Conclusions

Our meta-analysis indicates that TA-ESD offers clear procedural and safety advantages over C-ESD for esophageal cancer treatment: comparable en-bloc and R0 resection rates, a larger resection area (32.49 vs 25.05 cm², p < 0.05), and a lower perforation rate (2.0% vs 3.6%, p = 0.03) - findings supported by lower heterogeneity and therefore the most robust in this analysis. TA-ESD was also associated with a higher pooled curative resection rate (52.5% vs 36.6%, p = 0.0018) and a higher rate of stricture formation (35.4% vs 19.5%, p = 0.0079); however, both of these estimates derive from only two studies with extreme heterogeneity driven largely by differences in lesion depth and size across the contributing cohorts, and should be regarded as hypothesis-generating rather than conclusive. TA-ESD's improved visualization and tissue stabilization may make it particularly valuable for larger or more complex lesions, while C-ESD remains a viable option for standard cases. Future large-scale prospective studies stratifying by depth of invasion and lesion size, comparing different traction techniques, and incorporating cost-effectiveness analysis are needed before firm treatment recommendations can be made. Until then, the choice between TA-ESD and C-ESD should be individualized, weighing TA-ESD's procedural and safety advantages against its associated stricture risk and the still-preliminary evidence on curative resection.