Efficacy and Safety of Advanced Endoscopic Techniques in Early Barrett's Neoplasia: A Systematic Review and Pooled...

Focal endoscopic mucosal resection (f-EMR) followed by radiofrequency ablation (f-EMR+RFA), stepwise/complete EMR (c-EMR), and endoscopic submucosal dissection (ESD) are used to manage Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and early adenocarcinoma (EAC). We present a systematic review and meta-analysis evaluating these modalities' cumulative and comparative efficacy and safety. We evaluated studies reporting efficacy and safety of ESD, f-EMR+RFA, and c-EMR for BE-related early neoplasia management. Primary outcomes were recurrence of HGD or EAC and risk of strictures, perforation, and bleeding. Secondary outcomes were en bloc and R0 resections for ESD and complete eradication of neoplasia for f-EMR-RFA and c-EMR. Thirty-eight studies with 2,434 patients (684 ESD, 938 f-EMR+RFA, 812 c-EMR) were included. Weighted pooled rates (WPR) for recurrence were 10.3% (ESD), 5% (f-EMR+RFA), and 7.4% (c-EMR). There was no difference in recurrence with any endoscopic modality (p>0.05). WPR for strictures was 9.5% (ESD), 11.5% (f-EMR+RFA), and 29% (c-EMR). ESD and f-EMR+RFA were associated with lower stricture formation compared to c-EMR (p<0.05), while there was no difference seen between ESD and f-EMR+RFA. WPR for perforation was 3.7% (ESD), 1.6% (f-EMR+RFA), and 2% (c-EMR). F-EMR+RFA was associated with a lower risk of perforation compared to ESD (p=0.01), while no difference was found between ESD and c-EMR. WPR for bleeding was 3.5% (ESD), 3% (f-EMR+RFA), and 6% (c-EMR). There was no difference in the recurrence of neoplasia with any endoscopic modality. f-EMR+RFA appears to be the preferred endoscopic modality for the management of BE-related neoplasia.