Scheduled Second-look Endoscopy Research Articles

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.

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

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.

Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial

This study aimed to investigate the effectiveness of scheduled second-look endoscopy (EGD) with endoscopic hemostasis on peptic ulcer rebleeding and to identify the risk factors related to the need for second-look EGD. We prospectively randomized patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of active bleeding, visible vessel, or adherent clot into 2 groups between August 2010 and January 2013. Hemoclip application or thermal coagulation and/or epinephrine injection were allowed for initial endoscopic therapy. The same dosage of proton pump inhibitor was injected intravenously. The study group received scheduled second-look EGD 24 to 36 hours after the initial hemostasis, and further therapy was applied if endoscopic stigmata persisted, as above. Those patients who developed rebleeding underwent operation or radiologic intervention despite the additional endoscopic therapy. Outcome measures included rebleeding, amount of transfusion, duration of hospitalization, and mortality. After initial endoscopic hemostasis, 319 eligible patients were randomized into 2 groups. Sixteen(10.1%) and 9 (5.6%) patients developed rebleeding (P= .132), respectively. There was also no difference in surgical intervention (0, 0% vs 1, .6%, P >.999) or radiologic intervention (3, 1.9% vs 2, 1.2%, P= .683), median duration of hospitalization (6.0 vs 5.0 days, P= .151), amount of transfusion (2.4±1.7 vs 2.2 ± 1.6 units, P= .276), and mortality (2, 1.3% vs 2, 1.2%, P > .999) between the 2 groups. Multivariate analysis showed that grades 3 to 4 of endoscopists' estimation to success of initial hemostasis, history of nonsteroidal anti-inflammatory drug (NSAID) use, and larger amounts of blood transfusions (≥4units of red blood cells) were the independent risk factors of rebleeding. A single EGD with endoscopic hemostasis is not inferior to scheduled second-look endoscopyin terms of reduction in rebleeding rate of peptic ulcer bleeding. Repeat endoscopy would be helpful in the patients with unsatisfactory initial endoscopic hemostasis, use of NSAIDs, and larger amounts of transfused blood. (Clinical trial registration number: KCT0000565; 4-2010-0348.).

Risk factors for bleeding evaluated using the Forrest classification in Japanese patients after endoscopic submucosal dissection for early gastric neoplasm.

Bleeding remains a serious complication after endoscopic submucosal dissection (ESD). Second-look endoscopy for hemostasis helps prevent post-ESD bleeding. We investigated the relationships between patient characteristics, tumor characteristics, and the Forrest classification for exposed vessels on artificial ulcers after ESD and evaluated whether hemostasis during second-look endoscopy was useful for preventing post-ESD bleeding. We analyzed 250 patients (265 lesions) who underwent ESD for gastric neoplasms. Vessels classified by Forrest classifications during scheduled second-look endoscopy were analyzed for associations with patient characteristics, tumor characteristics, and recurrent bleeding. Two of 250 patients (0.8%) underwent emergency hemostatic endoscopy before scheduled second-look endoscopy. The remaining 248 patients (99.2%) underwent scheduled second-look endoscopy on the day after ESD. Patients with Forrest classification Ia, Ib, or IIa vessels had a significantly higher risk for recurrent bleeding after scheduled second-look endoscopy compared with patients with IIb or III vessels according to univariate analysis (P<0.05) and multivariate logistic regression analysis (odds ratio: 3.45; 95% confidence interval: 1.04-11.41; P=0.042). Univariate analysis indicated that hemodialysis correlated significantly with the presence of Ia, Ib, or IIa vessels compared with that of IIb or III vessels found during second-look endoscopy (P<0.05). Multivariate analysis indicated a significant relationship between hemodialysis and recurrent bleeding after second-look endoscopy (odds ratio: 10.05; 95% confidence interval: 1.97-51.26; P=0.006). Hemodialysis is a risk factor for post-ESD bleeding. Proper classification of exposed vessels within post-ESD ulcers according to the Forrest classification using second-look endoscopy might help predict or prevent recurrent bleeding.

Scheduled second-look endoscopy is not recommended after endoscopic submucosal dissection for gastric neoplasms (the SAFE trial): a multicentre prospective randomised controlled non-inferiority trial

ObjectiveTo clarify the effectiveness of second-look endoscopy (SLE) at preventing bleeding after gastric endoscopic submucosal dissection (ESD).DesignA multicentre prospective randomised controlled non-inferiority trial was conducted at five referral institutions across...

