A prospective randomized trial of either famotidine or pantoprazole for the prevention of bleeding after endoscopic submucosal dissection

The effect of PPIs Alone, PPIs plus cytoprotective agent, and H2RA plus cytoprotective agent on ulcer healing after endoscopic submucosal dissection: A prospective randomized controlled trial

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is the most effective treatment for early gastric cancer or gastric adenoma. However, ESD results in iatrogenic ulcers and postoperative bleeding from ulcers. This study aimed to evaluate the effect of using a proton pump inhibitor (PPI) alone, a PPI + rebamipide combination therapy, and an H2 receptor antagonist (H2RA) + rebamipide combination therapy on ulcer healing after ESD.

PATIENTS AND METHODS

A total of 204 patients who underwent ESD from April 2014 to July 2017 at Dong-A University Hospital were randomly assigned to the following groups: PPI-alone group, PPI + rebamipide combination therapy group, and H2RA + rebamipide combination therapy group. However, only 156 patients were studied since we excluded those who were lost to follow-up or had diseases other than early gastric cancer or gastric adenoma. Twenty-eight days after ESD, we evaluated the ulcer residual ratio, S stage rates, ulcer bleeding ratio, and gastric pH.

RESULTS

This study included 156 patients (PPI-alone group: 52 patients; PPI + rebamipide group: 52 patients; H2RA + rebamipide group: 52 patients). The ulcer residual ratios were 24.3 ± 14.2%, 17.0 ± 12.1%, and 21.0 ± 13.8% in the PPI alone, PPI + rebamipide, and H2RA + rebamipide groups, respectively (P = 0.048).

CONCLUSIONS

PPI + rebamipide was more effective in reducing the ulcer residual ratio after ESD. There was no statistical difference in ulcer stage and delayed bleeding after ESD among the groups. These findings showed that PPI + rebamipide had limited benefits after ESD.

Histamine2-Receptor Antagonists, Proton Pump Inhibitors, or Potassium-Competitive Acid Blockers Preventing Delayed Bleeding After Endoscopic Submucosal Dissection: A Meta-Analysis

Background: Endoscopic submucosal dissection (ESD) was commonly used for en bloc resection in gastric cancer and adenoma with the risk of delayed bleeding after ESD. We conducted a direct and indirect comparison meta-analysis to evaluate the best choice in preventing post-ESD bleeding among proton pump inhibitors (PPIs), histamine₂-receptor antagonists (H₂RAs), and the most widely used potassium-competitive acid blocker, vonoprazan.

Methods: The Pubmed, Cochrane Library, and Embase were searched for randomized trials. We pooled odds ratios (OR) for preventing post-ESD bleeding using meta-analysis.

Results: Sixteen randomized trials met the inclusion criteria including 2,062 patients. Direct comparisons showed slightly significant efficacy in PPIs rather than H₂RAs in preventing post-ESD bleeding [OR: 1.83; 95% confidence interval (CI): 1.10 to 3.05] and vonoprazan was better than PPIs (OR: 0.46; 95% CI: 0.25 to 0.86). The adjusted indirect comparison indicated vonoprazan was superior to H₂RAs (OR: 0.30, 95% CI: 0.12 to 0.74). In subgroup analysis, PPIs had similar efficacy as H₂RAs in 4 weeks, while PPIs were better than H₂RAs in 8 weeks’ treatment (OR: 1.91; 95% CI: 1.08 to 3.40). The superiority of vonoprazan than PPIs was more significant in combination therapy (OR: 0.18; 95% CI: 0.04 to 0.69). There was a significant difference in vonoprazan for 8 weeks of medication (OR: 0.44; 95% CI: 0.21 to 0.92).

Conclusions: The effects of vonoprazan is better than PPIs than H₂RAs in preventing bleeding after ESD. When vonoprazan combined with mucosal protective antiulcer drug in treatment or used in 8 weeks of medication, the efficacy may be even better.

