Post-endoscopic Submucosal Dissection Bleeding Research Articles

Risk factors for postoperative bleeding following endoscopic submucosal dissection in early gastric cancer: A systematic review and meta-analysis.

Early gastric cancer (EGC) presents a significant challenge in surgical management, particularly concerning postoperative bleeding following endoscopic submucosal dissection. Understanding the risk factors associated with postoperative bleeding is crucial for improving patient outcomes. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review and meta-analysis were conducted across PubMed, Embase, Web of Science, and the Cochrane Library without publication date restrictions. The inclusion criteria encompassed observational studies and randomized controlled trials focusing on EGC patients undergoing endoscopic submucosal dissection and their risk factors for postoperative bleeding. The Newcastle-Ottawa Scale was utilized for quality assessment. The effect size was calculated using random or fixed-effects models based on the observed heterogeneity. We assessed the heterogeneity between studies and conducted a sensitivity analysis. In our meta-analysis, 6 studies involving 4868 EGC cases were analyzed. The risk of postoperative bleeding was notably increased with intraoperative ulcer detection (odds ratio: 1.97, 95% confidence interval [CI]: 1.03-3.76, I2 = 61.0%, P = .025) and antithrombotic medication use (odds ratio: 2.02, 95% CI: 1.16-3.51, I2 = 57.2%, P = .039). Lesion resection size showed a significant mean difference (5.16, 95% CI: 2.97-7.98, P < .01), and longer intraoperative procedure time was associated with increased bleeding risk (mean difference: 11.69 minutes, 95% CI: 1.82-26.20, P < .05). Sensitivity analysis affirmed the robustness of these findings, and publication bias assessment indicated no significant bias. In EGC treatment, the risk of post-endoscopic submucosal dissection bleeding is intricately linked to factors like intraoperative ulcer detection, antithrombotic medication use, the extent of lesion resection, and the length of the surgical procedure. These interwoven risk factors necessitate careful consideration and integrated management strategies to enhance patient outcomes and safety in EGC surgeries.

Could immediate second-look endoscopy reduce post-endoscopic submucosal dissection bleeding?

Background and study aimGastric endoscopic submucosal dissection (ESD) is a curative treatment for gastric neoplasm. A scheduled second-look endoscopy could be performed to prevent delayed post-ESD bleeding. However, no studies on the efficacy of second-look endoscopy for the prevention of early delayed post-ESD bleeding have been conducted. So, the aim of this study was to be the first to investigate the efficacy of immediate second-look endoscopy for the prevention of post-ESD bleeding. Patients and methodsThe 266 gastric ESD cases were included. Immediate second-look endoscopy was defined as repeated upper endoscopy soon after complete hemostasis of the ESD site and specimen fixation. Early and late delayed bleeding were classified as before or after 24 h after the ESD, respectively. ResultsThe 262 ESD cases were enrolled and divided into three groups: the immediate second-look (n = 79), scheduled second-look (n = 86), and no second-look (n = 97). Post-ESD bleeding occurred in 19 cases (7.3%). Of these, 13 (68.4%) were early delayed post-ESD bleeding. The immediate second-look endoscopy had a lower incidence of early delayed post-ESD bleeding compared to the groups without immediate second-look endoscopy, (3.8% vs. 0.8%, p = 0.009). In a multivariate analysis, immediate second-look endoscopy significantly reduced early delayed post-ESD bleeding (OR 0.39, p = 0.022). The resected specimen area ≥ 1,000 mm2 was an independent risk factor for early delayed post-ESD bleeding (OR 8.98, p = 0.010). However, the frequency of delayed post-ESD bleeding did not differ between the three groups. ConclusionImmediate second-look endoscopy after gastric ESD may prevent early delayed post-ESD bleeding under certain circumstances.

S796 A Systematic Review and Meta-Analysis on the Efficacy of Fibrin Sealant in Preventing Post-Endoscopic Submucosal Dissection Bleeding

S796 A Systematic Review and Meta-Analysis on the Efficacy of Fibrin Sealant in Preventing Post-Endoscopic Submucosal Dissection Bleeding

Does second-look endoscopy reduce the bleeding after gastric endoscopic submucosal dissection for patients receiving antithrombotic therapy?

