Optimizing Endoscopic Submucosal Dissection: A Meta-Analysis of the S–O Clip’s Impact on Procedural Outcomes and Lesion-Specific Applications

Abstract

Background: Endoscopic submucosal dissection (ESD) is a minimally invasive procedure used to treat early-stage gastrointestinal neoplasms. While effective, ESD can be technically challenging due to limited submucosal visibility, prolonged procedure time, and increased risk of adverse events such as perforation and bleeding. The S–O clip, a traction device designed to enhance submucosal exposure, may help overcome these limitations and improve procedural outcomes. Methods: We conducted a systematic review and meta-analysis of studies comparing ESD with and without the S–O clip in patients with gastrointestinal neoplasms. Primary outcomes included en-bloc resection rate, complete resection rate, and procedure time. Secondary outcomes were dissection speed and adverse events, including intraoperative perforation and post-ESD bleeding. Pooled relative risks (RR) and mean differences (MD) were calculated. Subgroup analyses were performed based on lesion location. Results: Seventeen studies involving 1,449 patients were included. Use of the S–O clip significantly reduced procedure time (MD: − 19.63 min, 95% CI: − 28.02 to − 11.23, P < 0.001) and increased en-bloc resection rate (RR: 1.05, 95% CI: 1.01–1.09, P = 0.01). Complete resection rates were similar between groups (RR: 1.03, P = 0.23). Dissection speed was significantly higher with the S–O clip (MD: 10.18 mm2/min, P < 0.001). No significant differences were observed in intraoperative perforation or post-ESD bleeding rates. Conclusions: The S–O clip is a useful adjunct in ESD, improving efficiency and en-bloc resection without increasing adverse events. Its use may enhance outcomes, particularly in gastric and colorectal ESD.