Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial.

BACKGROUND: Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy (POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy, has emerged as a promising minimally invasive technique for the management of this condition. AIM: To compare POEM and laparoscopic myotomy and partial fundoplication (LM-PF) regarding their efficacy and outcomes for the treatment of achalasia. METHODS: Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria (dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis (as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min (on a barium esophagogram), pressure at the LES, the occurrence of adverse events (AEs), length of stay (LOS), and quality of life (QoL). RESULTS: There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up (P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group (P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group (185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min, respectively; P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group. CONCLUSION: POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia, shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

Effects of intragastric balloon placement in metabolic dysfunction-associated fatty liver disease: A systematic review and meta-analysis.

BACKGROUND: Metabolic dysfunction-associated fatty liver disease corresponds to a clinical entity that affects liver function triggered by the accumulation of fat in the liver and is linked with metabolic dysregulation. AIM: To evaluate the effects of the intragastric balloon (IGB) in patients with metabolic dysfunction-associated fatty liver disease through the assessment of liver enzymes, imaging and several metabolic markers. METHODS: A comprehensive search was done of multiple electronic databases (MEDLINE, EMBASE, LILACS, Cochrane and Google Scholar) and grey literature from their inception until February 2021. Inclusion criteria involved patients with a body mass index > 25 kg/m2 with evidence or previous diagnosis of hepatic steatosis. Outcomes analyzed before and after 6 mo of IGB removal were alanine aminotransferase (IU/L), gamma-glutamyltransferase (IU/L), glycated hemoglobin (%), triglycerides (mg/dL), systolic blood pressure (mmHg), homeostatic model assessment, abdominal circumference (cm), body mass index (kg/m2) and liver volume (cm3). RESULTS: Ten retrospective cohort studies evaluating a total of 508 patients were included. After 6 mo of IGB placement, this significantly reduced alanine aminotransferase [mean difference (MD): 10.2, 95% confidence interval (CI): 8.12-12.3], gamma-glutamyltransferase (MD: 9.41, 95%CI: 6.94-11.88), glycated hemoglobin (MD: 0.17%, 95%CI: 0.03-0.31), triglycerides (MD: 38.58, 95%CI: 26.65-50.51), systolic pressure (MD: 7.27, 95%CI: 4.79-9.76), homeostatic model assessment (MD: 2.23%, 95%CI: 1.41-3.04), abdominal circumference (MD: 12.12, 95%CI: 9.82-14.41) and body mass index (MD: 5.07, 95%CI: 4.21-5.94). CONCLUSION: IGB placement showed significant efficacy in improving alanine aminotransferase and gamma-glutamyltransferase levels in patients with metabolic dysfunction-associated fatty liver disease as well as improving metabolic markers related to disease progression.

Endoscopic retrograde cholangiopancreatography drainage for palliation of malignant hilar biliary obstruction - stent-in-stent or side-by-side? A systematic review and meta-analysis.

BACKGROUND: Biliary drainage, either by the stent-in-stent (SIS) or side-by-side (SBS) technique, is often required when treating a malignant hilar biliary obstruction (MHBO). Both methods differ from each other and have distinct advantages. AIM: To compare both techniques regarding their efficacy and safety in achieving drainage of MHBO. METHODS: A comprehensive search of multiple electronic databases (MEDLINE, Embase, LILACS, BIREME, Cochrane) was conducted and grey literature from their inception until December 2020 with no restrictions regarding the year of publication or language, since there was at least an abstract in English. The included studies compared SIS and SBS techniques through endoscopic retrograde cholangiopancreatography. Outcomes analyzed included technical and clinical success, early and late adverse events (AEs), stent patency, reintervention, and procedure-related mortality. RESULTS: Four cohort studies and one randomized controlled trial evaluating a total of 250 patients (127 in the SIS group and 123 in the SBS group) were included in this study. There were no statistically significant differences between the two groups concerning the evaluated outcomes, except for stent patency, which was higher in the SIS compared with the SBS technique [mean difference (d) = 33.31; 95% confidence interval: 9.73 to 56.90, I 2 = 45%, P = 0.006]. CONCLUSION: The SIS method showed superior stent patency when compared to SBS for achieving bilateral drainage in MHBO. Both techniques are equivalent in terms of technical success, clinical success, rates of both early and late AEs, reintervention, and procedure-related mortality.

