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Efficacy, Safety and Oncological Outcomes of Minimally Invasive Approaches (EMR, ESD and TAMIS) for Early Rectal Tumors: A Systematic Review and Meta-Analysis
Authors Hussain M 
, Kayali F, O Surkhi A, Shartouni R, Moothathamby T , Akmal AH , Vyas R, Ammari L, Sharaf I , Jaffar-Karballai M, Refaie M , Jubouri YF, Jubouri M , Bashir M, Murtada A
Received 5 February 2026
Accepted for publication 5 May 2026
Published 12 May 2026 Volume 2026:19 599781
DOI https://doi.org/10.2147/MDER.S599781
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Ching-Hsien Chen
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, UK
Correspondence: Ali Murtada, Department of General surgery, Royal Liverpool University Hospital, Mount Vernon St, Liverpool L7 8YE, Liverpool, UK, Email [email protected]
Background: 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.
Keywords: rectal cancer, minimally invasive surgery, endoscopic mucosal resection, endoscopic submucosal dissection, transanal minimally invasive surgery
Introduction
Colorectal cancer is the third most commonly diagnosed malignancy and the second leading cause of cancer-related mortality worldwide.1 Approximately 40% of colorectal cancers arise in the rectum,2,3 with an increasing proportion detected at an early stage due to the widespread implementation of population-based screening programmes.3 Early rectal tumors are commonly defined as clinical (T1-T2), node negative (N0), non-metastatic disease confined to the rectal wall and amenable to local excision, in accordance with contemporary oncological definitions and international guidelines.4
Conventional radical rectal surgery is associated with substantial morbidity, largely related to the complex pelvic anatomy and the extent of tissue resection required. These procedures carry significant risks of gastrointestinal, urinary, and sexual dysfunction, as well as prolonged recovery.5,6 Consequently, there has been growing interest in device-based minimally invasive approaches that enable local excision of early rectal tumors while minimizing physiological insult and preserving quality of life.7
Three principal device-dependent platforms are currently utilized for local excision for early rectal tumors: endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and transanal minimally invasive surgery (TAMIS).8 Although these approaches are often compared as techniques, each device is underpinned by distinct technological systems and operative principles, resulting in differences in access, precision, tissue interaction, and oncological performance. This device-centered perspective remains scarcely addressed despite its importance in technology selection and clinical decision making.
EMR is a well-established endoscopic technique that employs injection needles, electrosurgical snares, and energy delivery systems to remove superficial neoplastic lesions and has been widely adopted in colorectal practice.9–11 EMR is associated with short procedure times and a favorable safety profile, with reported resection rates approaching 80% in early rectal neoplasia.12 However, for lesions larger than 20 mm, EMR frequently requires piecemeal resection, which limits histopathological margin assessment and is associated with higher local recurrence rates.13 A meta-analysis by Belderbos et al demonstrated a recurrence rate of 20% following piecemeal EMR compared with 3% after en bloc resection, raising concerns regarding its suitability for larger lesions.14
ESD represents a more advanced endoscopic platform, utilizing dedicated dissection knives, electrosurgical generators, and, increasingly, traction devices to enable controlled submucosal dissection and en bloc resection irrespective of lesion size.15 Compared with conventional surgery, ESD has been associated with lower morbidity, faster recovery, and improved functional outcomes.16 The technique involves circumferential mucosal incision and meticulous submucosal dissection to achieve complete resection with precise margin control.17 However, reliance on a single working channel and the technical complexity of the procedure pose challenges, particularly for fibrotic or anatomically challenging lesions.18
TAMIS was introduced in 2010 as a minimally invasive alternative to transanal endoscopic microsurgery (TEM), combining a transanal access port with conventional laparoscopic or robotic instrumentation.19,20 This hybrid device platform allows full-thickness excision under direct visualization and has demonstrated favorable resection outcomes in selected patients. Nevertheless, its reliance on rigid access systems and laparoscopic instruments may influence recurrence patterns, functional outcomes, and reintervention rates.19,20
Although EMR, ESD and TAMIS are all minimally invasive in nature, they differ substantially in access route, degrees of freedom, depth of resection and specimen integrity. These differences in device specification also influence patient selection and lesion characteristics. For instance, EMR is often the modality of choice for superficial lesions, while ESD’s ability to achieve en bloc resection and high-quality histopathological margin assessment makes it suitable for large non-pedunculated lesions. Finally, TAMIS is used for large and complex tumors requiring transanal access for full thickness excision.