448 Scheduled Second-Look Endoscopy Is Not Routinely Recommended After Endoscopic Submucosal Dissection for Gastric Neoplasms (the Safe Trial): an Intention-to-Treat Analysis of Multicenter, Prospective Randomized Controlled Non-Inferiority Trial

Introduction: Postoperative bleeding is a major complication of gastric endoscopic submucosal dissection (ESD), occurring in 0 to 11.3% of cases. To reduce the incidence of postoperative bleeding, second-look endoscopy (SLE) is routinely performed the day after ESD. However, the effectiveness of SLE in the prevention of post-ESD bleeding remains controversial.

Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding

Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding

Sa1612 Effect of Scheduled Second-Look Endoscopy on Peptic Ulcer Bleeding: Interim Analysis of a Prospective Randomized Multicenter Trial in Korea

Sa1612 Effect of Scheduled Second-Look Endoscopy on Peptic Ulcer Bleeding: Interim Analysis of a Prospective Randomized Multicenter Trial in Korea

The value of routine second-look endoscopy in the management of the acute gastroduodenal ulcer bleeding

The role of routine second-look endoscopy in the management of patients with acute peptic ulcer bleeding is controversial. A more precise identification of higher risk patient group, based on both clinical and endoscopic criteria, is needed to determine whether there are high-risk patients who may benefit from this management strategy. Or aim was to find out whether scheduled second-look endoscopy has any beneficial effect in the clinical outcome. Both endoscopic and clinical data were analyzed in 274 acute gastroduodenal ulcer bleeding patients. The need for repeated endoscopic haemostatic intervention was used as a measure to evaluate the potential beneficial effect of the second look endoscopy. Patients were categorized according to the Forrest classification detected during the emergency endoscopy. In the subgroup of actively bleeding patients (Forrest Ia, Ib) a second endoscopic haemostasis was performed in 23.8% of cases. In the patient subgroup with visible vessel ulcers (Forrest IIa) and in those with adherent clot covered ulcers (Forrest IIb) the needs for a repeated haemostasis were 13.0% and 13.3% respectively. Despite the not statistically significant differences, remarkable clinical impact was noted favoring scheduled second look endoscopy in patients with initially active ulcer bleeding. In the light of the retrospective study results it may be concluded that the scheduled second look endoscopy strategy offers a beneficial clinical outcome for selected patients estimated to be a very high risk of re-bleeding following the initial endoscopic therapy for active bleeding.

Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is an important condition facing gastroenterologists. The focus of this article is the management of NVUGIB, with a particular emphasis on the endoscopic modalities and techniques that are most effective for various bleeding etiologies. Attention also is given to medical management, risk assessment, and issues pertaining to the timing of endoscopy and need for scheduled second-look endoscopy.

Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer

Objective. To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. Material and methods. The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. Results. All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. Conclusions. Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.

Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors?

In a previous study we demonstrated the efficacy of second-look endoscopy with therapy within 16 - 24 hours after index endoscopy in reducing major recurrent peptic ulcer bleeding. In this study, we sought to identify factors that might predict further rebleeding after this scheduled second-look endoscopy. We studied 249 patients (181 men, 68 women) with acute bleeding peptic ulcers who were treated at the United Christian Hospital, Hong Kong from 1999 to 2002 and who underwent a scheduled second endoscopy. Those patients who developed rebleeding after the second endoscopy were evaluated, and possible predictive factors for rebleeding were analyzed using a logistic regression model. Of the 249 patients who underwent scheduled second-look endoscopy, 17 patients (6.8 %) developed rebleeding: seven of these patients were treated by another endoscopic therapy; ten patients required surgery. The overall mortality rate was 3.1 %. A logistic regression analysis performed on the possible predictive factors for rebleeding found that the following factors were associated with a significant risk of further rebleeding after scheduled second endoscopy: American Society of Anesthesiologists (ASA) grade III or grade IV status (odds ratio 3.81, 95 % CI 1.27 - 11.44), ulcer size greater than 1.0 cm (odds ratio 4.69, 95 % CI 1.60 - 13.80), and a finding of persistent stigmata of recent hemorrhage at the scheduled second endoscopy (odds ratio 6.65, 95 % CI 2.11 - 20.98). Endoscopic factors, including large ulcer size and the persistence of endoscopic stigmata of recent hemorrhage are important predictors for recurrent bleeding after scheduled second endoscopy.