Efficacy of vonoprazan in prevention of bleeding from endoscopic submucosal dissection-induced gastric ulcers: a prospective randomized phase II study

BACKGROUND

Vonoprazan, potassium-competitive acid blocker, is expected to reduce incidence of delayed bleeding after gastric endoscopic submucosal dissection (ESD); however, preliminary data to design a large-scale comparative study are lacking. This study aimed to assess the efficacy of vonoprazan in preventing delayed bleeding after gastric ESD.

METHODS

In this single-center randomized phase II trial, a modified screened selection design was used with a threshold non-bleeding rate of 89% and an expected rate of 97%. In this design, Simon's optimal two-stage design was first applied for each parallel group, and efficacy was evaluated in comparison with the threshold rate using binomial testing. Patients were randomly assigned in a 1:1 ratio to receive either vonoprazan 20 mg (VPZ group) or lansoprazole 30 mg (PPI group) for 8 weeks from the day before gastric ESD. The primary endpoint was the incidence of delayed bleeding, defined as endoscopically confirmed bleeding accompanied by hematemesis, melena, or a decrease in hemoglobin of ≥ 2 g/dl.

RESULTS

Delayed bleeding occurred in three of 69 patients (4.3%, 95% CI 0.9-12.2%, p = 0.047) in the VPZ group, and four of 70 (5.7%, 95% CI 1.6-14.0%, p = 0.104) in the PPI group. As only vonoprazan showed significant reduction in delayed bleeding compared with the threshold rate, it was determined to be efficacious treatment.

CONCLUSIONS

Vonoprazan efficaciously reduced the delayed bleeding rate in patients with an ESD-induced gastric ulcer. A large-scale, randomized, phase III study is warranted to definitively test the effectiveness of vonoprazan compared with proton pump inhibitors.

Is it possible to perform gastric endoscopic submucosal dissection without discontinuation of a single antiplatelet of thienopyridine derivatives?

BACKGROUND AND STUDY AIMS

Combined use of thienopyridine derivatives and other antithrombotic agents is reported to be a risk factor for postoperative bleeding after gastric endoscopic submucosal dissection (ESD). However, risk associated with a single thienopyridine derivative has not been evaluated. In this study, we aimed to evaluate bleeding risks of gastric ESD without discontinuation of a single thienopyridine derivative agent.

PATIENTS AND METHODS

 This multicenter, prospective, observational cohort study included patients who had undergone implantation of a coronary artery stent and who were taking a combination of aspirin antiplatelet therapy and a thienopyridine derivative agent. Enrolled patients discontinued aspirin and underwent gastric ESD without the discontinuation of a single thienopyridine derivative agent. The primary endpoint was the major bleeding complication rate after gastric ESD.

RESULTS

 Eleven patients were enrolled in this study from April 2015 to November 2016 after written informed consent was obtained. Among them, 1 patient, who had undergone surgery for a primary cardiac tumor before ESD, was excluded from the study. Ten patients underwent gastric ESD for neoplasms. En-bloc resections were achieved in all cases without intraoperative bleeding complications. Two patients experienced postoperative bleeding although neither case required a blood transfusion (95 % CI 2.5 - 55.6 %).

CONCLUSION

 En-bloc resections were possible although the postoperative bleeding rate tended to be higher in gastric ESD without discontinuation of a single thienopyridine derivative agent. Additional preventive measures are mandatory to carry out safe gastric ESD in such settings.

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.

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.

Second-look endoscopy and factors associated with delayed bleeding after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy (SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.

Proton pump inhibitors therapy vs H2 receptor antagonists therapy for upper gastrointestinal bleeding after endoscopy: A meta-analysis

AIM: To compare the therapeutic effects of proton pump inhibitors vs H₂ receptor antagonists for upper gastrointestinal bleeding in patients after successful endoscopy.

METHODS: We searched the Cochrane library, MEDLINE, EMBASE and PubMed for randomized controlled trials until July 2014 for this study. The risk of bias was evaluated by the Cochrane Collaboration’s tool and all of the studies had acceptable quality. The main outcomes included mortality, re-bleeding, received surgery rate, blood transfusion units and hospital stay time. These outcomes were estimated using odds ratios (OR) and mean difference with 95% confidence interval (CI). RevMan 5.3.3 software and Stata 12.0 software were used for data analyses.

