Modified Endoscopic Mucosal Resection Outperforms Endoscopic Submucosal Dissection for Rectal Neuroendocrine Tumors ≤10 mm: A Systematic Review and Meta Analysis

Abstract Background Endoscopic resection is the standard treatment for rectal neuroendocrine tumors (r-NETs) ≤10 mm, yet the optimal technique remains controversial. Modified endoscopic mucosal resection (m-EMR) has emerged as a potential alternative compared to endoscopic submucosal dissection (ESD), but existing evidence is largely retrospective and the results of recent randomized controlled trials (RCTs) are inconclusive. Aims To compare the efficacy and safety of m-EMR versus ESD for r-NETs ≤10 mm. Methods We systematically searched CENTRAL, PubMed, Embase, and WanFang from January 1st, 1970 to December 23, 2025 for RCTs comparing m-EMR with ESD in r-NETs ≤10 mm. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. Results Six RCTs involving 440 patients were analyzed. No significant difference between m-EMR and ESD was found in histologic complete resection (RR = 1.00, 95% CI 0.97–1.03; I 2 = 0%), en bloc resection rates (P = 0.75) and procedure-related complications (P = 0.94). And m-EMR was associated with a significantly shorter procedure time (P