Postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method for the prevention of delayed bleeding after ESD. Surg Endosc. 2013;27:1292-1301. [PMID: 23232998 DOI: 10.1007/s00464-012-2600-1]

Aspiration and coagulation to reduce risk of delayed bleeding after gastric endoscopic submucosal dissection (with video)

OBJECTIVES

The purpose of this study was to evaluate the feasibility of a simple method named aspiration and coagulation (AC) for reducing the risk of postoperative bleeding after gastric endoscopic submucosal dissection (ESD).

METHODS

Data were retrospectively reviewed and collected from the medical records and endoscopic and pathologic reports about consecutive patients who underwent ESD for early gastric cancer or precancerous lesions or gastric submucosal lesions from January 2016 to December 2021 at the Seventh Medical Center of Chinese PLA General Hospital. Enrolled patients who underwent the AC method during ESD were included in the AC group, and the others were included in the control group. Propensity score (PS) matching (1:1 match) was used to compensate for the differences that might affect post-ESD bleeding. Massive hemorrhage and overall delayed bleeding events after gastric ESD were compared between the two groups.

RESULTS

Propensity score matching analysis created 242 matched pairs in the study. Characteristics of the subjects such as age and use of antithrombotic drugs were all similar between the two groups after PS matching. The rate of massive hemorrhage and overall delayed bleeding was both significantly lower in the AC group than in the control (0.4% vs. 3.3% for massive hemorrhage, P = 0.037, and 1.2% vs. 5.0% for overall delayed bleeding, P = 0.032), predominantly in mucosal lesions (0.6% vs. 4.4% for massive hemorrhage, P = 0.032, and 1.2% vs. 5.6% for overall delayed bleeding, P = 0.031).

CONCLUSIONS

Our study demonstrated that the AC method effectively decreased delayed bleeding events after ESD.

Strategies that Reduce Post-endoscopic Submucosal Dissection Bleeding

Bleeding after endoscopic submucosal dissection (ESD), one of the most common postprocedural adverse events, is the main cause of increased readmission rates and hospital costs. Generally, the incidence of post-ESD bleeding is estimated to be about 5%. However, the incidence of bleeding is particularly increased in high-risk patients. In particular, it has an incidence of over 50% in patients that use antithrombotic agents. The well-known risk factors for post-ESD bleeding include antithrombotic therapy, lesions in the proximal stomach, specimen size >4 cm, and concomitant renal disease. Currently, the number of patients at a high risk of post-ESD bleeding has been increasing. This may be due to the aging society and the increase in the usage of antithrombotic agents. Therefore, several strategies have been employed to prevent post-ESD bleeding. These strategies include acid inhibition therapy, preventive hemostasis using Doppler endoscopic ultrasound and artery-selective clipping, second look endoscopy, the closings method, and the shield methods. However, these methods are technically demanding, which hinders their wide usage in clinical practice. Recently, several hemostatic powders have been developed and clinically used in the treatment of gastrointestinal bleeding. In this article, we review the risk factors for post-ESD bleeding and the recently introduced prevention methods. Moreover, we aimed to explore realistic and appropriate strategies for the prevention of post-ESD bleeding.

Feasibility of a modified search, coagulation, and clipping method with and without the use of polyglycolic acid sheets and fibrin glue for preventing delayed bleeding after gastric endoscopic submucosal dissection

BACKGROUND

Methods have been developed for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (GESD). However, none of the methods can completely prevent DB. We hypothesized that DB could be prevented by a modified search, coagulation, and clipping (MSCC) method for patients at low risk for DB and by combining the use of polyglycolic acid sheets and fibrin glue with the MSCC method (PMSCC method) for patients at high risk for DB (antibleeding [ABI] strategy). This study assessed the technical feasibility of this novel strategy.

METHOD

We investigated 123 lesions in 121 consecutive patients who underwent GESD in Kushiro Rosai Hospital between April 2018 and January 2020. The decision for continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment.

RESULTS

Oral antithrombotic agents were administered to 28 patients (22.8%). The en bloc R0 resection rate was 98.4%. The MSCC method and the PMSCC method for preventing DB were performed in 114 and 9 lesions, respectively. The median time of the MSCC method was 16 min, and the median speed (the resection area divided by the time of method used) was 3.6 cm2/10 min. The median time of the PMSCC method was 59 min, and the median speed was 1.3 cm2/10 min. The only delayed procedural adverse event was DB in 1 (0.8%) of the 123 lesions.

CONCLUSIONS

The ABI strategy is feasible for preventing DB both in patients at low risk and in those at high risk for DB after GESD, whereas the PMSCC method may be necessary for reduction of time.

