Underwater versus traction-assisted endoscopic submucosal dissection for colorectal lesions: a network meta-analysis of randomized controlled trials - 19/12/25

Doi : 10.1016/j.gie.2025.09.054

Roberto de Sire, MD, PhD ^1,², Marco Spadaccini, MD, PhD ¹, Diletta De Deo, MD ³, Davide Massimi, MD ^1,^⁎ , Ludovico Alfarone, MD ¹, Antonio Capogreco, MD ¹, Antonio Facciorusso, MD, PhD ⁴, Gianluca Andrisani, MD ⁵, Sandro Sferrazza, MD ⁶, Jeremie Jacques, MD ⁷, Asma Alkandari, MD ⁸, Pradeep Bhandari, MD ⁹, Yuichi Mori, MD, PhD ¹⁰, Cesare Hassan, MD, PhD ^1,³, Roberta Maselli, MD, PhD ^1,³, Alessandro Repici, MD ^1,³

¹ Endoscopy Unit, Gastroenterology Department, Humanitas Research Hospital IRCCS, Rozzano, Italy

² IBD Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy

³ Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy

⁴ Experimental Medicine, Università del Salento, Lecce, Italy

⁵ Digestive Endoscopy Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy

⁶ Gastroenterology and Endoscopy Unit, “ARNAS Civico-Di Cristina-Benfratelli” Hospital, Palermo, Italy

⁷ Gastroenterology and Endoscopy Unit, Dupuytren University Hospital, Limoges, France

⁸ Thanyan Alghanim Gastroenterolgy and Hepatology Center, Amiri Hospital, Kuwait City, Kuwait

⁹ Department of Gastroenterology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK

¹⁰ Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway

^∗ Corresponding author: Davide Massimi, MD, Endoscopy Unit, Gastroenterology Department, Humanitas Research Hospital IRCCS, Via Alessandro Manzoni, 56, Rozzano 20089, Italy. Endoscopy Unit Gastroenterology Department Humanitas Research Hospital IRCCS Via Alessandro Manzoni, 56 Rozzano 20089 Italy

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Friday 19 December 2025

Abstract

Background and Aims

Among the newly established endoscopic submucosal dissection (ESD) techniques, underwater ESD (UW-ESD) using saline solution and traction-assisted ESD (T-ESD) aim to address the limitations of conventional ESD (C-ESD) for the resection of colorectal lesions. However, their comparative efficacy and safety remain uncertain.

Methods

A systematic review and network meta-analysis of randomized controlled trials was conducted to compare UW-ESD and T-ESD. Main outcomes included R0 resection, dissection speed, and adverse events (AEs). We conducted indirect comparisons between UW-ESD and T-ESD and direct comparisons with C-ESD. Results were presented as risk ratios (RR) and standard mean deviations (SMDs) with 95% confidence intervals (CIs).

Results

Four RCTs including 543 ESDs (98 UW-ESDs, 171 T-ESDs, and 274 C-ESDs) were analyzed. For R0 resection, no significant difference was observed between UW-ESD and T-ESD (RR = 0.99; 95% CI, 0.92-1.07), and both were comparable to C-ESD (UW-ESD: RR = 1.02; 95% CI, 0.98-1.07; T-ESD: RR = 1.01; 95% CI, 0.96-1.07). Dissection speed was significantly higher with UW-ESD compared with both T-ESD (SMD = 0.36; 95% CI, 0.14-0.87) and C-ESD (SMD = 0.54; 95% CI, 0.15-0.92). No significant difference in AEs was observed between UW-ESD and T-ESD (RR = 1.80; 95% CI, 0.14-23.16), and both were comparable to C-ESD (UW-ESD: RR = 0.48; 95% CI, 0.06-4.15; T-ESD: RR = 0.86; 95% CI, 0.22-3.37).

Conclusions

UW-ESD and T-ESD are both effective and safe strategies for colorectal lesion resection; however, UW-ESD is the only technique that has demonstrated superior dissection speed.

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