (23.3), and delayed bleeding (23.6) according to SUCRA values. Regarding safety outcomes, T-ESD showed the most favorable SUCRA ranking for perforation (73.6), and U-ESD showed the most favorable SUCRA ranking for delayed bleeding (74.9). CONCLUSIONS: T-ESD ranked higher according to SUCRA values across multiple efficacy and safety outcomes. U-ESD ranked favorably for complete resection and delayed bleeding based on SUCRA values. H-ESD had a higher SUCRA value for dissection speed but ranked lower for en bloc resection, complete resection, and delayed bleeding.