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

Prophylactic clip closure in preventing delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulants: a multicenter retrospective cohort study in Japan

BACKGROUND

 The effectiveness of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) is uncertain among patients on anticoagulants. We therefore aimed to assess this effectiveness using data from a large multicenter study.

METHODS

 We used the ABCD-J study database to analyze delayed bleeding among 34 455 colorectal ESD cases from 47 Japanese institutions. Delayed bleeding rates among the no/partial and complete closure groups were compared in patients on direct oral anticoagulants (DOACs) or warfarin. Propensity score matching was used for baseline characteristics to reduce the effects of selection bias.

RESULTS

 Overall, data from 1478 patients on anticoagulants who underwent colorectal ESD were examined. After propensity score matching, the complete and no/partial closure groups were compared in 212 patients on DOACs and 82 on warfarin. The complete closure group showed a significantly lower delayed bleeding rate in patients receiving DOACs (10.8 % vs. 5.2 %, absolute risk reduction [ARR] 5.7 %, P = 0.048) and warfarin (17.1 % vs. 6.1 %, ARR 11.0 %, P = 0.049). Additionally, complete closure significantly reduced the risk of delayed bleeding among patients taking DOACs for right-sided lesions (ARR 6.7 %, P = 0.04), whereas no risk reduction was observed for left-sided (P > 0.99) or rectal (P = 0.50) lesions. A similar trend was observed among patients on warfarin.

CONCLUSIONS

 Prophylactic complete clip closure after colorectal ESD significantly reduced the delayed bleeding rate in patients receiving DOACs or warfarin. It should be performed after ESD, particularly for right-sided lesions.

Endoscopic closure using a dedicated device following gastric endoscopic submucosal dissection: Multicenter, prospective, observational pilot study

Background and study aims

Development of a simple, optimized closure method for mucosal defects left by gastric endoscopic submucosal dissection (ESD) is warranted. Herein, we developed a novel and dedicated closure device called FLEXLOOP and aimed to assess feasibility and safety of the closure using FLEXLOOP following gastric ESD.

Patients and methods

This multicenter, prospective, observational study enrolled patients clinically diagnosed with gastric neoplasms < 30 mm in size. Following gastric ESD, closure of the mucosal defect was performed using a FLEXLOOP with standard clips. The primary outcome was the complete closure rate. The secondary outcomes were procedure time, number of clips, sustained closure rate on second-look endoscopy on postoperative days (PODs) 5 to 7, and rate of post-ESD bleeding.

Results

Overall, 35 patients were included in this study. The median specimen size was 32 mm. The mucosal defect was completely closed in 31 patients (89%; 95% confidence interval, 73%-99%) and incompletely closed in four patients (11%). Median closure time was 11 minutes and median number of clips was 10. Second-look endoscopy performed on PODs 5 to 7 demonstrated sustained, partially sustained, and unsustained closures in seven (20%), 22 (63%), and six patients (17%), respectively. Post-ESD bleeding and complications related to FLEXLOOP were not observed.

Conclusions

Closure using FLEXLOOP is feasible and safe. Our technique using this new device can be an attractive option for more easily closing mucosal defects. However, further clinical research is warranted to confirm that this technique can prevent delayed complications.

Feasibility of a new endoscopic suturing device: a first Western experience (with video)

BACKGROUND AND AIMS

Endoscopic hand suturing (EHS) is a new technique for the closure of mucosal defects in the GI tract. Although this method was tested for wound closure after endoscopic submucosal dissection (ESD) in Japan, a feasibility test in a Western setting is lacking. In this study, we present our first experience with EHS for different indications and in different anatomic locations.

METHODS

The technical success of EHS and suturing speed were retrospectively determined for all available EHS cases in our center. Technical success was defined as complete closure of the mucosal defect or visually tight fixation of the target.

RESULTS

A total of 19 EHS procedures were performed in 17 patients (mean age, 54.9 years; standard error of the mean [SEM], 4.2 years; male, 53% [n = 9]). Technical success was achieved in 78.9% (n = 15). Total EHS operation time was 40.0 minutes (SEM, 3.1 minutes) with 3.3 minutes (SEM, 0.2 minutes) per single stitch. In a constant team of endoscopist and assistant, mean stitch times declined significantly from the first 4 to the second 4 of 8 cases (4.0 [SEM, 0.6] vs 2.3 [SEM, 0.2] minutes, P = .02).