Importantly, TAMIS may be delivered through different technological ecosystems, including conventional laparoscopic and robotic platforms, each with distinct implications for precision, ergonomics, and learning curve. Existing studies vary considerably in patient selection, lesion characteristics, and operator expertise, and comparative data remain fragmented. Therefore, this systematic review and meta-analysis aims to evaluate the efficacy, safety, and oncological performance of EMR, ESD, and TAMIS as device-based minimally invasive platforms, to inform clinical decision-making, technology selection, and future innovation.
Methods
Protocol and Registration
The meta-analysis was conducted in accordance with the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).21,22 The trial protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number of CRD42024606474.
Study Design and Search Criteria
This is a meta-analysis exploring minimally invasive approaches for early rectal cancer, including EMR, ESD, and TAMIS. A comprehensive search strategy was developed using the Population, Intervention, Comparator, and outcome (PICO) framework by two authors with experience in evidence synthesis. The search strategy consisted of keywords and MESH terms combined using Boolean operators to maximize the retrieval of relevant results. Multiple databases, including PubMed, MEDLINE, EMBASE, OVID, and Web of Science, were searched using distinct search criteria, yielding the highest number of studies. The final search strategy included following combinations of keywords: “(((Endoscopic submucosal dissection) OR (Endoscopic submucosal resection) OR (ESD)) OR (((Robotic) OR (robot-assisted) OR (laparoscop*)) AND (trans anal minimally invasive)) OR (TAMIS) OR (r-TAMIS) OR (L-TAMIS)) AND ((rect*) AND ((cancer) OR (carcinoma) OR (tumor) OR. (tumour)))”. All records underwent a two-phase screening process, in which abstracts were independently screened by two reviewers, followed by full-text review to identify studies that met the predefined eligibility criteria. Additionally, a thorough search of the reference list of each included study was conducted to identify any further relevant studies.
Inclusion and Exclusion Criteria
A study was included if the pathology treated was clearly stated as early-stage rectal tumors that could be resected using the endoscopic (ESD or EMR) or TAMIS technique. Studies with multiple procedures should have clearly separate data for each procedure. The study should only include adult patients (>18 Years). Studies should mainly be in English and consist of controlled trials, retrospective or prospective cohort studies, or case-control studies. Studies should also include at least one primary or secondary outcome. The primary outcomes of this meta-analysis are R0 resection rate, en bloc resection rate, and disease recurrence. Secondary outcomes consisted of intraoperative and postoperative complications such as perforation and bleeding. Literature and narrative reviews, editorials, letters and case reports were excluded. Studies with non-human data, non-adult populations, and mixed data with non-cancerous lesions were excluded.
Data Extraction
Two reviewers independently extracted data using a standardized data extraction form. The variables collection included patient demographics, study characteristics, clinical characteristics, tumor features, details of the interventional technique, intraoperative and postoperative complications, oncological outcomes, recurrence data, reintervention rates, and follow-up durations. The collected data were further independently reviewed by two additional reviewers to ensure accuracy. Any discrepancies were resolved through discussion and the involvement of a third, independent author.
Statistical Analysis
A proportional meta-analysis was conducted using Comprehensive Meta-Analysis Software v4, calculating overall rates and pooled means for the study population. Heterogeneity was assessed using Cochrane’s Q-test and the I2 statistic, with I2 values above 50% and significant Q-tests indicating substantial heterogeneity and supporting the application of Random Effects models. Potential publication bias was evaluated through Egger’s test and Funnel plots, when appropriate. To explore the influence of comorbidities on study outcomes, we performed Meta-Regression analyses. All continuous variables were expressed as Mean ± Standard Deviation (SD); when such data were not directly available, they were converted to Mean and SD following the method described by Wan et al (2014).
