Updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: A systematic review and meta-analysis

Endoscopic resection (ER) has been a standard treatment modality for early gastric cancer with ignorable risks of lymph node metastasis. As for EGCs within expanded indications, endoscopic submucosal dissection (ESD) has considerable advantages over endoscopic mucosal resection (EMR) regarding higher rate of en bloc resection, complete resection, but lower risk of local recurrence. Previous meta-analyses comparing ESD with surgery for EGC are scarce and not robust to reach definitive conclusions. We searched PubMed, Web of Science, EMBASE, Cochrane Library Databases and Google Scholar through July 2019 to identify studies evaluating ESD vs surgery for EGC. Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of enrolled studies. Patient baseline characteristics, procedure-related and prognosis outcomes, and adverse event data were extracted and pooled for analyses by the Review Manager 5.3 software. Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) were used to assess the quality of evidence. Trial Sequential Analysis (TSA) was conducted to weaken random error and enhance the reliability of evidence. Totally 18 retrospective studies, involving 5993 patients, were included. ESD benefits were 128.38 min shorter operation duration [95%CI: (−204.68, −52.09), P = 0.001], 7.13 days shorter hospital stay [95%CI: (−7.98, −6.28), P < 0.00001], lower risk of procedure-related death [OR = 0.21, 95%CI: (0.07, 0.68), P = 0.009], lower risk of overall complication [OR = 0.47, 95%CI: (0.34, 0.63), P < 0.00001]. ESD was also associated with lower costs and better quality of life. However, ESD had lower rate of en bloc resection [OR = 0.07, 95%CI: (0.03, 0.21), P < 0.00001], histologically complete resection [OR = 0.07, 95%CI: (0.03, 0.14), P < 0.00001], curative resection [OR = 0.06, 95%CI: (0.01, 0.27), P = 0.002], and higher rate of local recurrence [OR = 5.42, 95%CI: (2.91, 10.11), P < 0.00001], metachronous cancer [OR = 10.84, 95%CI: (6.43, 18.26), P < 0.00001], synchronous cancer [OR = 6.59, 95%CI: (1.96, 22.1), P = 0.002]. ESD also led to lower disease-free survival [HR = 4.58, 95%CI: (2.79, 7.52), P < 0.00001] and recurrence-free survival [HR = 1.99, 95%CI: (1.38, 2.87), P = 0.0002]. No significant differences in overall survival (OS) and disease-specific survival (DSS) between ESD and surgery were observed. ESD offers a method of less expensive, less trauma, faster recovery and better quality of life compared to surgery for EGC. However, ESD is associated with higher risk of recurrence without compromising OS and DSS. Strict and careful surveillance after ESD is needed. Recurrent EGCs following ESD can usually be detected in early stage and successfully managed by repeated ESD. Accordingly, ESD technique provides an alternative to surgical resection for highly selected EGC patients.