Tunneled or pocket creation method versus conventional endoscopic submucosal dissection for gastric lesions: a systematic review and meta-analysis

Background and aims: Tunneled endoscopic submucosal dissection (T-ESD) and pocket creation-method ESD (PCM-ESD) are considered to have technical advantages over conventional ESD (C-ESD). However, data comparing these techniques for ESD of gastric lesions are limited.

Methods: PubMed and Cochrane databases were reviewed for relevant studies from their inceptions to October 31, 2023. Studies comparing T-ESD or PCM-ESD (T/PCM-ESD) with C-ESD for gastric lesions were included. The primary outcomes were dissection speed and en-bloc resection. Secondary outcomes were R0 resection, recurrence, perforation, and post-ESD bleeding. A random effects meta-analysis was conducted.

Results: Eight observational studies (359 patients with T/PCM-ESD, 670 patients with C-ESD) were included. T/PCM-ESD was associated with a significantly faster dissection speed (mean difference, 4.42 mm²/min; 95% confidence interval [CI], 2.05-6.79; I² = 79%). There were no significant differences between the groups in terms of en-bloc resection (risk ratio [RR], 1.01; 95% CI, 1.00-1.03; I² = 0%), R0 resection (RR, 1.03; 95% CI, 0.99-1.07; I² = 0%), and recurrence (RR, 0.73; 95% CI, 0.14-3.84; I² = 0%). Although T/PCM-ESD was associated with a significantly lower risk of perforation (RR, 0.21; 95% CI, 0.06-0.80; I² = 0%), post-ESD bleeding rates were not significantly different.

Conclusions: T/PCM-ESD facilitates faster and safer gastric ESD than C-ESD, with similar en-bloc resection, R0 resection, and recurrence rates. A future randomized controlled control trial is required.