Dissection Bleeding Research Articles

Continuous aspirin use does not increase post-endoscopic dissection bleeding risk for gastric neoplasms in patients on antiplatelet therapy.

Background and study aims: Discontinuation of all antiplatelet agents before endoscopic procedures may cause serious complications in some patients. The aim of this study was to evaluate the hemorrhagic risk of post-endoscopic submucosal dissection (ESD) in patients on antiplatelet therapy (APT). Patients and methods: The subjects were 350 patients (377 lesions) who underwent gastric ESD between January 2007 and July 2013. The patients were categorized based on antiplatelet therapies. The primary outcome was post-ESD bleeding. Multivariate analysis was performed to identify independent risk factors for post-ESD bleeding. Results: The patients were categorized into three groups: (1) no APT, 261 patients with 281 lesions; (2) single APT, 58 patients with 63 lesions (53 patients with low dose aspirin [LDA] and 5 patients with a thienopyridine); and (3) dual APT (DAPT), 31 patients with 33 lesions (DAPT with LDA and a thienopyridine). Post-ESD bleeding occurred in 16 of 261 patients in the no APT group (6.1 %), 9 of 58 patients in the single APT group (15.5 %), and 11 of 31 patients in the DAPT group (35.5 %). In multivariate analysis with a Cox proportional hazards model in the no APT and single APT groups, APT (HR 2.7, 95 %CI 1.1 – 6.6, P = 0.03) and diameter of the resected specimen of 40 mm or greater (HR 2.7, 95 %CI 1.2 – 5.9, P = 0.01) were significant risk factors for post-ESD bleeding. In multivariate analysis in the no APT and DAPT groups, DAPT was the only significant risk factor for post-ESD bleeding (HR 16.3, 95 %CI 3.4 – 78.2, P < 0.01). Continuous LDA was not a significant risk factor for post-ESD bleeding in both analyses (HR 0.8, 95 %CI 0.2 – 3.6, P = 0.72 in the no APT and single APT groups; HR 1.0, 95 %CI 0.2 – 5.1, P = 0.95 in the no APT and DAPT groups). Conclusions: APT increased the risk for post-ESD bleeding, and DAPT markedly increased the risk for bleeding. Continuous LDA did not produce an additional hemorrhagic risk in all patients treated with APT. Thus, patients treated with APT should be careful monitored for post-ESD bleeding, and LDA should not be interrupted in patients with a high thromboembolic risk.

Is a second-look endoscopy necessary after endoscopic submucosal dissection for gastric neoplasm?

Background/AimsSecond-look endoscopy is performed to check for the possibility of post-endoscopic submucosal dissection (ESD) bleeding and to perform prophylactic hemostasis in most hospitals; however, there is little evidence about the efficacy of second-look endoscopy. We investigated whether second-look endoscopy after ESD is useful in the prevention of post-ESD bleeding.MethodsA total of 550 lesions with gastric epithelial neoplasms in 502 patients (372 men and 130 women) were treated with ESD between August 18, 2009 and August 18, 2010. After the exclusion of three lesions of post-ESD bleeding within 24 hours, 547 lesions (335 early gastric cancers and 212 gastric adenomas) were included for the final analysis.ResultsThe occurrence rate of delayed post-ESD bleeding was not significantly different between the second-look group and the no second-look group (1% vs 2.5%, p>0.05). The only predictor of delayed bleeding was tumor size, regardless of second-look endoscopy after ESD (22.8±9.87 vs 15.1±10.47, p<0.05). There was no difference between the prophylactic hemostasis and nonprophylactic hemostasis groups, including the occurrence rate of delayed bleeding. In the second-look group with prophylactic hemostasis, the hospital stay was more prolonged than in the second-look group without prophylactic hemostasis, but there was no significant difference (p=0.08).ConclusionsSecond-look endoscopy to prevent delayed bleeding after ESD provides no significant medical benefits.

451 Risk Factors for Post-Endoscopic Submucosal Dissection Bleeding: a Matched Case-Control Study

BACKGROUND: Post-endoscopic submucosal dissection (ESD) bleeding is major complication and occurs in 3 to 10%. Various risk factors for post-ESD bleeding have been reported, however, sample size of these studies were relatively small. This study aimed to assess the risk factors for post-ESD bleeding.

Comparison between Intravenous Pantoprazole and Oral Lansoprazole about the Prevention against Bleeding after Endoscopic Submucosal Dissection

Background/Aims: Proton pump inhibitor (PPI) is generally prescribed to prevent post endoscopic submucosal dissection (ESD) bleeding. However, there was no consensus about the effectiveness of intravenous (IV) or oral PPI. We conducted this investigation to evaluate whether oral PPI can be also safely and effectively used to prevent post-ESD bleeding by measurement of intragastric pH. Materials and Methods: Patients were assigned in the fixed order to IV pantoprazole by 40 mg every 12 hours and oral lansoprazole fast disintegrating tablet (LFDT) by 30 mg every 8 hours. We checked intragastric pH and hemoglobin (Hb) levels at pre and post-ESD procedure. Results: A total of 10 patients (LFDT group: 6 patients, IV pantoprazole group: 4 patients) were included. There was no difference of baseline Hb level between two groups (LFDT, 14.38±0.46 mg/dL; IV pantoprazole, 13.85±0.83 mg/dL; P=0.18). After 24 hours, change of Hb level was not different between LFDT (0.95±0.30 mg/dL) and IV pantoprazole group (0.98±0.45 mg/dL; P=0.96). Baseline intragastric pH was 3.72±0.19 with LFDT and 4.31±0.41 with IV pantoprazole group (P=0.18). After 24 hours, there was no significant difference of the extent of pH increase between LFDT (2.38±0.28) and IV pantoprazole group (2.17±0.21; P=0.60). Conclusions: There was no difference in both the increase of post-24 hour intragastric pH and decrease of post-24 hour Hb between LFDT and IV pantoprazole group. Oral PPI regimen may be able to replace IV PPI therapy for the prevention of post-ESD bleeding and LFDT might be superior to IV PPIs in the aspect of cost-effectiveness. (Korean J Helicobacter Up Gastrointest Res 2014;14:103107)

