Endoscopic resection versus surgery for T1 rectal cancer: A systematic review and meta-analysis of oncologic and safety outcomes

초록

BackgroundSurgical resection (SR) has been recommended for T1 rectal cancer, but concerns about postoperative morbidity and impaired quality of life continue to pose a significant burden for patients. Endoscopic resection (ER) offers a minimally invasive alternative; however, its oncologic sufficiency compared to SR remains unclear. We conducted a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of ER versus SR in patients with T1 rectal cancer.MethodsWe systematically searched MEDLINE, EMBASE, Cochrane Library, and KMBASE up to October 2024 for studies comparing ER and SR in patients with T1 rectal cancer. Thirty-one non-randomized observational studies involving 63,443 patients were included. Outcomes of interest were overall survival (OS), disease-free survival (DFS), recurrence, and adverse events. Risk of bias was assessed using the ROBINS-I tool, and the certainty of evidence was evaluated with the GRADE framework.ResultsCompared with SR, ER was associated with a higher risk of death and tumor recurrence, along with a non-significant trend toward higher hazards for OS and DFS. It also carried an increased risk of delayed bleeding and perforation. However, ER demonstrated significantly fewer postoperative complications, including intra-abdominal leakage, wound infection, and minor adverse events. The certainty of evidence was rated as low to very low due to confounding, selection bias, and imprecision. While many patients favored curability and recurrence prevention, others valued reduced invasiveness and faster recovery.ConclusionIn patients with T1 rectal cancer, ER is associated with a lower incidence of postoperative complications compared to SR. However, current evidence does not support the superiority of ER in terms of long-term oncologic outcomes. ER may be considered a reasonable option in carefully selected patients-particularly older adults or those at high surgical risk-through shared decision-making that incorporates clinical factors and individual preferences.

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