Results
Search and Screening
A total of 6597 studies were identified using the previously mentioned search terms and underwent screening after duplicates were removed. Of these studies, 629 passed the primary abstract screening stage and were selected for further evaluation. A total of 108 studies were included in the final extraction and analysis. 98 studies were retrospective observational studies, 8 were prospective cohort studies, and 2 were randomized controlled trials. The screening process is visualized in Figure 1 using a PRISMA flowchart.
 |
Figure 1 PRISMA model for study screening. |
Patient Characteristics
The total number of patients across all studies was 8705. The aggregated mean age for the entire population was 55.5 years (95% CI: 46.3–64.7 years; I2 = 99%). The aggregated male ratio across all studies was 59.1% (95% CI: 57.2–61%, I2 = 54%). EMR was the most commonly performed procedure in 4848 (55.7%) patients; followed by ESD in 3516 (40.4%) patients; and TAMIS in 461 (5.3%) patients. Table 1 summarizes the essential information from included studies.
 |
Table 1 Characteristics of the Included Studies |
Procedure
The average distance of the lesion from the anal verge for the entire population was 6.6 cm (95% CI: 6–7.2, I2 = 99%), with similar average distances across the different procedure types. The aggregated average time for all procedures was 18.9 minutes (95% CI: 18–19.9, I2 = 99%). Procedural times for each procedure type showed EMR at 7.5 minutes (95% CI: 6.9–8.1, I2=98%), ESD at 32.6 minutes (95% CI: 29.3–36, I2=99%), and TAMIS at 101 minutes (95% CI: 83.9–119, I2=95%) (Figure 2).
 |
Figure 2 Procedural Times with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
Outcomes
R0 Resection Rate
The aggregated R0 Resection rate for all procedures was 79.7% (95% CI: 78.6–80.8%, I2 = 80%), as shown in Figure 3. EMR had an R0 resection rate of 79.9% (95% CI: 78.3–81.5%, I2=85%), ESD at 78.7% (95% CI: 77.1–80.3%, I2=76%), and TAMIS at 87.1% (95% CI: 82.8–90.4%, I2=42%). A meta-regression analysis shows no significant difference by procedure type (Q = 11.5, p-value = 0.691) (Figure 3).
 |
Figure 3 R0 Resection Rates with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
En-Bloc Resection Rate
The en-bloc resection rate for the entire population was 87.1% (95% CI: 85.6–88.5%, I2 = 81). The en-bloc resection rate for patients treated with EMR was 86.5% (95% CI: 84.4–88.4%, I2=82%), ESD was 87.2% (95% CI: 84.4–89.5%, I2=80%), and TAMIS was 94.1% (95% CI: 88.9–97%, I2=0). A meta-regression analysis of en-bloc resection revealed a significant correlation between en-bloc resection rate and procedure type (Q=6, p-value=0.04) (Figure 4).
 |
Figure 4 En Bloc Resection Rates with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
Local Recurrence Rates
Local recurrence was reported at an aggregated rate of 2.8% (95% CI: 2.3–3.5%, I2=16%) across the entire population. Local recurrence for patients undergoing EMR was reported at 2.7% (95% CI: 1.9–3.7%, I2=32%), ESD at 1.7% (95% CI: 1.2–2.4%, I2= 0%), and TAMIS at 6.3% (95% CI: 4.2–9.2%, I2= 0%). A meta-regression analysis studying the effect of procedure type on local recurrence showed a strong relationship (Q=28, p<0.0001) (Figure 5).
 |
Figure 5 Local Recurrence Rates with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
Distant Recurrence Rates
Distant recurrence or metastasis was also reported in 2.3% (95% CI: 1.8–3%, I2=0%) of the population. EMR patient had a distal recurrence rate of 1.9% (95% CI: 1.3–3%, I2=0%), ESD had a rate of 1.6% (95% CI: 1.1–2.5%, I2= 0%), and TAMIS had a rate of 5.8% (95% CI: 3.3–9.8%, I2= 0%). A meta-regression analysis testing the relation between procedure type and distal recurrence revealed a significant relationship (Q=13, p-value=0.001) (Figure 6).
