Additional Surgery versus Surveillance After Non-curative ESD for Early Colorectal Cancer: A Systematic Review and Reconstructed Individual Patient Data Meta-analysis.

Background

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Aims

Management after non-curative endoscopic submucosal dissection (ESD) for early colorectal cancer (CRC) remains controversial. We performed a pairwise and reconstructed individual patient data (IPD) meta-analysis to compare outcomes between surveillance and additional surgery.

Methods

A systematic search of PubMed, Embase, Web of Science, and the Cochrane Library was conducted through March 25, 2026. Studies comparing surveillance versus additional surgery after non-curative ESD for CRC were included. Overall survival was the primary outcome and was analyzed as a time-to-event endpoint using reconstructed IPD from published Kaplan-Meier curves. Secondary outcomes included cancer-specific survival (time-to-event), overall recurrence, local recurrence, and distant recurrence. Random-effects models were applied using hazard ratios (HRs) and risk ratios (RRs) with 95% confidence intervals (CIs).

Results

Four studies with 815 patients were included. Additional surgery was associated with improved overall survival (HR, 0.37; 95% CI, 0.23-0.59), but not cancer-specific survival (HR, 0.63; 95% CI, 0.26-1.52). Overall recurrence did not differ significantly (RR, 0.44; 95% CI, 0.14-1.38), whereas local recurrence was lower with surgery (RR, 0.16; 95% CI, 0.04-0.63). No difference was observed in distant recurrence (RR, 0.65; 95% CI, 0.14-2.93).

Conclusion

Additional surgery after non-curative ESD for colorectal cancer is associated with improved overall survival and reduced local recurrence, without significant differences in cancer-specific survival or distant recurrence. These findings highlight the importance of individualized treatment decisions that balance risk of surgery with risk of local recurrence and take into account patient preferences, particularly in patients with advanced age or comorbidities.