Adverse Events and Complications with Intragastric Balloons: a Narrative Review (with Video).

Intragastric balloon (IGB) is a minimally invasive and reversible therapy for weight loss with a good efficacy and safety profile. Introduced in the 1980s, IGBs have significantly evolved in the last couple of decades. They mechanically act by decreasing the volume of the stomach and its reservoir capacity, delaying gastric emptying, and increasing satiety leading to a subsequent weight loss. Despite the low rates of complications and mortality associated with IGBs, adverse events and complications still occur and can range from mild to fatal. This review aims to provide an update on the current scientific evidence in regard to complications and adverse effects of the use of the IGB and its treatment. This is the first comprehensive narrative review in the literature dedicated to this subject.

Risk factors for gastroesophageal reflux after POEM for achalasia: a systematic review and meta-analysis.

INTRODUCTION: Peroral endoscopic myotomy (POEM) demonstrated similar efficacy to surgical myotomy in the management of achalasia. However, gastroesophageal reflux disease (GERD) is common after POEM. The aim of this study is to identify factors associated with GERD after POEM. METHOD: After searching electronic databases, randomized trials and observational studies including patients with achalasia or other spastic esophageal disorders, treated by POEM, and providing GERD data were selected. GERD was evaluated by 3 methods: pH monitoring, endoscopic findings, and symptoms. For each method, an analysis was performed comparing the outcomes related to the following independent variables: full-thickness (FT) vs circular myotomy, anterior vs posterior, long myotomy vs short myotomy, naive vs previous treatment failure, previous Heller myotomy (HM) vs non-previous-HM, Type I vs II, Type I vs III, and Type II vs III. RESULTS: 2869 publications were identified, and 25 studies met criteria for inclusion in the qualitative analysis. Of these, 18 were included in the meta-analysis. According to the endoscopic findings, circular and anterior myotomy demonstrated a lower trend of GERD with borderline significance (p = 0.06; p = 0.07, respectively). In the pH monitoring and symptom analyses, circular myotomy, anterior myotomy, treatment naive, and non-HM patients were associated with a lower occurrence of GERD; however, no statistically significant difference was found. When comparing achalasia subtypes, no statistical difference was found in all analyses. CONCLUSION: This systematic review and meta-analysis suggest that a circular anterior approach may limit post-POEM GERD and should be considered in appropriate patients.

Peroral endoscopic myotomy (POEM) is more cost-effective than laparoscopic Heller myotomy in the short term for achalasia: economic evaluation from a randomized controlled trial.

Background and study aims We aimed to perform an economic evaluation of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia. Materials and methods An economic cost-utility analysis was carried out over a time horizon of 1 year. Patients with achalasia who were admitted to the gastroenterology outpatient clinic of a public tertiary referral hospital were assigned to undergo POEM or LHM. The monetary amounts ​​were extracted from the intranet of the institution using microcosting. All costs associated with the procedure, hospitalization, clinical follow-up and resolution of therapeutic complications were included. The utility data were measured in quality-adjusted life years (QALYs), which were estimated from the scores of a quality-of-life questionnaire. Results Forty patients (20 POEM patients and 20 LHM patients) were included. The final cost associated with POEM and LHM was US$ 2,619.19 ±â€Š399.53 and US$ 1,696.44 ±â€Š412.21, respectively ( P  < 0.001). However, the QALYs in the POEM group (0.434 ±â€Š0.215 vs 0.332 ±â€Š0.222, P  = 0.397) were slightly higher than those in the LHM group. The incremental cost-utility ratio (ICUR) suggested that an additional US$ 9,046.41/QALY gained was required when using POEM. Conclusion For the treatment of achalasia in the public health system, POEM appears to be more cost-effective than LHM in the short term.

Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic procedure for treatment of diseases that affect the biliary tree and pancreatic duct. While the therapeutic success rate of ERCP is high, the procedure can cause complications, such as acute pancreatitis (PEP), bleeding, and perforation. This meta-analysis aimed to assess the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing PEP following (ERCP). Materials and methods We searched databases, such as MEDLINE, Embase, and Cochrane Central Library. Only randomized controlled trials (RCTs) that compared the efficacy of NSAIDs and placebo for the prevention of PEP were included. Outcomes assessed included incidence of PEP, severity of pancreatitis, route of administration, and type of NSAIDs. Results Twenty-one RCTs were considered eligible with a total of 6854 patients analyzed. Overall, 3427 patients used NSAIDs before ERCP and 3427 did not use the drugs (control group). In the end, 250 cases of acute pancreatitis post-ERCP were diagnosed in the NSAIDs group and 407 cases in the placebo group. Risk for PEP was lower in the NSAID group (risk difference (RD): -0.05; 95 % confidence interval (CI): -0.07 to - 0.03; number need to treat (NNT), 20; P  < 0.05). Use of NSAIDs effectively prevented mild pancreatitis compared with use of placebo (2.5 % vs. 4.1 %; 95 % CI, -0.05 to - 0.01; NNT, 33; P  < 0.05), but the information on moderate and severe PEP could not be completely elucidated. Only rectal administration reduced incidence of PEP (6.8 % vs. 13 %; 95 % CI, -0.10 to - 0.04; NNT, 20; P  < 0.05). Furthermore, only diclofenac or indomethacin use was effective in preventing PEP. Conclusions Rectal administration of diclofenac and indomethacin significantly reduced risk of developing mild PEP. Further RCTs are needed to compare efficacy between NSAID administration pathways in prevention of PEP after ERCP.

EUS-Guided Intragastric Injection of Botulinum Toxin A in the Preoperative Treatment of Super-Obese Patients: a Randomized Clinical Trial.

BACKGROUND: Obesity is a disease that is highly prevalent in Brazil, and the associated comorbidities represent a major global public health challenge. Botulinum toxin type A (BTX-A) is a potent neurotoxin and inhibitor of gastric smooth muscle activity. In theory, BTX-A administration should promote early satiety and weight loss because it delays gastric emptying by inhibiting acetylcholine-mediated peristalsis, which is primarily responsible for gastric motility. Because results in the literature are discrepant, the efficacy of intragastric injections of BTX-A as a primary treatment for obesity remains unknown. The objective of this prospective, double-blind, single-center randomized study was to evaluate the effects of endoscopic ultrasound-guided intragastric BTX-A injections, as a bridge to bariatric surgery, in super-obese patients. METHODS: Thirty-two super-obese patients were randomized to one of two groups: BTX-A, in which 200 units of BTX-A were injected into the gastric antrum and body; and control, in which the same injections were performed with 0.9% saline. Weight, body mass index (BMI), and loss of excess weight were measured monthly over a 6-month period. Gastric emptying scintigraphy was performed before and after the procedure. RESULTS: The patients in both groups showed significant weight loss over the course of the study (p < 0.001). There were no statistically significant differences between the groups regarding weight loss, excess weight, total loss of excess weight, total weight loss, or change in BMI. CONCLUSIONS: Intragastric injection of BTX-A does not appear to be an effective method of achieving preoperative weight loss in super-obese patients.

Primary adenocarcinoma arising in esophageal colon interposition for corrosive esophageal injury: a case report and review of the literature.

Background and study aims Colon interposition for benign strictures is associated with significant perioperative complications that carry high morbidity and mortality. Although rarely reported in the literature, adenocarcinoma can occur as a late complication in an interposed colonic segment. We report a case of a late-stage adenocarcinoma in a colonic interposition performed for benign esophageal stricture.

The Effectiveness of Endoscopic Gastroplasty for Obesity Treatment According to FDA Thresholds: Systematic Review and Meta-Analysis Based on Randomized Controlled Trials.

Endoscopic bariatric therapies (EBTs) are promising alternatives to conventional surgery for obesity. The aim of this study is to compare efficacy and safety through a systematic review and meta-analysis of the endoscopic gastroplasty techniques versus conservative treatment. We searched MEDLINE, EMBASE, Cochrane CENTRAL, Lilacs/Bireme. Randomized controlled trials (RCTs) enrolling obese patients comparing endoscopic gastroplasty to sham or diet/exercise were considered eligible. Among 6014 records, three RCTs were selected for meta-analysis. The total sample was 459 patients (312 EBTs vs 147 control). Mean total body weight loss in the intervention group (IG) was 4.8% higher than the control group (CG) at 12 months (p = 0.01). The IG responder rate was 44.31% at 12 months. Therefore, the endoscopic gastroplasty is more effective than conservative therapies but do not achieve FDA thresholds.