The role of second-look endoscopy in endoscopic submucosal dissection for early gastric cancer

Delayed bleeding is a major complication of endoscopic submucosal dissection. Second-look endoscopy is routinely performed in most hospitals to reduce the possibility of delayed bleeding without solid evidence to support this practice. The aim of this study was to evaluate whether second-look endoscopy prevents delayed bleeding, and to verify clinicopathological features of delayed bleeding in order to identify lesions that may benefit from a second-look endoscopy. We investigated 392 lesions in 388 patients who underwent endoscopic submucosal dissection for early gastric cancer from January 2006 to July 2011. Clinically evident bleeding from mucosal defects 24 hours after endoscopic submucosal dissection was considered delayed bleeding. Data including characteristics of patients, lesions, and procedures were reviewed. Furthermore, the rate of delayed bleeding before and after second-look endoscopy, performed within three days of endoscopic submucosal dissection, was investigated to determine the utility of second-look endoscopy. Delayed bleeding was evident in 12 of 392 lesions (3,1%), all of which achieved endoscopic hemostasis. The only significant factor predicting delayed bleeding was a resected specimen size of over 40 mm (OR=6,200, 95% CI=1,912 - 20,108). Delayed bleeding occurred more frequently prior to the second-look endoscopy (p=0,022). In our endoscopic submucosal dissection data about early gastric cancer, it is too early to conclude that second-look endoscopy is not a valuable procedure, and second-look endoscopy may be useful for preventing post-endoscopic submucosal dissection bleeding, especially in resected specimens greater than 40 mm in size.

A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding

Endoscopic submucosal dissection (ESD) is one of the curative endoluminal surgical procedures for gastric epithelial neoplasms. There has been little research on bleeding after gastric ESD. To investigate cases of post-ESD bleeding and to verify whether a second-look endoscopy after ESD is effective in the prevention of delayed bleeding. A retrospective study with consecutive data. A single tertiary referral center. A total of 454 gastric epithelial neoplasms (386 early gastric cancers and 68 gastric adenomas). ESD and second-look endoscopy. Predictors on post-ESD bleeding by univariate analysis, incidence of post-ESD bleedings, and the timing of those before and after second-look endoscopy. Post-ESD bleeding occurred in 26 (5.7%) lesions. Gross type (flat or depressed type) was the only factor influencing post-ESD bleeding. All cases of post-ESD bleeding occurred within 14 days after ESD (median 2; range 0-14), and bleeding tended to occur from the lower and upper stomach earlier and later, respectively. In 19 lesions with delayed bleeding more than 24 hours after ESD, the maximum delayed bleeding rates before and after the second-look endoscopy were 2.8% and 2.5%, respectively. A retrospective, single-center analysis. A second-look endoscopy after gastric ESD may contribute little to the prevention of delayed bleeding.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery. Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible. A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma. Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Clinicopathological Analysis of Post-ESD (Endoscopic Submucosal Dissection) Bleeding in Patients with Gastric Neoplasmas

Clinicopathological Analysis of Post-ESD (Endoscopic Submucosal Dissection) Bleeding in Patients with Gastric Neoplasmas

Submuscular periareolar approach to augmentation mammoplasty in Korean women.

Augmentation mammoplasty can be approached by various methods according to the type of implant and implantation site depending on the status of the patient or surgeon's preference. The advantage for submuscular placement is based on problems associated with subglandular placement, especially capsular contracture and sensory changes in the nipple, and interference with the interpretation of mammograms is avoided. There are fewer complications such as hematoma, infection, and extrusion of the implant with submuscular dissection and relatively avascular, minimal sensory changes in the nipple compared with subglandular approach. The submuscular periareolar approach to augmentation mammoplasty was first described in the 1970s. This approach provides easy access to both the subglandular and subpectoral planes. It also provides a central point of access for creation of the implant pocket, which allows for easier and more accurate dissection in all diameters. The resultant periareolar scar is usually minimal with less injury to breast parenchyme and eventual biopsy or mastectomy incision to be performed through or around the areola. During the period of March 1999 to January 2000, 19 cases of who received submuscular periareolar augmentation mammoplasty under general anesthesia resulted in favorable scars with accurate access to pocket margin, easier dissection, and less bleeding compared with submuscular transaxillary augmentation mammoplasty. In our experience with the submuscular periareolar approach to breast augmentation it was highly versatile, safe, and less painful; postoperative hematoma incidence was greatly reduced and breast tissue injury was minimized.