Endoscopic Doppler probe ultrasonography for detecting blood flow at post-endoscopic submucosal dissection ulcers of the stomach

Background and study aims  The rate of early rebleeding after endoscopic submucosal dissection (ESD) for early gastric cancer ranges from 5 % to 38 %, despite application of preventive methods. Post-ESD rebleeding may be caused by "invisible" vessels that may not be detectable using ultrasonographic techniques. Recently, Doppler probe ultrasonography (DOP) has been used in endoscopy. Because little is known about the usefulness of DOP for decreasing the post-ESD rebleeding rate, we performed a preliminary case series study. Patients and methods  Twelve patients underwent DOP for post-ESD ulcer evaluation after visible vessel coagulation. In this study, the novel DOP system used in the vascular surgery department was used. DOP-positive invisible vessels were shown as a pulse wave on the monitor. Results  No (0 %) cases of post-ESD rebleeding occurred. Twenty invisible vessels were detected, and 13 were subjected to additional coagulation up to a depth of 3 mm. Mean DOP procedure time was 11.6 minutes (range: 8-18 minutes). In these latter cases, disappearance of the Doppler pulse wave was confirmed. No early rebleeding or other adverse events were experienced. Conclusion  DOP is a safe and feasible method for detecting invisible vessels in post-ESD ulcers. Further investigation of the clinical relevance is warranted.

Risk factors for complications after endoscopic treatment in Chinese patients with early esophageal cancer and precancerous lesions

BACKGROUND

This study aimed to analyze the risk factors for complications after endoscopic treatment of early esophageal cancer and precancerous lesions and provides evidence for developing preventive measures against these complications.

METHODS

The clinical data of patients with early esophageal cancer and precancerous lesions treated in the Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College from January 2009 to December 2015 were analyzed. The risk factors related to delayed bleeding, perforation, and stenosis were assessed.

RESULTS

Of 459 patients, 15 (3.3%) had delayed bleeding, 16 (3.5%) had perforation, and 82 (17.9%) had stenosis. Conservative treatment was performed for patients with bleeding and perforation, and endoscopic dilation was performed to relieve stenosis. The independent risk factors for delayed bleeding were lesion size (OR = 1.51, P = 0.020), circumferential diameter [odds ratio (OR) = 1.24, P = 0.037]. The kind of operation method [endoscopic submucosal dissection (ESD)/cap-based endoscopic resection (EMR-Cap): OR = 15.38, P = 0.013) was the independent risk factor for perforation. The independent predictors of stenosis were circumferential diameter (OR = 1.58, P < 0.001), lesion in the neck (OR = 0.12, P = 0.003), and surgical time (OR = 1.02, P = 0.007).

CONCLUSION

Few complications occur after the endoscopic treatment of early esophageal cancer and precancerous lesions which can be treated by endoscopic and conservative medical therapies. Strict operational training is required for ESD treatment.

A case of gastric pseudoaneurysm following endoscopic submucosal dissection of early gastric cancer

A woman in her 80s underwent endoscopic submucosal dissection (ESD) for a 20-mm-sized early gastric cancer lesion in the posterior wall of the upper gastric body. The lesion was resected en bloc with no adverse events. However, bleeding was observed in a post-ESD mucosal defect the day after ESD, so endoscopic hemostasis was performed. Moreover, hematemesis occurred 4 days after ESD, when the bleeding site showed a sign of pulsatile aneurysm. Therefore, endoscopic hemostasis was considered difficult, and angiographic treatment was chosen. Since angiography revealed a pseudoaneurysm in a portion of a branch of the left gastric artery, embolization with microcoils was performed. Thereafter, no bleeding occurred. To the best of our knowledge, there is no case report about the formation of a pseudoaneurysm in a post-gastric ESD mucosal defect. Thus, this case is being reported to document valuable information.

The search, coagulation, and clipping (SCC) method prevents delayed bleeding after gastric endoscopic submucosal dissection

BACKGROUND

Delayed bleeding is an important complication after gastric endoscopic submucosal dissection (ESD). The search, coagulation, and clipping (SCC) method can be used to prevent delayed bleeding after ESD. However, its safety and efficacy are unclear. We compared the SCC method with post-ESD coagulation (PEC) to clarify the safety and efficacy of the SCC method for preventing delayed bleeding after gastric ESD.

METHODS

This retrospective study included 438 patients (478 lesions) who underwent gastric ESD. Multivariate logistic regression analysis was performed to identify the significant independent factors associated with delayed bleeding and we performed propensity-score matching (PSM) to reduce the effect of procedure-selection bias of SCC method.

RESULTS

Of the 438 patients, 216 underwent PEC and 222 underwent SCC. Delayed bleeding was significantly less common in the SCC than in the PEC (2.6% vs. 7.2%; P = 0.013). Among patients treated with antithrombotic therapy, the delayed bleeding rate was lower in the SCC group than in the PEC group; however, the difference was not significant (P = 0.15). The SCC method was found to be a significant independent factor for the prevention of delayed bleeding. PSM was performed in 156 patients in the PEC group and SCC group. There was a significant difference in the incidence of bleeding in the PEC and SCC groups (P = 0.013). No patient had perforation/bleeding associated with the SCC method.

