Outcomes and safety of duodenal endoscopic submucosal dissection for nonampullary lesions: systematic review and meta-analysis

Background and Aims: The indications for endoscopic submucosal dissection (ESD) have been constantly expanding since its introduction. The duodenum represents a difficult endoscopic scenario because of its thin wall and the potential consequences of endoscopic adverse events. We performed a systematic review and meta-analysis to assess the current state of the art. Methods: We performed a systematic review of EMBASE, MEDLINE, and Cochrane databases up to October 18, 2024 according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and the Joanna Briggs Institute methodologies. We included all studies on human endoscopy. The literature was searched to answer the following question: “Is it effective and safe to conduct ESD in nonampullary duodenal lesions (NADLs)?” A pooled prognosis meta-analysis was performed. Risk of bias was evaluated according to Newcastle-Ottawa Scale and Grading of Recommendations Assessment, Development and Evaluation. Results: After screening 541 articles, 54 studies accounting for 3672 procedures were included in this systematic review and meta-analysis. The outcomes and safety performance of ESD for NADLs were as follows: en-bloc resection, 98.1% (95% CI, 96.2-99.1); R0 resection, 86.3% (95% CI, 82.0-89.7); intraprocedural perforation, 8.5% (95% CI, 6.4-11.2); intraprocedural bleeding, 0.01% (95% CI, 0.001-0.1); delayed perforation, 2.0% (95% CI, 1.3-3.1); delayed bleeding, 3.8% (95% CI, 2.8-5.2); and need for surgery, 1.2% (95% CI, 0.6-2.5). Low recurrence and mortality were observed. Quality of evidence ranged from very low to moderate, and most evidence came from Asian centers (48/54, 88.8%) and retrospective single monocentric studies (45/84, 83.3%). Conclusions: ESD for NADLs can be considered an alternative to standard techniques or surgery when en-bloc and R0 resection is requested. High experience and proficiency are required to replicate the outcomes found by this meta-analysis.