Endoscopic polymer injection and endoluminal plication in treatment of gastroesophageal reflux disease: evaluation of long-term results.

BACKGROUND AND STUDY AIMS: Us of proton pump inhibitors (PPIs) has made endoscopic treatment of gastroesophageal reflux disease (GERD) more efficient, with reduction in morbidity and complications. However, some patients persist with symptoms despite medical treatment and some are not compliant with it or cannot afford it for financial reasons, and thus they require non-pharmacological therapeutic options such as surgical fundoplication. Surgery may be effective in the short term, but there is related morbidity and concern about its long-term efficacy. The possibility of minimally invasive endoluminal surgeries has resulted in interest in and development of newly endoscopic devices. Good short-term results with surgical fundoplication lack of studies of is with long follow-up justify our interest in this study. The aim of this study was to investigate the efficacy of endoscopic polymer injection and endoluminal full-thickness plication in the long-term control of GERD. PATIENTS AND METHODS: Forty-seven patients with GERD who underwent an endoscopic procedure were followed up for 60 months and evaluated for total response (RT), partial response (RP) and no response (SR) to endoscopic treatment with reintroduction of PPIs. RESULTS: Twenty-one patients received polymer injection (G0) and 26 endoluminal plication (G1). The number of patients with no response to endoscopic treatment with reintroduction of PPIs increased in time for both techniques (G0 P  = 0.006; G1 P  < 0.001). There was symptomatic improvement up to 12 months, with progressive loss of this trending up to 60 months in G0 and G1 ( P  < 0.001). Health-related quality of life score (GERD-HRQL) demonstrated TR in G0 and G1 at 1, 3, 6 and 12 months. The 60-month analysis showed an increased number of patients with SR in both groups. The quality of life assessment (SF-36) showed benefit in G0 up to 3 months. G0 showed a higher rate of complications. There were no deaths. There was healing of esophagitis at 3 months in 45 % of patients in G0 and 40 % in G1. There was no improvement in manometric or pH findings. CONCLUSION: Endoscopic therapies were ineffective in controlling GERD in the long term.

Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis.

BACKGROUND AND AIMS: There are no systematic reviews comparing the use of endoscopic retrograde cholangiopancreatography (ERCP)-based brush cytology and forceps biopsy and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of malignant biliary stricture; so in this revision, we will compare ERCP against EUS-FNA for tissue diagnosis of malignant biliary stricture. DESIGN: A systematic review was conducted of comparative studies (prospective or retrospective) analyzing EUS and ERCP for tissue diagnosis of malignant biliary stricture. MATERIALS AND METHODS: The databases Medline, EMBASE, Cochrane, LILACS, CINAHL, and Scopus were searched for studies dated previous to November 2014. We identified three prospective studies comparing EUS-FNA and ERCP for the diagnosis of malignant biliary stricture and five prospective studies comparing EUS-FNA with the same diagnosis of the other three studies. All patients were subjected to the same gold standard method. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values, and accuracy) and performed a meta-analysis using the Review Manager (RevMan) 5.3 software. RESULTS: A total of 294 patients were included in the analysis. The pretest probability for malignant biliary stricture was 76.66%. The mean sensitivities of ERCP and EUS-FNA for tissue diagnosis of malignant biliary stricture were 49% and 75%, respectively; the specificities were 96.33% and 100%, respectively. The posttest probabilities positive predictive value (98.33% and 100%, respectively) and negative predictive value (34% and 47%, respectively) were determined. The accuracies were 60.66% and 79%, respectively. CONCLUSION: We found that EUS-FNA was superior to ERCP with brush cytology and forceps biopsy for diagnosing malignant biliary strictures. However, a negative EUS-FNA or ERCP test may not exclude malignant biliary stricture because both have low negative posttest probabilities.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: A systematic review and meta-analysis.