RESULTS: Ten randomized controlled trials involving 1283 patients were included in this review; 678 subjects were in the proton pump inhibitors (PPI) group and the remaining 605 subjects were in the H₂ receptor antagonists (H₂RA) group. The meta-analysis results revealed that after successful endoscopic therapy, compared with H₂RA, PPI therapy had statistically significantly decreased the recurrent bleeding rate (OR = 0.36; 95%CI: 0.25-0.51) and receiving surgery rate (OR = 0.29; 95%CI: 0.09-0.96). There were no statistically significant differences in mortality (OR = 0.46; 95%CI: 0.17-1.23). However, significant heterogeneity was present in both the numbers of patients requiring blood transfusion after treatment [weighted mean difference (WMD), -0.70 unit; 95%CI: -1.64 - 0.25] and the time that patients remained hospitalized [WMD, -0.77 d; 95%CI: -1.87 - 0.34]. The Begg’s test (P = 0.283) and Egger’s test (P = 0.339) demonstrated that there was no publication bias in our meta-analysis.

CONCLUSION: In patients with upper gastrointestinal bleeding after successful endoscopic therapy, compared with H₂RA, PPI may be a more effective therapy.

Second-look endoscopy after gastric endoscopic submucosal dissection for reducing delayed postoperative bleeding

BACKGROUND/AIMS

This study evaluated the role of a second-look endoscopy after gastric endoscopic submucosal dissection in patients without signs of bleeding.

METHODS

Between March 2011 and March 2012, 407 patients with gastric neoplasms who underwent endoscopic submucosal dissection for 445 lesions were retrospectively reviewed. After the patients had undergone endoscopic submucosal dissection, they were allocated to two groups (with or without second-look endoscopy) according to the following endoscopy. The postoperative bleeding risk of the lesions was not considered when allocating the patients.

RESULTS

The delayed postoperative bleeding rates did not differ between the two groups (with vs without second-look endoscopy, 3.0% vs 2.1%; p=0.546). However, a tumor in the upper-third of the stomach (odds ratio [OR], 5.353; 95% confidence interval [CI], 1.075 to 26.650) and specimen size greater than 40 mm (OR, 4.794; 95% CI, 1.307 to 17.588) were both independent risk factors for delayed postoperative bleeding. Additionally, second-look endoscopy was not related to reduced delayed postoperative bleeding. However, delayed postoperative bleeding in the patients who did not undergo a second-look endoscopy occurred significantly earlier than that in patients who underwent a second-look endoscopy (4.5 and 14.0 days, respectively, p=0.022).

CONCLUSIONS

A routine second-look endoscopy after gastric endoscopic submucosal dissection is not necessary for all patients.

Preprocedural rabeprazole treatment before endoscopic submucosal dissection for gastric neoplasms

BACKGROUND

The maximal effect of proton pump inhibitors (PPI) is reported to take 5 days. However, most current protocols start PPI on the day of gastric endoscopic submucosal dissection (ESD).

AIMS

We aimed to evaluate the benefit of 5 days pretreatment with oral PPI before ESD to prevent bleeding.

METHODS

This was a prospective randomized controlled trial. Patients were administered oral rabeprazole 20 mg or placebo twice daily for 5 days before ESD. Intravenous pantoprazole 40 mg was administered 2 h before ESD and at postprocedure day 1, and then oral rabeprazole 20 mg was administered once daily. Follow-up endoscopy was performed on days 1 and 30. Forty-eight-hour measurement of intragastric pH was performed in 26 patients. The primary endpoint was major bleeding related to ESD.

RESULTS

One-hundred and twenty patients were enrolled. Of these, 45 in the pretreatment and 53 in the placebo group were analyzed. Each group had three cases of major bleeding. There were no significant differences in the ulcer healing rate. Intragastric pH percentage times greater than 4, 5, and 6 were 86.61 ± 19.45 %, 83.30 ± 22.06 %, and 76.86 ± 25.35 %, respectively, in the pretreatment and 85.54 ± 19.45 %, 84.08 ± 27.11 %, and 81.53 ± 27.81 %, respectively, in the placebo group, without significant differences.