CONCLUSIONS

Our findings suggest that the SCC method is a simple, safe, and effective approach for preventing delayed bleeding after gastric ESD.

Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis

BACKGROUND AND AIMS

Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD.

METHODS

Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I(2).

RESULTS

Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12).

CONCLUSIONS

Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.

Complications of endoscopic resection techniques for upper GI tract lesions

Adverse events can occur during and after the endoscopic resection of upper gastrointestinal lesions. Their incidence can be minimized through the adoption of preventive measures and their final outcomes can be optimized through prompt identification and adequate treatment. In this evidence-based review we describe the risk factors for adverse events, preventive measures to avoid them and their management when they occur. Algorithms of action are also provided. Oesophageal strictures can be prevented with corticosteroids (either locally injected or systemically administered) and treated with endoscopic dilatation. Bleeding can be minimized through the adoption of prophylactic coagulation and novel preventive measures are emerging and being evaluated. Bleeding management includes coagulation therapy, clips and haemostatic powders. Perforations can nowadays be successfully treated endoscopically in the majority of the cases and conservative treatment is associated with favourable outcomes although optimal management is unclear.

New Endoscopic Technologies and Procedural Advances for Endoscopic Hemostasis

Endoscopic interventions are first-line therapy for upper and lower gastrointestinal bleeding. Injection therapy in combination with a second endoscopic modality has reduced re-bleeding, need for surgery and mortality in non-variceal bleeding. For variceal bleeding endoscopic banding or cyanoacrylate injection techniques are recommended interventions. However, despite ease of application and general acceptance of these techniques, there is an ongoing re-bleeding rate associated with significant in-hospital mortality. We discuss current literature on new advances in endoscopic technologies and procedural techniques that have emerged to improve patient outcomes.

Bleeding after endoscopic submucosal dissection: Risk factors and preventive methods

Endoscopic submucosal dissection (ESD) has become widely accepted as a standard method of treatment for superficial gastrointestinal neoplasms because it enables en block resection even for large lesions or fibrotic lesions with minimal invasiveness, and decreases the local recurrence rate. Moreover, specimens resected in an en block fashion enable accurate histological assessment. Taking these factors into consideration, ESD seems to be more advantageous than conventional endoscopic mucosal resection (EMR), but the associated risks of perioperative adverse events are higher than in EMR. Bleeding after ESD is the most frequent among these adverse events. Although post-ESD bleeding can be controlled by endoscopic hemostasis in most cases, it may lead to serious conditions including hemorrhagic shock. Even with preventive methods including administration of acid secretion inhibitors and preventive hemostasis, post-ESD bleeding cannot be completely prevented. In addition high-risk cases for post-ESD bleeding, which include cases with the use of antithrombotic agents or which require large resection, are increasing. Although there have been many reports about associated risk factors and methods of preventing post-ESD bleeding, many issues remain unsolved. Therefore, in this review, we have overviewed risk factors and methods of preventing post-ESD bleeding from previous studies. Endoscopists should have sufficient knowledge of these risk factors and preventive methods when performing ESD.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

A second-look endoscopy may not reduce the bleeding after endoscopic submucosal dissection for gastric epithelial neoplasm

Background

Gastric endoscopic submucosal dissection (ESD) has gradually come to be recommended as the optimal treatment for early gastric cancer; however, one of the primary issues is postoperative bleeding. Although second-look endoscopy is conventionally performed to reduce the risk of postoperative bleeding, its benefit has not yet been clearly elucidated. The objective of this study was to elucidate the benefit of second-look endoscopy.

Methods

A total of 459 lesions in patients were underwent gastric ESD from May 2004 to April 2013 at our hospital were included in the analysis. The patients were divided into those who had bleeding within 24 hours after ESD (immediate bleeding) and those in whom bleeding occurred 24 hours or more after the procedure (delayed bleeding); the underlying disease, age, lesion site, diameter of the resected specimen, and lesion diameter were analyzed to identify the risk factors for postoperative bleeding after ESD.

Results

Post-ESD immediate or delayed bleeding occurred in 23 of the 459 cases (5.0%). Second-look endoscopy was performed in 210 of 447 cases (47.0%) excluding 12 cases with immediate bleeding; in the remaining 237 of the 447 cases (53.0%), it was not performed. Post-ESD delayed bleeding occurred in 6 of the 210 cases (2.9%) and 5 of the 237 cases (2.1%), with no statistically significant difference between the two groups. Overall, the following factors were identified as the risk factors for postoperative bleeding: young age (P = 0.005), lesions in the L segment (P = 0.042), and large size of the resected specimen (P = 0.005). The risk factors identified in the immediate bleeding group were lesions in the L segment (P = 0.032), large size of the resected specimen (P < 0.001), and large tumor size (P = 0.011), and those in the delayed bleeding group were young age (P = 0.013) and concomitant renal disease (P = 0.011).

Conclusions

The results of this study suggest that second-look endoscopy after gastric ESD may not be useful for preventing postoperative bleeding.