 |
Figure 6 Distant Recurrence Rates with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
Bleeding Rates
Bleeding rates for the entire population were 5.5% (95% CI: 4.9–6.2%; I2 = 43%). Patients treated with EMR had a bleeding rate of 6.6% (95% CI: 5.4–7.9%, I2=66%), ESD with 4.7% (95% CI: 4–5.6%, I2=0%), and TAMIS with 5.7% (95% CI: 3–10.5%, I2=0%). A meta-regression studying the relationship with procedure type revealed a non-significant relation (Q=1.1, p=0.055) (Figure 7).
 |
Figure 7 Bleeding rates with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
Reintervention Rates
8.2% (95% CI: 6.3–10.5%, I2=73%) of the entire population required reintervention for the disease. EMR patients had a reintervention rate of 7.5% (95% CI: 4.7–11.7%, I2=78%), ESD at 7.3% (95% CI: 5.1–10.4%, I2= 67%), and TAMIS at 12.2% (95% CI: 6.3–22.4%, I2= 68%). A meta-regression analysis revealed no significant relationship (Q = 2.3, p = 0.300) (Figure 8).
 |
Figure 8 Reintervention rates with 95% Confidence Intervals. Abbreviations: EMR, Endoscopic mucosal resection; ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery. |
Discussion
This systematic review and meta-analysis synthesized evidence from 108 studies including 8705 patients to compare the performance of EMR, ESD, and TAMIS as access and device-based minimally invasive platforms for early rectal tumors, while acknowledging that these approaches are often applied to different tumor phenotypes. Rather than assessing these interventions solely as procedural techniques, our findings highlight how differences in device architecture, access platforms, and mechanisms of tissue interaction translate into clinically meaningful differences in procedural efficiency, oncological outcomes, and safety.
Across the pooled cohort, EMR demonstrated the shortest procedure times, reflecting its snare-based endoscopic architecture and application to predominately smaller and superficial lesions. In contrast, ESD required longer procedure times, consistent with the technical demands of circumferential incision and meticulous submucosal dissection using dedicated knives and electrosurgical systems.131 TAMIS, which incorporates transanal access ports and laparoscopic or robotic instrumentation, unsurprisingly demonstrated the longest operative duration, reflecting both port setup and full-thickness excision requirements. This progression in procedural duration highlights increasing technological complexity and depth of tissue manipulation.
In terms of resection quality, TAMIS achieved the highest en bloc resection rates, consistent with its ability to achieve full-thickness excision under direct visualization. However, despite this technical advantage, R0 resection rates were broadly comparable across EMR, ESD, and TAMIS. This finding highlights the distinction between technical completeness and oncological adequacy and suggests that achieving an en bloc specimen alone does not necessarily translate into superior oncological outcomes. Despite the advanced resection technique of ESD, pooled R0 resection rates were marginally lower in this group, compared to EMR (78.7% vs 79.9%). This may be explained by patient selection bias and the mean allocation of smaller tumors for EMR, and subsequent lower recurrence rates in the ESD group. Margin status and long-term disease control appear to be influenced by tumor biology, depth of invasion, and pathological assessment rather than access platform alone. However, overall outcomes were often grouped without this subgroup analysis. For instance, neuroendocrine tumors (NETs) were often grouped with the remaining sample size, despite their indolent biology and overall known improved R0 resection and recurrence rates, likely skewing overall outcomes.
