Efficacy, Safety and Oncological Outcomes of Minimally Invasive Approaches (EMR, ESD and TAMIS) for Early Rectal Tumors: A Systematic Review and Meta-Analysis

Mariam Hussain,1 Fatima Kayali,2 Abdelaziz O Surkhi,3 Roy Shartouni,4 Thurkga Moothathamby,5 Ahmed Hamza Akmal,6 Rohan Vyas,7 Leen Ammari,8 Ibrahim Sharaf,8 Mona Jaffar-Karballai,9 Mohamed Refaie,10 Yousif F Jubouri,6 Matti Jubouri,10 Mohamad Bashir,11 Ali Murtada2 1Department of Surgery, Manchester University Foundation Trust, Manchester, UK; 2Department of General Surgery, Royal Liverpool University Hospital, Liverpool, UK; 3Faculty of Medicine, Al-Quds University, Jerusalem, Palestine; 4Department of Medicine, European University Cyprus, Nicosia, Cyprus; 5Department of Medicine, Queen Mary University of London, London, UK; 6Department of Medicine, Aston Medical School, Birmingham, UK; 7Department of Surgery, Royal Free Hospital London NHS Foundation Trust, London, UK; 8Department of Surgery, Jordan University of Science and Technology, Ar Ramtha, Jordan; 9Department of medicine, Imperial College Healthcare NHS Trust, London, UK; 10Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK; 11Department of Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UKCorrespondence: Ali Murtada, Department of General surgery, Royal Liverpool University Hospital, Mount Vernon St, Liverpool L7 8YE, Liverpool, UK, Email amurtada@nhs.netBackground: Device-based minimally invasive techniques have transformed the management of early rectal tumors by enabling organ-preserving treatment while reducing morbidity compared with radical surgery. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are flexible endoscopic techniques, whereas transanal minimally invasive surgery (TAMIS) is a transanal access platform that allows excision using laparoscopic or robotic instrumentation. These approaches differ in access route, instrumentation, and depth of tissue excision. However, comparative evaluation from a device-centered and oncological perspective remains limited.Methods: A systematic review and proportional meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, Ovid, Scopus, and Web of Science were searched for studies reporting outcomes of EMR, ESD, or TAMIS in adult patients with early rectal tumors. Primary outcomes included R0 resection rate, en bloc resection rate, and local and distant recurrence. Secondary outcomes included procedure time, bleeding, and reintervention rates. Random-effects models were applied, and heterogeneity was assessed using the I2 statistic.Results: A total of 108 studies encompassing 8705 patients were included. EMR demonstrated the shortest procedure time, ESD showed the lowest local and distant recurrence rates, and TAMIS achieved the highest en bloc resection rates. Despite differences in technical performance, R0 resection rates were broadly comparable across platforms. Substantial heterogeneity was observed, reflecting variation in tumor characteristics, access platforms, instrumentation, and operator expertise.Conclusion: EMR, ESD, and TAMIS are safe and effective device-based minimally invasive platforms for the treatment of early rectal tumors. Despite differences in access route and technological configuration, oncological outcomes appear more strongly influenced by tumor biology, depth, and pathological assessment than by the choice of platform alone. These findings support device-informed decision-making by guiding platform selection according to lesion characteristics and oncological outcomes while highlighting the need for randomized trials to optimize device selection in early rectal cancer management.