AIM: To compare the diagnostic accuracy of video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) in cases of obscure gastrointestinal bleeding (OGIB) of vascular origin. METHODS: MEDLINE (via PubMed), LILACS (via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software. RESULTS: In the per-patient analysis, 17 studies (1477 lesions) were included. We identified 3150 exams (1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864 (58.5%) were diagnosed by VCE, and 613 (41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84% (95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was 92% (95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29 (95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20 (95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to 90%. CONCLUSION: The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Subepithelial rectal gastrointestinal stromal tumor - the use of endoscopic ultrasound-guided fine needle aspiration to establish a definitive cytological diagnosis: a case report.

BACKGROUND: Gastrointestinal stromal tumors are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The stomach is the most common location to be affected, and the rectum one of the rarest, but the whole gastrointestinal tract remains susceptible. Gastrointestinal stromal tumors account for only 0.1% of rectal tumors. Currently, endoscopic ultrasound plays an essential role in the diagnostic process of gastrointestinal stromal tumors, especially when the affected sites have a worse outcome and higher morbidity rates. CASE PRESENTATION: We describe the case of a 68-year-old white Japanese man with a history of long-term mild rectal pain and tenesmus. A digital rectal examination revealed a right palpable solid mass ranging from 3 to 7 cm from his anal verge. A colonoscopy was performed and showed a 5 cm elevated lesion covered by normal mucosa, located 4 cm above the pectineal line. Endoscopic ultrasound confirmed the diagnosis of a homogeneous hypoechoic mass with areas of necrosis as a rectal subepithelial lesion originating at the fourth layer (muscularis propria). He then underwent endoscopic ultrasound-guided fine needle aspiration of the lesion, followed by cytological and immunohistochemistry evaluation. The evaluation showed spindle and epithelioid cells of variable sizes, in fascicles separated by stroma, which reacted firmly and consistently to CD117/c-kit and CD34, and negative to desmin and S-100 protein. There was weak staining for nuclear Ki-67 in the tumor cells. A diagnosis of rectal gastrointestinal stromal tumor was confirmed. After a multidisciplinary meeting, an abdominoperineal resection of his rectum was performed. The pathology of the specimen confirmed the diagnosis of rectal gastrointestinal stromal tumor. He is now asymptomatic after 3 months' follow-up and is on adjuvant therapy with a tyrosine-kinase inhibitor. CONCLUSIONS: Gastrointestinal stromal tumors are rare tumors, and among the variety of primary location sites, the rectum is one of the rarest. The localization of this type of tumor has worse outcomes and higher morbidity rates. We report this rare case to emphasize the need for precise diagnosis and the important role of endoscopic ultrasound-guided fine needle aspiration in such situations.

Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis.

To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies.

Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review.

AIM: To report a systematic review, establishing the available data to an unpublished 2a strength of evidence, better handling clinical practice. METHODS: A systematic review was performed using MEDLINE, EMBASE, Cochrane, LILACS, Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants, inclusion and exclusion criteria, interventions (mainly, mucosal resection and submucosal dissection vs surgical approach) and outcomes (adverse events, different survival rates, mortality, recurrence and complete resection rates). To ascertain the validity of eligible studies, the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ(2) and the Higgins method (I (2)). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. RESULTS: Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Three-year survival data were available for six studies (n = 1197). There were no risk differences (RD) after endoscopic and surgical treatment (RD = 0.01, 95%CI: -0.02-0.05, P = 0.51). Five-year survival data (n = 2310) showed no difference between the two groups (RD = 0.01, 95%CI: -0.01-0.03, P = 0.46). Recurrence data were analized in five studies (1331 patients) and there was no difference between the approaches (RD = 0.01, 95%CI: -0.00-0.02, P = 0.09). Adverse event data were identified in eight studies (n = 2439). A significant difference was detected (RD = -0.08, 95%CI: -0.10--0.05, P < 0.05), demonstrating better results with endoscopy. Mortality data were obtained in four studies (n = 1107). There was no difference between the groups (RD = -0.01, 95%CI: -0.02-0.00, P = 0.22). CONCLUSION: Three-, 5-year survival, recurrence and mortality are similar for both groups. Considering complication, endoscopy is better and, analyzing complete resection data, it is worse than surgery.