Despite achieving slightly lower pooled R0 rates, ESD demonstrated the lowest rates of both local and distant recurrence. This highlights the oncological value of precise submucosal dissection and high-quality histopathological margin assessment achievable through advanced endoscopic platforms. This finding is consistent with previous studies reporting higher oncological durability following en bloc ESD resection.82,90,100 Randomized and prospective data have similarly shown minimal or absent recurrence following R0 ESD resection, supporting the oncological advantage conferred by precise submucosal dissection and margin control.132–134 In contrast, TAMIS demonstrated higher recurrence rates despite technically robust resections, further reinforcing the concept that deeper or more aggressive resection does not inherently translate into superior oncological durability and that recurrence risk is strongly influenced by tumor biology and pathological risk features. Recent trial data, including the TRIASSIC study, further support the role of ESD in reducing recurrence compared with TAMIS in selected non-pedunculated rectal lesions.135
Bleeding and reintervention rates were broadly comparable across all three platforms. Although earlier studies have suggested higher adverse event rates with ESD compared with EMR,132 our pooled analysis demonstrated numerically lower bleeding rates in the ESD group. This may reflect advances in electrosurgical technology, hemostatic techniques, and operator experience. Emerging innovations such as cold resection and underwater EMR may further modify the safety profiles of these device platforms, although high-quality comparative data remain limited.136 Reintervention rates were similar between EMR and ESD and slightly higher following TAMIS, though this difference was not statistically significant. This pattern may reflect differences in resection strategy, access limitations, and recurrence management inherent to each device platform. High rates of re-intervention of TAMIS may be attributed to the selection criteria of larger and more complex tumors, as well as the technical limitations of instrument maneuvering in a confined space and less precise visualization, as opposed to ESD and EMR.
Several limitations must be acknowledged. Firstly, the majority of included studies were retrospective and observational, with only two randomized controlled trials available. Secondly, there was a lack of consistent stratification by tumor stage (T1 versus T2) across included studies. Tumor depth is a critical determinant of lymphovascular invasion, recurrence risk, and oncological outcomes, and failure to account for this factor limits attribution of outcome differences to access platform or device configuration alone. Thirdly, clinical heterogeneity must be considered as tumor size and morphology were inconsistently reported. EMR is preferentially applied to smaller, superficial lesions, whereas ESD and TAMIS—whether laparoscopic or robotic—are more commonly used for larger, flat, or deeper tumors. Consequently, higher recurrence rates observed following EMR likely reflect lesion complexity and limitations of piecemeal resection rather than technical inadequacy.14 Fourthly, substantial heterogeneity was observed, reflecting variation in access modality, instrumentation, operator expertise, institutional volume, and technological evolution. Nonetheless, the large, pooled sample and consistency of outcome trends provide meaningful insights into how device design and technological capability influence clinical performance.
From a medical device perspective, these findings emphasize that local excision for early rectal cancer should not be guided solely by whether a procedure is endoscopic or transanal. Instead, optimal outcomes depend on aligning tumor biology and anatomical characteristics with the appropriate access platform and instrumentation ecosystem, whether flexible endoscopic, laparoscopic transanal, or robotic transanal.
Conclusion
In conclusion, this meta-analysis demonstrates that EMR, ESD and TAMIS are safe and effective minimally invasive platforms for management of early rectal tumors. EMR and ESD represent flexible endoscopic solutions whereas TAMIS provides a transanal access platform adaptable to laparoscopic or robotic technology. While TAMIS achieves higher en bloc resection rates, EMR offers procedural efficiency for selected lesions and ESD provides superior oncological durability with the lowest recurrence rates. Importantly, these comparative findings should be interpreted in the context of tumor biology, depth, and pathological assessment than by access route or device choice alone. Future research should prioritize platform-specific comparative studies with appropriate stratification by tumor stage, size, and morphology to further optimize innovation-based approaches and guide clinical decision making in of early rectal cancer.
Data Sharing Statement
The data presented in the study are publicly available on search engines such as PubMed, Google Scholar, Ovid, Scopus and Embase, further inquiries can be directed to the corresponding author.
Acknowledgments
Parts of this work were presented at the Annual Meeting of the Surgical Research Society 2026 and subsequently published as an abstract in the British Journal of Surgery.137 https://doi.org/10.1093/bjs/znag018.338
Disclosure
The authors report no conflicts of interest in this work.
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