# Poster Session I - A157 EFFICACY OF ENDOSCOPIC MUCOSAL RESECTION (EMR) VERSUS ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) FOR SUPERFICIAL DUODENAL LESIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS

## TL;DR

This study compares two endoscopic techniques for removing duodenal lesions, finding that ESD offers better resection quality but higher risks, while EMR is safer for most cases.

## Contribution

The study provides a systematic review and meta-analysis comparing EMR and ESD for superficial duodenal lesions, offering evidence-based guidance for clinical practice.

## Key findings

- ESD improves en-bloc and R0 resection rates compared to EMR.
- ESD increases procedural risks like perforation and delayed bleeding.
- For lesions ≥20 mm, ESD's advantages diminish except for higher intraprocedural perforation risk.

## Abstract

ESD has been established as a minimally invasive resection method for superficial neoplasms of the esophagus, stomach, and colorectum. However, the optimal technique for superficial non-ampullary duodenal lesions (SDLs) is uncertain because potential gains in resection quality with ESD may trade off against safety.

This systematic review and meta-analysis aimed to evaluate the efficacy and adverse event rates of EMR versus ESD in adult patients with SDLs.

We searched MEDLINE and Embase (via Ovid) to July 14, 2025, for experimental and observational comparative studies. Two reviewers independently screened/extracted data assessed risk of bias and graded the level of certainty (GRADE). Random-effects models yielded risk ratios (RRs) and 95% CIs. A prespecified subgroup analysis examined studies in which the EMR group reported mean/median lesion diameter ≥20 mm.

Twenty-four retrospective cohort studies (5,515 lesions: EMR 3,709; ESD 1,806) were included. ESD improved en-bloc (RR 1.10, 95% CI 1.05–1.16) and R0 resection (RR 1.15, 95% CI 1.01–1.31); local recurrence did not differ (RR 0.62, 95% CI 0.28–1.39). Procedural risk was higher with ESD, including intraprocedural perforation (RR 9.34, 95% CI 6.03–14.45) and delayed perforation (RR 5.82, 95% CI 3.09–10.96); delayed bleeding and the need for surgery or endoscopic reintervention were also increased. In the ≥20 mm subgroup, differences diminished; only intraprocedural perforation remained higher with ESD (RR 3.76, 95% CI 1.04–13.58). Certainty of evidence (GRADE) was low for efficacy (en-bloc, R0) and local recurrence, high for perforations, delayed bleeding, and surgical intervention, moderate for endoscopic reintervention, and low for mortality.

For SDLs, ESD achieves better resection quality but at greater procedural risk. EMR is a reasonable default first-line strategy for most benign polyps, reserving ESD for lesions where en bloc histology would alter management and where ESD can be completed in expert centers. Randomized trials, particularly lesion-stratified studies, are needed.

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