CONCLUSIONS

Preprocedural administration of rabeprazole offers no additional benefit over postprocedural administration alone in preventing major bleeding after gastric ESD.

Oral rabeprazole administration on a procedure day suppresses bleeding after endoscopic submucosal dissection for gastric neoplasms

AIM

The efficacy of pre-procedure oral proton pump inhibitor (PPI) administration for gastric endoscopic submucosal dissection (ESD) is unclear. This study evaluated oral PPI administration effectiveness on the day of ESD to prevent post-ESD bleeding.

METHODS

This study examined 55 patients who underwent ESD for gastric neoplasm. Group A comprised 31 patients who took rabeprazole sodium (RPZ) 20 mg/day beginning 7-8 hr before ESD. Group B comprised 24 who took RPZ 20 mg/day beginning three days before ESD. Gastric pH (G-pH) was measured at one month before ESD (pre-ESD pH), immediately before ESD (ESD pH), and seven days after ESD (post-ESD pH). The post-ESD bleeding rate and changes in G-pH were recorded.

RESULTS

No significant difference in post-ESD bleeding rates was found (Group A 3.2%, Group B 0%). ESD pH and post-ESD pH were significantly higher than pre-ESD pH in both groups (P<0.001). The ESD pH for Group A was higher than 6 (6.5±1.1), providing hemostasis for intragastric bleeding.

CONCLUSIONS

Oral RPZ administration on the day of gastric ESD can suppress post-ESD bleeding equivalently to administration three days before ESD.

Efficacy of treatment with rebamipide for endoscopic submucosal dissection-induced ulcers

AIM: To prospectively compare the healing rates of endoscopic submucosal dissection (ESD)-induced ulcers treated with either a proton-pump inhibitor (PPI) or rebamipide.

METHODS: We examined 90 patients with early gastric cancer who had undergone ESD. All patients were administered an intravenous infusion of the PPI lansoprazole (20 mg) every 12 h for 2 d, followed by oral administration of lansoprazole (30 mg/d, 5 d). After 7-d treatment, the patients were randomly assigned to 2 groups and received either lansoprazole (30 mg/d orally, n = 45; PPI group) or rebamipide (300 mg orally, three times a day; n = 45; rebamipide group). At 4 and 8 wk after ESD, the ulcer outcomes in the 2 groups were compared.

RESULTS: No significant differences were noted in patient age, underlying disease, tumor location, Helicobacter pylori infection rate, or ESD-induced ulcer size between the 2 groups. At both 4 and 8 wk, the healing rates of ESD-induced ulcers were similar in the PPI-treated and the rebamipide-treated patients (4 wk: PPI, 27.2%; rebamipide, 33.3%; P = 0.5341; 8 wk: PPI, 90.9%; rebamipide, 93.3%; P = 0.6710). At 8 wk, the rates of granulation lesions following ulcer healing were significantly higher in the PPI-treated group (13.6%) than in the rebamipide-treated group (0.0%; P = 0.0103). Ulcer-related symptoms were similar in the 2 treatment groups at 8 wk. The medication cost of 8-wk treatment with the PPI was 10945 yen vs 4889 yen for rebamipide. No ulcer bleeding or complications due to the drugs were observed in either treatment group.

CONCLUSION: The healing rate of ESD-induced ulcers was similar with rebamipide or PPI treatment; however, rebamipide treatment is more cost-effective and prevents granulation lesions following ulcer healing.

Role of antisecretory agents for gastric endoscopic submucosal dissection

Gastric endoscopic submucosal dissection (ESD) causes artificial gastric ulcers and there is no consensus regarding the optimal perioperative management in terms of prevention of intra- or postoperative bleeding and promotion of healing. Traditionally, 8-week administration of proton pump inhibitors (PPI) and mucosal protective agents were used in the same way as for peptic ulcer management. However, recent studies have revealed that prior use of PPI might reduce intraoperative bleeding or early-phase postoperative bleeding, and combination of histamine-2 receptor antagonist (H2RA), and second-look endoscopy might have a similar effect on postoperative bleeding to PPI. Additionally, the advantage of PPI over H2RA is not proven and the optimal duration of PPI may be shortened until 2 weeks when the deteriorating factors for ESD ulcer are excluded. Furthermore, mucosal protective agents may facilitate ulcer healing. Further studies are needed to determine the optimal treatment protocol before and after ESD for both prevention of bleeding complication and promotion of ulcer healing, by using available antisecretory agents and mucosal protective agents.

