Bleeding in patients who underwent scheduled second-look endoscopy 5\xa0days after endoscopic submucosal dissection for gastric lesions

Koichi Izumikawa,Sakuma Takahashi,Hiroyuki Okada,Tomoki Inaba,Kumiko Yamamoto,Shigetomi Tanaka,Shigenao Ishikawa,Masaya Iwamuro,Masaki Wato,Kenji Kuwaki,Ichiro Sakakihara

doi:10.1186/s12876-018-0774-2

Abstract

BackgroundBleeding after endoscopic submucosal dissection (ESD) in antithrombotic drug users is still one of the important issues to be solved. We performed scheduled second-look endoscopy (SLE) 5 days after ESD, when the resumption of antithrombotic agents is assumed to have achieved a steady state, rather than on the day after ESD. We investigated bleeding incidence and the status of ulcers.MethodsA total of 299 lesions in 299 patients subjected to ESD for gastric neoplasms were enrolled. A double dose of proton pump inhibitors was administered after ESD. SLE was planned 5 days after ESD. Post-ESD bleeding occurring before SLE was defined as early phase post-ESD bleeding, whereas bleeding after SLE was defined as later phase post-ESD bleeding. Forrest IIa and IIb ulcers are defined as high-risk ulcers requiring prophylactic hemostasis. We investigated risk factors for post-ESD bleeding, particularly focusing on the use of antithrombotic agents and the presence of high-risk ulcers requiring prophylactic hemostasis during SLE.ResultsUnder a double dose of proton pump inhibitors, early phase post-ESD bleeding occurred in 2.3% of non-users (5/218) and 6.2% of users of antithrombotic agents (5/81). High-risk ulcers were found in 19.0% of the cases during scheduled SLE (55/289). Later phase bleeding occurred in 5.5% of cases [2.8% of non-users (6/213) and 13.2% of users of antithrombotic agents (10/76)]. Cox regression analysis revealed that the risk factor for post-ESD bleeding was antithrombotic treatment (HR: 3.56; 95% CI: 1.63–8.02, p = 0.002) alone. Among patients with high-risk ulcers, a statistically significant increase in bleeding was observed in the later phase in patients under antithrombotic therapy, compared to those not receiving any antithrombotic agents (p = 0.001).ConclusionsAntithrombotic treatment is a risk factor for post-ESD bleeding despite SLE being scheduled 5 days after ESD. Later phase post-ESD bleeding was observed in 13.2% of the patients under antithrombotic treatment even after prophylactic hemostasis for high-risk ulcers.Trial registrationThis study was registered in the UMIN Clinical Trials Registry System (000023306). Retrospectively registered on 23rd July 2016.

Highlights

Bleeding after endoscopic submucosal dissection (ESD) in antithrombotic drug users is still one of the important issues to be solved
Post-ESD bleeding that occurred before second-look endoscopy (SLE) was defined as early phase post-ESD bleeding, whereas bleeding that occurred after SLE was defined as later phase post-ESD bleeding
Among patients in whom SLE was not performed on day 5, 6 patients who were not on antithrombotic agents experienced post-ESD bleeding

Summary

Introduction

Bleeding after endoscopic submucosal dissection (ESD) in antithrombotic drug users is still one of the important issues to be solved. Endoscopic submucosal dissection (ESD) has been established as a standard treatment for gastric neoplasms [1,2,3], post-ESD bleeding remains one of the various procedure-related adverse events that should not be overlooked [4, 5]. Known factors affecting the incidence of post-ESD bleeding include ESD technique, drugs administered prior to ESD (such as antiplatelet and anticoagulant drugs), gastric acid suppressing agents, and second-look endoscopy (SLE) [6,7,8,9]. Post-ESD bleeding in antithrombotic drug users is still one of the important issues to be solved. A consensus on the proper time of performing SLE has yet to be reached

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Discussion

Conclusion