Outcomes and safety of duodenal endoscopic submucosal dissection for non-ampullary lesion: a systematic review and meta-analysis

Background and aims: The indications for endoscopic submucosal dissection (ESD) have been constantly increasing since its introduction. The duodenum represents a difficult endoscopic scenario due to 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, Cochrane databases up to 18-Oct-2024 according to PRISMA guidelines and the Joanna Briggs Institute methodologies. We included all studies on human endoscopy. Literature was searched to answer the following question:"Is it effective and safe to conduct endoscopic submucosal dissection in non-ampullary duodenal lesions (NADL)?". A pooled prognosis meta-analysis was performed. Risk of bias was evaluated according to Newcastle Ottawa Scale and GRADE. PROSPERO (CRD42024517598). Results: After screening 541 papers, a total of 54 studies accounting for 3672 procedures were included in a systematic review and meta-analysis. The outcomes and safety performance of ESD for NADL were as follows: en-bloc 98.1%(95%CI=96.2-99.1), R0 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), 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, most of the evidence came from Asian centres(48/54,88.8%) and from retrospective single monocentric studies(45/84,83.3%). Discussion: ESD for NADL 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.