BackgroundIn patients with average risk of bleeding, second-look endoscopy does not reportedly reduce bleeding after gastric endoscopic submucosal dissection. However, effectiveness of second-look endoscopy for patients with a high risk of bleeding, such as those who are taking antithrombotic agents, is unclear. Hence, this study aims to clarify the effectiveness of second-look endoscopy for patients with antithrombotic therapy.MethodsWe studied 142 consecutive patients with 173 gastric epithelial neoplasms who were routinely taking antithrombotic agents and were treated by endoscopic submucosal dissection at Tonan Hospital between November 2013 and December 2019. They were classified into two groups: those with second-look endoscopy (SLE group, 69 patients with 85 lesions) and those without second-look endoscopy (non-SLE group, 73 patients with 88 lesions). The incidence of post-endoscopic submucosal dissection bleeding was compared between the SLE and non-SLE groups.ResultsThere were no statistical differences in the rate of patients undergoing single antiplatelet therapy, single anticoagulant therapy, and multiple therapy between the SLE and non-SLE groups (SLE group vs. non-SLE group; 32 [46.4%], 16 [23.2%], and 21 [30.4%] patients vs. 37 [50.7%], 20 [27.4%], and 16 [21.9%] patients, respectively; p = 0.50). Post-endoscopic submucosal dissection bleeding incidence was 21.7% (15/69) and 21.9% (16/73) in the SLE and non-SLE groups, respectively, and did not significantly differ between the two groups (p = 0.98).ConclusionsFor patients taking antithrombotic agents, the incidence of post-endoscopic submucosal dissection bleeding was not reduced by second-look endoscopy.

Endoloop closure following gastric endoscopic submucosal dissection to prevent delayed bleeding in patients receiving antithrombotic therapy

Objectives Given the high risk of bleeding in post-endoscopic submucosal dissection (ESD) patients receiving antithrombotic therapy, a new effective method is needed to prevent delayed bleeding among such patients. The aim of this study was to assess the efficacy of endoloop closure, using an endoloop and clips, after gastric ESD to prevent bleeding among patients receiving antithrombotic therapy. Methods This retrospective study enrolled patients taking antithrombotic agents who underwent ESD for early gastric cancer between March 2016 and January 2019. Patients were classified into two groups: the endoloop closure group and the control group (no prophylactic treatment). We compared the rates of post-endoscopic submucosal dissection bleeding between the two groups. Results Overall, 178 patients were included, with 37 patients in the endoloop closure group and 141 patients in the control group. The rate of post-endoscopic submucosal dissection bleeding was in general lower in the endoloop closure group than in the control group; however, the difference was not statistically significant (8% vs. 23%, p = 0.06). Among patients with a resected specimen size <40 mm and those using multiple antithrombotic agents, the endoloop closure group showed a lower rate of post-endoscopic submucosal dissection bleeding (0% vs. 16%, p = 0.03 and 10% vs. 70%, p = 0.02, respectively). Conclusions Closure using an endoloop and endoclips after gastric ESD might prevent post-procedure bleeding in patients receiving antithrombotic therapy, particularly in those patients with a resected specimen <40 mm and those receiving multiple antithrombotic agents.

Vonoprazan versus proton pump inhibitors for postendoscopic submucosal dissection bleeding in the stomach: a multicenter population-based comparative study

The effectiveness of vonoprazan relative to that of proton pump inhibitors (PPIs) after gastric endoscopic submucosal dissection (ESD) is unclear. Although previous studies used post-ESD ulcer healing as the outcome measure, post-ESD bleeding rate is the most objective and appropriate outcome measure because it has less ascertainment bias. We aimed to compare the post-ESD bleeding rates between vonoprazan and PPIs. This nationwide population-based retrospective cohort study was conducted between 2014 and 2018 and involved 9 hospitals. After 2 days of intravenous PPI administration, either vonoprazan or PPI was administrated from postoperative day 2 to30. Overall, data of 1715 patients (627 patient pairs) were analyzed through propensity score matching. The vonoprazan group had significantly lower post-ESD bleeding rates than the PPI group (overall, 11.9% vs 17.2%, P= .008; bleeding between days 2 and 30, 7.8% vs 11.8%, P= .015). The readmission rate because of post-ESD bleeding was lower in the vonoprazan group (2.4% vs 4.1%, P= .081). Blood transfusion (2.1% vs 3.0%, P= .15) and additional surgery because of delayed perforation (.5% vs 1.0%, P= .32) were not significantly different between the 2 groups. No deaths within 30 days occurred in both groups. On Cox regression analysis, vonoprazan use, lesion location (antrum), aspirin use, direct oral anticoagulant use, and Charlson Comorbidity Index (≥2) were associated with an increased risk of post-ESD bleeding within 30 days. Vonoprazan has a lower post-ESD bleeding rate than PPIs. Further prospective studies are required to confirm these results.