CONCLUSIONS

EHS was technically feasible and applicable in different anatomic locations. Further studies may elucidate a possible effect on adverse event rates of endoscopic resections.

Loop9 closure technique for mucosal defects after colorectal endoscopic submucosal dissection (with video)

Background and study aims Mucosal defect closure after colorectal endoscopic submucosal dissection (ESD) has the potential to reduce the occurrence of delayed adverse events (AEs) such as bleeding and perforation. This study aimed to assess the feasibility and effectiveness of the Loop9 method for closing mucosal defects following colorectal ESD. Patients and methods A retrospective single-center study was conducted using prospectively collected data from May 2020 to March 2023. Loop9 was deployed through a single instrument channel and anchored with clips at the defect site. Closure was accomplished by tightening the loop and deploying additional conventional clips as needed for complete closure. The primary outcome was complete closure rate, with secondary outcomes including the sustained closure rate at 4 to 5 days post-ESD, closed defect size, closure time, number of additional clips, and incidence of delayed AEs. Results This study included 118 cases. Complete closure was achieved in 96.6% of cases (114/118) with a sustained closure rate of 93.9% (107/114). The median size of the closed mucosal defects was 30 mm (interquartile range [IQR]: 25-38, range: 15-74). The median closure time was 14 minutes (IQR: 11.25-17), and the median number of additional clips deployed was six (IQR: 4-7). Stenosis requiring balloon dilatation was observed in one patient; however, there were no instances of post-ESD bleeding or delayed perforation. Conclusions The Loop9 method proved feasible and effective for closing mucosal defects following colorectal ESD, achieving high rates of complete and sustained closure.

A strategy combining endoscopic hand-suturing with clips for closure of rectal defects after endoscopic submucosal dissection with or without myectomy (with video)

BACKGROUND AND AIMS

Endoscopic hand-suturing (EHS) has been preliminarily demonstrated to be effective in closing defects after endoscopic submucosal dissection (ESD), but it is not easily performed. We proposed a strategy combining EHS with clips (EHS-Clips) and explored its effectiveness in closing rectal defects after ESD or ESD with myectomy (ESD-ME).

METHODS

In this observational study, data from patients with rectal defects closed using EHS-Clips were reviewed. EHS-Clips refers to a strategy where defects are sutured as much as possible by EHS first, with clips being used to close the remaining parts of defects that cannot be completely sutured. The primary endpoints included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for the sustained closure.

RESULTS

All 49 (100%) defects (42 ESD defects and 7 ESD-ME defects) were completely closed through the strategy of EHS-Clips, with 35 (71.4%) through EHS alone and 14 (28.6%) through EHS and additional clips. No patients experienced DB. Thirty-six (73.5%) defects remained sustained closure on postoperative days 3 to 5 (73.8% for ESD defects vs 71.4% for ESD-ME defects). The multivariate analyses identified a stitch margin of ≥5 mm (hazard ratio, 0.313; 95% confidence interval, 0.023-0.781; P = .009) as the only independent advantage factor for the sustained closure.

CONCLUSIONS

EHS-Clips can be used to effectively close the rectal defects after ESD or ESD-ME and prevent DB. Complete suture with a stitch margin of ≥5 mm may achieve more reliable sustained closure.

Does Prophylactic Closure Improve Outcomes After Colorectal Endoscopic Submucosal Dissection? A Systematic Review and Meta-analysis

BACKGROUND

Several studies have described prophylactic closure after endoscopic submucosal dissection (ESD) of colorectal lesions for improving postoperative outcomes. We reviewed the evidence on the impact of prophylactic closure after ESD.

METHODS

A literature search was conducted on PubMed, Embase, CENTRAL, and Web of Science by 2 reviewers independently for studies published up to July 9, 2023. All types of comparative studies were eligible.