Endoscopic submucosal dissection for removal of superficial gastrointestinal neoplasms: A technical review

Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.

Do antiplatelets increase the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms?

BACKGROUND

It is rarely known whether antiplatelets increase the risk of bleeding after endoscopic submucosal dissection (ESD).

OBJECTIVE

To evaluate the effect of antiplatelets on post-ESD bleeding.

DESIGN

Retrospective study.

SETTING

Single, tertiary-care referral center.

PATIENTS

This study involved 1591 gastric neoplasms (815 adenomas and 776 early gastric cancers) in 1503 patients who had ESD between April 2005 and April 2010.

INTERVENTION

ESD.

MAIN OUTCOME MEASUREMENTS

Overt hematemesis/hematochezia, a drop of hemoglobin >2 g/dL from baseline, or requirement of endoscopic hemostasis, angiographic embolization, and/or transfusion.

RESULTS

Of 1591 subjects, 274 took antiplatelets, among whom 102 discontinued them for 7 days or more before ESD. Post-ESD bleeding occurred in 94 subjects including 20 from the continuation group, 6 from the withdrawal group, and 68 from the no-antiplatelet group. In univariate analysis, antiplatelets, early gastric cancer (EGC), comorbidity, and specimen diameter were related to post-ESD bleeding. In multivariate analysis, EGC (odds ratio [OR] 1.839; 95% confidence interval [CI], 1.168-2.896; P = .009), comorbidity (OR 2.246; 95% CI, 1.280-3.939; P = .005), and specimen diameter (OR 2.315; 95% CI, 1.282-4.180; P = .005) were independent risk factors of post-ESD bleeding, whereas antiplatelet usage was not (OR 1.596; 95% CI, 0.877-2.903; P = .126). In subgroup analysis, continuous antiplatelet usage was not found to be an independent risk factor of post-ESD bleeding in multivariate analysis (OR 2.027; P = .146). Among 102 subjects who discontinued antiplatelets, 1 developed an acute cerebral infarction (1.0%).

LIMITATION

A retrospective, single-center analysis.

CONCLUSION

In ESD for antiplatelet users, continuous administration was not found to have an independent significant association with bleeding.

Analysis of delayed bleeding after endoscopic submucosal dissection for gastric epithelial neoplasms

Aim. Delayed bleeding after endoscopic submucosal dissection (ESD) for gastric epithelial neoplasms is a major complication. We investigated factors related to post-ESD bleeding to identify preventive measures. Methods. The study included 161 gastric epithelial neoplasms in 142 patients from June 2007 to September 2010. Post-ESD bleeding was defined as an ulcer with active bleeding or apparent exposed vessels diagnosed by an emergency endoscopy or a planned follow-up endoscopy. We analyzed associations between bleeding and the following factors: age, sex, morphology, pathology, tumor depth, ulcer presence/absence, location, size of the resected lesion, duration of the procedure, the number of times bleeding occurred during ESD, and the use of anticoagulants and/or antiplatelet drugs. Subsequently, we examined characteristics of bleeding cases. Results. Post-ESD bleeding occurred in 21 lesions. Univariate analysis of these cases showed that ulcer presence/absence (P < 0.001), middle or lower third lesions (P = 0.036), circumference (P = 0.014), and a post-ESD ulcer with an extended lesser curve (P = 0.009) were significant predictors of bleeding. Multivariate analysis showed that ulcer presence/absence (OR 9.73, 95% CI 2.28–41.53) was the only significant predictor. Conclusion. Ulcer presence/absence was considered the most significant predictor of post-ESD bleeding.