Su1331 GASTRIC ESD IN DAY SURGERY

Although endoscopic submucosal dissection (ESD) is generally accepted for the standard treatment for early gastric cancer, few days hospitalization is necessary because of surveillance of post ESD bleeding. In this study, we analyzed the feasibility of gastric ESD at outpatient’s setting.

Risk factors for delayed bleeding by onset time after endoscopic submucosal dissection for gastric neoplasm

Post-endoscopic submucosal dissection bleeding (PEB) is one of the important complications after endoscopic submucosal dissection (ESD), but still difficult to predict. The present study aimed to identify significant risk factors for PEB according to onset time. Between November 2008 and January 2016, a total of 1864 lesions resected via ESD were analyzed. PEB was classified as either early or late according to onset time (within or after 24 hours post-ESD, respectively). During second-look endoscopy, the artificial ulcer bed was subjected to Forrest classification. A high risk of stigma was defined as active spurting bleeding, oozing bleeding, and a non-bleeding visible vessel in the ulcer. The endoscopic factors and medications associated with PEB were analyzed. PEB occurred in 77 lesions (4.1%): early only in 46 (2.4%), late only in 22 (1.1%), and early and late in 9 (0.4%). Among 55 early PEB events, 25 were asymptomatic and diagnosed during second-look endoscopy. Age ≤65 years, resection size ≥30 mm, procedure time ≥20 min, lower third of the stomach, erosion, and clopidogrel use were significantly associated with early PEB. If the number of risk factors were ≤1, the risk of early PEB was 0.6%. For late PEB, the mid to upper third of the stomach, undifferentiated carcinoma, erosion, high risk of stigma during second-look endoscopy, history of early PEB, and clopidogrel use were significant risk factors. If risk factors were absent, the risk of late PEB was 0.1%. For patients at high risk of early PEB, selective second-look endoscopy might be a useful. For patients at high risk of late PEB, careful monitoring of bleeding should be considered.

CEGP-003 Spray Has a Similar Hemostatic Effect to Epinephrine Injection in Cases of Acute Upper Gastrointestinal Bleeding.

Endoscopically applicable hemostatic agents have been demonstrated to have high initial hemostasis rates in cases of upper gastrointestinal bleeding (UGIB). The authors developed a new hemostatic powder (CEGP-003) and evaluated its hemostatic and ulcer healing effects in UGIB. Patients with peptic ulcer or post-endoscopic resection bleeding were randomly assigned to be treated by epinephrine injection or CEGP-003 spray. All patients were placed under observation for 3days and underwent second-look endoscopy. The primary outcome was initial hemostasis rate, and the secondary outcomes were rebleeding rate and ulcer healing effect. Seventy-two patients with UGIB were enrolled in this study. Causes of bleeding were peptic ulcer (15, 20.5%), post-endoscopic mucosal resection (11, 15.1%), and post-endoscopic submucosal dissection bleeding (47, 64.4%). Initial hemostasis was achieved in 89.2% (34/37) of patients in the epinephrine group and in 100% (35/35) in the CEGP-003 group (p = 0.115). Rebleeding occurred in 2.7% (1/37) and 8.6% (3/35) in the epinephrine and CEGP-003 groups, respectively (p = 0.35). Three days after endoscopic hemostasis, the ulcer healing effects of epinephrine and CEGP-003 were similar (p = 0.79). This study shows that CEGP-003 spray has a hemostatic effect similar to epinephrine in terms of initial hemostasis and rebleeding rates. The authors consider CEGP-003 a potential therapeutic tool for UGIB as a definitive or bridge therapy and that it is particularly useful for oozing lesions after endoscopic resection.

