Endoscopic resection versus esophagectomy for early esophageal cancer: a meta-analysis

BACKGROUND: Esophagectomy is the standard treatment for early-stage esophageal cancer but is associated with high morbidity and mortality. Thus, endoscopic resection is increasingly used as an alternative option. However, the literature is inconsistent regarding the efficacy of these treatments. This meta-analysis aimed to compare the efficacy and safety of these two treatments. METHODS: A systematic electronic search of PubMed, EMBASE, and the Cochrane Library was performed for studies comparing endoscopic resection and surgery for early-stage esophageal cancer. The overall survival, tumor recurrence, major adverse events, procedure-related mortality, and R0 resection rates were investigated. Forest plots were constructed based on the random-effects model. RESULTS: We found 15 studies involving 2,467 and 2,264 patients who underwent endoscopic resection and surgery, respectively. The meta-analysis showed that patients undergoing endoscopic resection had significantly fewer major adverse events (relative risk, 0.46; 95% confidence interval, 0.33–0.64) and a lower procedure-related mortality rate (relative risk, 0.27; 95% confidence interval, 0.10–0.73) than those undergoing surgery. The number of postprocedural stricture events did not significantly differ between the two treatments (relative risk, 0.89; 95% confidence interval, 0.53–1.49). Endoscopic resection was associated with higher recurrence rates (relative risk, 1.69; 95% confidence interval, 0.99–2.89) and lower R0 resection rates (relative risk, 0.92; 95% confidence interval, 0.86–0.98) than surgery. There may be some advantage conferred by esophagectomy in the long-term survival outcomes (hazard ratio, 1.21; 95% confidence interval, 1.02–1.43). DISCUSSION: Endoscopic resection is a minimally invasive and safe treatment for early-stage esophageal cancer. However, esophagectomy may be associated with better long-term survival.