Pantoprazole for the treatment of peptic ulcer bleeding and prevention of rebleeding

Adding proton pump inhibitors (PPIs) to endoscopic therapy has become the mainstay of treatment for peptic ulcer bleeding, with current consensus guidelines recommending high-dose intravenous (IV) PPI therapy (IV bolus followed by continuous therapy). However, whether or not high-dose PPI therapy is more effective than low-dose PPI therapy is still debated. Furthermore, maintaining pH ≥ 4 appears to prevent mucosal bleeding in patients with acute stress ulcers; thus, stress ulcer prophylaxis with acid-suppressing therapy has been increasingly recommended in intensive care units (ICUs). This review evaluates the evidence for the efficacy of IV pantoprazole, a PPI, in preventing ulcer rebleeding after endoscopic hemostasis, and in controlling gastric pH and protecting against upper gastrointestinal (GI) bleeding in high-risk ICU patients. The review concludes that IV pantoprazole provides an effective option in the treatment of upper GI bleeding, the prevention of rebleeding, and for the prophylaxis of acute bleeding stress ulcers.

Effect of lansoprazole versus roxatidine on prevention of bleeding and promotion of ulcer healing after endoscopic submucosal dissection for superficial gastric neoplasia

BACKGROUND

Proton pump inhibitors have been reported to be more useful than histamine-2 receptor antagonists for the prevention of bleeding after endoscopic submucosal dissection (ESD) for superficial gastric neoplasia. The aim of this study was to assess the effects of the proton pump inhibitor lansoprazole and the histamine-2 receptor antagonist roxatidine for the prevention of bleeding and the promotion of ulcer healing after ESD and to compare the cost-effectiveness of these two drugs.

METHODS

The study subjects were 129 patients who underwent ESD for superficial gastric neoplasia. The patients were randomly assigned to the lansoprazole group (L group) or the roxatidine group (R group). Either drug was administered intravenously from the morning of the ESD day to the day after the ESD, followed by oral treatment for an additional 8 weeks. A second-look endoscopy was performed on the day after the ESD, and a repeat endoscopy was performed at 8 weeks after the ESD. The incidence of bleeding and the ulcer-healing rate at 8 weeks after the ESD were analyzed, as well as the total cost of treatment with these antisecretory agents.

RESULTS

Three patients in each group were excluded from the analysis, leaving 62 patients in L group and 61 in R group. Two of the 62 patients (3.2%) in L group and three of the 61 patients (4.9%) in R group showed bleeding after ESD ; there was no significant difference between the two groups (P = 0.68). The ulcer-healing rate was 93.5% (58/62) in L group and 93.4% (57/61) in R group (P = 1). The total cost of treatment with the antisecretory agent from the day of the ESD to day 56 after the ESD was Yen 13,212 for lansoprazole and Yen 5,841 for roxatidine.

CONCLUSIONS

Roxatidine appears to have high cost-effectiveness in the prevention of bleeding and in the promotion of ulcer healing after ESD for superficial gastric neoplasia.

Short-term healing process of artificial ulcers after gastric endoscopic submucosal dissection

BACKGROUND/AIMS

The relationship between the appearance of an ulcer and postoperative bleeding after gastric endoscopic submucosal dissection (ESD) is not well understood. To explore this potential relationship, we retrospectively analyzed the short-term healing process of ESD.

METHODS

A total of 520 consecutive lesions in 434 patients seen between January 2004 and December 2009 were retrospectively investigated. At the second-look endoscopy, which occurred between 1 and 8 days after ESD, artificial ulcers were categorized into 6 patterns according to Forrest's classification: spurting bleeding, oozing bleeding, non-bleeding visible vessel, adherent clot, black base/spot, and clean base. From these data, a short-term healing model of the artificial ulcer was generated.

RESULTS

Ulcer base changed gradually from a bloody to a clean one. The bleeding or non-bleeding visible vessel categories, which occurred in approximately one quarter of the ulcers within 3 days of ESD, were rarely observed 4 days after ESD.

CONCLUSIONS

Ulcers that occur after gastric ESD heal in line with a specific time course, and it appears that most healing occurs without massive bleeding.