A double-channel cap-assisted closure of a gastric defect after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) has been widely accepted as a standard of care for early gastric cancer (EGC). However, post ESD bleeding is one of the adverse events after ESD procedure, particularly for patients with antithrombotic therapy. A 73-year-old male underwent ESD for EGC located on the anterior wall of upper gastric body. We closed the large mucosal defect after ESD because he was taking cilostazol (100 mg/day) for ischemic heart disease. Endoscopic closure of the mucosal defect was successfully performed with endoclips and two endoloops using a standard single accessory channel gastroscope with a double-channel cap-assisted. A second look endoscopy, 4 days after ESD, demonstrated sustained closure of the post ESD defect. He was discharged 7 days after ESD without post ESD bleeding. This method is technically useful for closure of large mucosal defects in difficult locations after gastric ESD.

Risk factors for postoperative bleeding after gastric endoscopic submucosal dissection in patients under antithrombotics.

To evaluate the risk factors for postoperative bleeding after gastric endoscopic submucosal dissection (ESD) based on the latest guidelines. A total of 262 gastric neoplasms were treated by ESD at our center during a 2-year period from October 2012. We analyzed the data of these cases retrospectively to identify the risk factors for post-ESD bleeding. Of the 48 (18.3%) cases on antithrombotic treatment, 10 were still receiving antiplatelet drugs perioperatively, 13 were on heparin replacement after oral anticoagulant withdrawal, and the antithrombotic therapy was discontinued perioperatively in 25 cases. Postoperative bleeding occurred in 23 cases (8.8%). The postoperative bleeding rate in the heparin replacement group was 61.5%, significantly higher than that in the non-antithrombotic therapy group (6.1%). Univariate analysis identified history of antithrombotic drug use, heparin replacement, hemodialysis, cardiovascular disease, diabetes mellitus, elevated prothrombin time-international normalized ratio, and low hemoglobin level on admission as risk factors for post ESD bleeding. Multivariate analysis identified only heparin replacement (OR = 13.7, 95%CI: 1.2-151.3, P = 0.0329) as a significant risk factor for post-ESD bleeding. Continued administration of antiplatelet agents, based on the guidelines, was not a risk factor for postoperative bleeding after gastric ESD; however, heparin replacement, which is recommended after withdrawal of oral anticoagulants, was identified as a significant risk factor.

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.

A Prospective, Randomized Trial of Sucralfate Versus Proton Pump Inhibitor On Prevention of Hemorrhage from the Artificial Ulcer After Endoscopic Submucosal Dissection

Background: Endoscopic submucosal dissection (ESD) is a novel technique that enables complete en bloc resection of the early gastric cancer(EGC). ESD renders the endoscopists to dissect the submucosal layer with direct vision and remove larger lesions, hence complete histological diagnosis is possible while recurrence can be avoided. Recently, the indication of ESD is adjusted to encompass premalignant lesions and early gastric cancers as this procedure is widely performed. However, the risk of bleeding increases considerably as compared to conventional mucosal resection. To prevent post ESD bleeding, phamarcologic treatment using proton pump inhibitor (PPI) has been recommended. Theoretically, bleeding could be avoided by meticulous coagulation during ESD procedure and the use of PPI can inflict unnecessary cost elevation. The aim of this study was to elucidate the effect of the PPI versus sucralfate on the prevention of bleeding after ESD. Materials and Methods: A total of 128 patients with gastric premalignant or superficial carcinoma who underwent ESD were enrolled in a prospective randomized trial. After stratification by tumor size, shape, location, and other clinical variables, the patients were randomly assigned to two treatment groups. They received either pantoprazole 80 mg for 3 days and then 40 mg for two months (PPI group) or sucralfate 6 mg a day for two months (non PPI group) after ESD. All ESD procedures ensured that every potential bleeding spots were thoroughly coagulated. Primary endpoint was incidence of bleeding that was defined as haematemesis or melena which needed endoscopic hemostasis and requirement of more than 2 units of blood. Other clinal variables includes degree of ulcer healing, pain score and hospital day. Results: 65 patients in the PPI group and 63 patients in the non PPI group were analyzed. There was no difference on age, ulcer size, Helicobacter pylori status, NSAID medication history between these groups. Bleeding occurred in 4 patients in the PPI group and 6 patients in the non PPI group (p = 0.89). Tumor size over 3 cm and location of tumor in upper body and posterior stomach were the independent predictor for the bleeding. No differences were found in terms of symptom score, ulcer healing rate, hospital stay days between these groups. Conclusion: The Effect of sucralfate was comparable to PPI treatment on reducing the risk of bleeding. Meticulous bleeding control during ESD and use of sucralfate is reasonable alternative to PPI for the management of the ulcer created after ESD with advantage of cost effectiveness.