Modified endoscopic mucosal resection offers comparable histologic efficacy to ESD for rectal neuroendocrine tumorsModified Endoscopic Mucosal Resection Shows Equal Results to ESD

BACKGROUND: Endoscopic resection is the standard treatment for rectal neuroendocrine tumors (r-NETs) ≤10 mm, yet the optimal technique remains debated. Modified endoscopic mucosal resection (m-EMR) has been proposed as an alternative to endoscopic submucosal dissection (ESD), but prior evidence is mainly retrospective and recent randomized controlled trials (RCTs) are inconclusive. METHODS: We systematically searched CENTRAL, PubMed, Embase, and WanFang from January 1, 1970 to December 23, 2025, for RCTs comparing m-EMR and ESD in r-NETs ≤10 mm. Evidence certainty was evaluated using GRADE, and trial sequential analysis (TSA) was conducted to support the statistical stability of the pooled estimate. RESULTS: Six RCTs involving 440 patients were included. No significant differences were found between m-EMR and ESD in histologic complete resection (RR = 1.00, 95% CI 0.97-1.03; I² = 0%), en bloc resection (P = 0.75), or procedure-related adverse events (P = 0.94). m-EMR was associated with significantly shorter procedure time and lower hospitalization cost. Evidence certainty was moderate; TSA confirmed the reliability of the findings, and both cumulative and sensitivity analyses supported the robustness. CONCLUSION: m-EMR provides comparable short-term histologic efficacy to ESD, while being associated with shorter procedure time and lower hospitalization costs, supporting its consideration as a reasonable first-line option for r-NETs ≤10 mm.