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Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis of randomized clinical trials

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Abstract

Background & Aims

Conventional endoscopic mucosal resection (CEMR) is the established method for the resection of non-pedunculated colorectal lesions (NPCRL) ≥ 10 mm. In the last decade, underwater endoscopic mucosal resection (UEMR) has been introduced as a potential alternative. The aim of this systematic review with meta-analysis is to compare the recurrence and safety of UEMR and CEMR by analyzing only randomized controlled trials (RCTs).

Methods

We systematically searched PubMed, Cochrane Library and EMBASE until April 2023. Studies met the following inclusion criteria: (1) RCTs, (2) comparing UEMR with CEMR, (3) NPCRL ≥ 10 mm, and (4) reporting the outcomes of interest. Primary outcomes were recurrence and safety. Secondary outcomes were en bloc, R0, complete resection, clipping and adverse events per type.

Results

Five RCTs were included. UEMR was associated with a lower recurrence rate (OR: 0.56; 95% CI: 0.32–0.97). Thus, the RR of recurrence was 1.7 times higher in the CEMR group (95% CI, 1.04–2.77). There was no significant difference in the pooled safety analysis. UEMR showed better en bloc resection rates (OR: 1.54; 95% CI: 1.15–2.07), but subgroup analysis showed comparable rates in lesions ≥ 20 mm. R0 resection was higher in UEMR (OR: 1.72; 95% CI: 1.23–2.41). Other outcomes were not different between the 2 groups.

Conclusions

UEMR is as safe as CEMR, with a higher overall R0 rate and a higher en bloc resection rate for lesions < 20 mm, leading to a lower overall recurrence rate. The results of this meta-analysis support the widespread use of UEMR.

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Data availability

The data supporting the findings of this paper are available within the article and its supplementary materials.

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Author notes

  1. Matheus Henrique Gonçalves de Souza and Paula Arruda do Espirito Santo contributed equally to the authorship of this manuscript.

Authors and Affiliations

  1. Universidade Federal Do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil

    Matheus Henrique Gonçalves de Souza

  2. Universidade Federal de São Carlos (UFSCAR), Sao Carlos, Sao Paulo, Brazil

    Paula Arruda do Espirito Santo

  3. Department of Gastroenterology of University of Sao Paulo, Instituto do Cancer do Estado de São Paulo (ICESP), Sao Paulo, Brazil

    Fauze Maluf-Filho & Luciano Lenz

  4. Scholar From National Council for Scientific and Technological Development - CNPq, Brasilia, Brazil

    Fauze Maluf-Filho

  5. Fleury Medicina E Saude, São Paulo, Brazil

    Luciano Lenz

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  1. Matheus Henrique Gonçalves de Souza
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  2. Paula Arruda do Espirito Santo
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  3. Fauze Maluf-Filho
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Contributions

Matheus Henrique Gonçalves de Souza and Paula Arruda do Espirito Santo contributed equally to the authorship of this study, writing the main manuscript text. Fauze Maluf-Filho and Luciano Lenz contributed to the analysis of the results and helped supervise the project. All authors reviewed the manuscript.

Corresponding authors

Correspondence to Matheus Henrique Gonçalves de Souza or Paula Arruda do Espirito Santo.

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Competing interests

No funding was received to assist with the preparation of this manuscript. The authors M.H.G.S., P.A.E.S. and L.L have no competing interests to declare that are relevant to the content of this article. The author F.M.F. declares that he has been employed on the advisory boards of Boston Scientific, Olympus, Medtronic and Cook in the past 3 years.

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de Souza, M.H.G., do Espirito Santo, P.A., Maluf-Filho, F. et al. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis of randomized clinical trials. Int J Colorectal Dis 38, 208 (2023). https://doi.org/10.1007/s00384-023-04505-7

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