RESULTS

Ten studies compared 939 patients undergoing prophylactic closure with 1074 controls. Three were randomized controlled trials (RCTs) while the rest were observational. Pooled data from all included studies showed that prophylactic closure resulted in reduced incidence of delayed bleeding after ESD [odds ratio (OR): 0.30; 95% CI: 0.15, 0.72; I2 =0%]. These results were significant only for observational studies but not for RCTs. Meta-analysis showed no significant difference in the risk of delayed perforation (OR: 0.55; 95% CI: 0.18, 1.70; I2 =0%) or post-ESD coagulation syndrome (PECS) (OR: 1.15; 95% CI: 0.41, 3.19; I2 =63%) between closure and nonclosure groups.

CONCLUSIONS

Observational data suggest that prophylactic closure of colorectal mucosal defects after ESD may reduce the risk of delayed bleeding. However, the results are not concurred by RCTs. Furthermore, there seems to be no impact of prophylactic closure on the risk of delayed perforation and PECS.

Curative endoscopic full-thickness resection of a fundic gland-type gastric adenocarcinoma

Video 1Summary of the presented case. Macroscopic images of the lesion in a white-light endoscopy and narrow-band imaging and in an underwater view followed by scenes from the resection with circular marking, submucosal injection, circumferential incision, and submucosal dissection using a multi-bend double-channel endoscope, as well as clip traction, controlled full-thickness dissection, and inspection of the defect plus closure of the defect with the clip-and-loop technique.

Suturing techniques with endoscopic clips and special devices after endoscopic resection

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.

Efficacy of local hemostatic agents after endoscopic submucosal dissection: a meta-analysis

INTRODUCTION

Topical hemostatic agents have been used to reduce bleeding rates after endoscopic submucosal dissection (ESD) for gastric cancer. However, to date, no review has summarized evidence on their efficacy.

MATERIAL AND METHODS

PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were searched for studies comparing bleeding rates after ESD with and without local hemostatic agents.

RESULTS

Eleven studies were included. The studies used polyglycolic acid (PGA) sheets and fibrin glue, fibrin glue, oxidized regenerated cellulose, polysaccharide hemostatic powder, or polyethylene oxide adhesive. Meta-analysis revealed a statistically significant reduction in the risk of delayed bleeding with the use of PGA sheets & fibrin glue (six studies; RR: 0.35 95% CI: 0.20, 0.63 p = 0.0005). However, meta-analysis of two studies showed no difference in the risk of bleeding based on the use of fibrin glue (RR: 0.44 95% CI: 0.03, 7.17 p = 0.56). Scarce data were available for the remaining hemostatic agents.

CONCLUSION

A large number of different hemostatic agents have been used to reduce the risk of bleeding after ESD for gastric cancer. Observational studies indicate that the use of PGA with fibrin glue could reduce the risk of bleeding after ESD. However, evidence for other agents was too scarce to derive conclusions.

Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

A narrative review of postoperative bleeding in patients with gastric cancer treated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is now considered a standard treatment for selected patients with early gastric cancer. Compared with endoscopic mucosal resection (EMR), ESD provides a higher complete resection rate (R0), and therefore, a lower local recurrence rate. However, ESD is a more time-consuming procedure, creating a wider and deeper ulcer floor which may cause complications. Post-ESD bleeding is one of them. Although most post-ESD bleedings can be controlled by endoscopic hemostasis at the time of operation, some bleeding after ESD may result in serious conditions such as hemorrhagic shock. Even with preventive methods such as ulcer closure, the application of fibrin glue and polyglycolic acid shielding, acid secretion inhibitors and hemostasis on second-look endoscopy, our experiences told us that post-ESD bleeding cannot be entirely avoidable, especially for patients with big size ulcer bed, anticoagulants/antithrombosis and chronic kidney diseases. The present review first defined post-ESD bleeding, then the incidence, the risk factors, such as the location of operative lesion, the size and depth, chronic kidney diseases, the impacts of anticoagulant and antithrombotic agents. We finally reviewed the managements of post-ESD bleeding, including approaches of coagulating potential bleeding spots during the procedure, lesion closure, lesion shielding and the application of gastric acid secretion inhibitors.