title: Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Endoscopic submucosal dissection (ESD) is an endoscopic resection technique for lesions suspicious of superficial malignancy. It is performed using an ESD knife on its own (standard technique) or by the sequential use of a knife and a snare (hybrid technique). The experience with these techniques is different in Asian and non-Asian countries. We performed a systematic review and meta-analysis of available evidence on colorectal ESD.
  
  
  METHODS
  Electronic databases were searched up to August 2016 for studies evaluating R0, en bloc resection, and adverse event rates of both techniques for the treatment of colorectal lesions. Proportions were pooled by a random effects model.
  
  
  RESULTS
  Ninety-seven studies (71 performed in Asia) evaluated the standard technique and 12 studies (7 in Asia) the hybrid technique. The R0 resection rate of the standard technique was 82.9%, and it was significantly lower in non-Asian versus Asian countries: 71.3% versus 85.6%. The en bloc resection rate was 91% and was significantly lower in non-Asian versus Asian countries (81.2% vs 93%, respectively). Surgery was needed in 1.1% of the ESD-related adverse events, with a significant difference between non-Asian and Asian countries (3.1% vs 0.8%). The R0 and en bloc resection rates with the hybrid technique were significantly lower than those achieved with the standard technique: 60.6% and 68.4%, respectively, with similar adverse event rates.
  
  
  CONCLUSIONS
  In non-Asian countries the standard ESD technique is still failing to achieve acceptable levels of performance. The hybrid technique showed low R0 resection rates and should not be considered as an adequate alternative to the standard technique.
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Fuccio
authors.affiliation: Nuovo Regina Margherita Hospital, Rome, Italy.
authors.forename: Cesare
authors.initials: C
authors.lastname: Hassan
authors.affiliation: Gastroenterology and Endoscopy, Edouard Herriot Hospital, Lyon, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Ponchon
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Mandolesi
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Farioli
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Frazzoni
authors.affiliation: Queen Alexandra Hospital, Cosham, Portsmouth, United Kingdom.
authors.forename: Pradeep
authors.initials: P
authors.lastname: Bhandari
authors.affiliation: Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology (CPO), University Hospital Città della Salute e della Scienza di Torino, Turin, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Bellisario
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Bazzoli
authors.affiliation: Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research and University Hospital, Rozzano (MI), Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Repici
mesh_terms: D001208:Asia; D015179:Colorectal Neoplasms / Q000601:surgery*; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000379:methods; D005060:Europe; D006801:Humans; D018365:Neoplasm, Residual; D009656:North America; D011183:Postoperative Complications / Q000601:surgery; D016896:Treatment Outcome