Prevention and treatment of gastrointestinal bleeding after therapeutic endoscopy for alimentary tract disease

AIM: To analyze the prevention and treatment of gastrointestinal bleeding after therapeutic endoscopy for alimentary tract disease.

METHODS: The clinical data for 42 patients who received endoscopic treatment for acute hemorrhage after endoscopic therapy were retrospectively analyzed.

RESULTS: Of 1 089 patients undergoing therapeutic endoscopy, 392 underwent argon plasma coagulation (APC), of them 3 (0.8%) had gastrointestinal bleeding; 36 underwent loop ligature, of them 4 (11.1%) had bleeding; 64 underwent endoscopic mucosal resection (EMR), of them 8 (12.5%) had bleeding; 367 underwent high frequency electric coagulation, of them 17 (4.6%) had bleeding; 230 underwent ERCP-EST, of them 10 (4.4%) had bleeding. The total incidence of iatrogenic bleeding was 3.9% (42/1 089). The majority of patients developing bleeding were managed successfully by APC or titanium clipping during endoscopic procedures, whereas 4 patients developed uncontrolled bleeding and turned to surgical intervention. One patient developed bleeding after loop ligature and died of multiple organ dysfunction syndrome and diaphragmatic paralysis after vascular interventional therapy.

CONCLUSION: Gastrointestinal bleeding after minimally invasive endoscopic surgery is preventable and controllable. Effective therapeutic measures for hemorrhage within 48 hours can decrease blood loss, blood transfusion and drug consumption, and increase the rate of cost/effectiveness. Preventive usage of metal clip can significantly decrease the incidence of post-operative bleeding after therapeutic endoscopy.

Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions

AIM

To assess risk factors for bleeding after gastric endoscopic submucosal dissection (ESD) and to develop preventive measures.

METHODS

This retrospective study was performed in a tertiary referral center. A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009. The main outcome was association between post-ESD bleeding and the following: age; sex; comorbidities; daily use of medicine potentially related to gastric injury/bleeding; location, size, and histological depth of lesions; ulceration; experience of operator coagulating the ulcer floor, and duration of operation. We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.

RESULTS

Univariate analysis revealed significant risk factors: tumor location [odds ratio (OR), 2.86; 95% CI: 1.21-6.79, P = 0.024], coagulator experience (OR, 4.29; 95% CI: 1.43-12.86, P = 0.009), and medicine potentially related to gastric injury/bleeding (OR, 2.80; 95% CI: 1.14-6.90, P = 0.039). Multivariate logistic regression analysis confirmed significant, independent risk factors: tumor in lower third of stomach (OR, 2.47; 95% CI: 1.02-5.96, P = 0.044), beginner coagulator (OR, 3.93; 95% CI: 1.29-11.9, P = 0.016), and medicine (OR, 2.76; 95% CI: 1.09-6.98, P = 0.032). We classified cases of post-ESD bleeding into two groups (bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts (OR, 16.00; 95% CI: 1.22-210.59, P = 0.040).

CONCLUSION

Beginner coagulators, tumor in the antrum, and medicines were significant risk factors for post-ESD bleeding. Bleeding at the ulcer margin frequently occurred with beginner operators.

[Guidelines of treatment for non-bleeding peptic ulcer disease]

Over the past century, since the introduction of non steroidal anti-inflammatory drugs (NSAID), antacid, histamine H2-receptor antagonists (H2RA), proton pump inhibitors (PPI), and discovery of Helicobacter pylori infection, the paradigm of peptic ulcer disease has changed with marked decrease in morbidity and mortality. However, peptic ulcer disease still occupies a position as a major health problem with increase of aged population and NSAIDs usage. In daily general practice, the management of peptic ulcer disease is directed according to the presence of bleeding or not. For non-bleeding peptic ulcer disease, proper acid suppression and the correction of underlying causes such as Helicobacter pylori infection and NSAID use is the main stay of treatment. Though a complete understanding of pathophysiology and a perfect treatment strategy are still a challenge, this guideline aims to provide practical recommendations based on evidences or consensus of experts through in-depth literature review and expert meeting.