Endoscopic submucosal dissection versus transanal endoscopic surgery in rectal neoplasms: Meta-analysis of randomized controlled trials and trial sequential analysis

Background and Aims Transanal endoscopic surgery (TES) and endoscopic submucosal dissection (ESD) are established organ-preserving approaches, but comparative randomized evidence remains limited. This meta-analysis of randomized controlled trials (RCTs) compared TES and ESD in rectal neoplasms. Methods Multiple databases were searched from inception through March 29, 2026. Outcomes of interest included en bloc resection, R0 resection, adverse events, procedure time, recurrence, and hospital stay. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Results Five RCTs with 624 patients (TES 307, ESD 317) were included. No statistically significant differences were observed in en bloc resection (RR, 1.02; 95% CI, 0.95–1.10; P = 0.55; I²= 73%), R0 resection (RR, 1.00; 95% CI, 0.90–1.10; P = 0.95; I² = 60%), recurrence (RR, 1.73; 95% CI, 0.53-5.67; P=0.36; I²=6%), bleeding (RR, 0.50; 95% CI, 0.10–2.63; P = 0.41; I² = 68%), perforation (RR, 0.22; 95% CI, 0.01–4.49; P = 0.33), or hospital stay (MD, 0.57 days; 95% CI, -0.52 to 1.67; P = 0.30; I² = 94%) between the TES and ESD. TES had a shorter procedure time compared with ESD (MD, -21.93; 95% CI, -28.22 to -15.64; P<0.00001; I² = 52%). Trial sequential analysis for bleeding, perforation, and recurrence found cumulative Z-curves crossed neither monitoring boundaries nor the diversity-adjusted required information size, leaving evidence inconclusive. Conclusions This RCT meta-analysis found no statistically significant differences between ESD and TES for short-term oncologic outcomes in selected rectal neoplasms; the certainty of the evidence was very low for these outcomes.