Comparison Among Endoscopic, Laparoscopic, and Open Resection for Relatively Small Gastric Gastrointestinal Stromal Tumors (<5 cm): A Bayesian Network Meta-Analysis

Background Endoscopic resection (ESR) is a novel minimally invasive procedure for superficial tumors. Its safety, efficiency and outcome for gastric gastrointestinal stromal tumors (gGISTs) less than 5cm remains unclear compared to laparoscopic resection (LAR) and open resection (ONR). The current network meta-analysis aimed to review and analyze the available evidence of this question. Methods PubMed, Embase, Cochrane Library and Web of Science databases were searched to identify eligible studies published up to July 6, 2020. The perioperative and long-term oncological outcomes among ESR, LAR and ONR for gGIST (< 5cm) were estimated through the Bayesian network meta-analysis with a random effect model. Results Fifteen studies with 1631 patients were included. ESR was associated with shorter operative time [MD: -36, 95% CI (-55, -16)], a higher rate of positive margin [OR: 5.1×1010, 95% CI (33, 2.5×1032)] and less costs [MD: -1×104, 95% CI (-1.6×104, -4.4×103)] but similar time to resume flatus [MD: 0.52, 95% CI (-0.16, 1.1)] and diet [MD: -3.5, 95% CI (-5.6, -1.6)] compared to LAR. A higher rate of total complications [OR: 11, 95% CI (1.2, 140)] was observed in patients received ESR compared to patients received LAR. After excluding perforation from total complication category, the difference of complication between ESR and LAR disappeared [OR: 0.87, 95% CI (0.22, 2.3)]. The recurrence rate [OR: 1.3, 95% CI (0.40, 4.5)] and disease-free survival (DFS) [HR: 1.26, 95% CI (0.60, 2.63)] showed no significant difference between ESR and LAR. ESR was associated with better or equivalent perioperative and long-term outcomes compared to ONR except for positive margin. Subgroup analysis (<2cm and 2-5cm) showed no significant different results among these three procedures either. Conclusion ESR was showed to be a safe and efficient alternative procedure to both LAR and ONR for gGISTs less than 2cm and within 2-5cm, respectively, without worsening the oncologic outcomes. However, preoperative assessment of tumor site is of importance for the determination of procedures regarding the increased incidence of positive margin related to ESR.