Importance of second-look endoscopy after per-oral endoscopic myotomy for safe postoperative management

OBJECTIVES

Per-oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second-look endoscopy (SE) on postoperative day 1 has not been examined. This study aimed to evaluate the findings and need of SE after POEM.

METHODS

This is a single-center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly-detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE.

RESULTS

Four-hundred-ninety-seven patients (mean age, 50.3 years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE.

CONCLUSIONS

Second-look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.

Efficacy of second-look endoscopy in preventing delayed bleeding after endoscopic submucosal dissection of early gastric cancer

The present study aimed to evaluate whether second-look endoscopy (SLE) is able to prevent delayed bleeding after endoscopic submucosal dissection (ESD) of gastric carcinoma and to identify which types of lesion require SLE. ESD of gastric cancer at the early stage was performed on 210 patients between October 2014 and September 2016. Mucosal damage-associated bleeding within 24 h after ESD was considered as delayed bleeding. The association of the characteristics of patients and lesions, as well as surgical factors, with the incidence of bleeding as a measure of outcome was analyzed. A total of 110 patients with melena and/or hematemesis underwent SLE on the second day following gastric ESD. Within the entire cohort (n=210), late delayed bleeding (LDB) was defined as hematemesis or melena occurring following second-look endoscopy. Early delayed bleeding (EDB) was defined as hematemesis or melena occurring from the end of ESD to second-look endoscopy, or as active or possible bleeding at the time of the second-look endoscopy was reported in 17 (8.1%) and 20 patients(9.5%), respectively. The median interval between late delayed bleeding and ESD was one day (range, 1–10 days). The incidence of late delayed bleeding was significantly decreased in the SLE group compared with that in the non-SLE group (4.5 vs. 12%, P=0.028). Multivariate analyses revealed that ulcer, flat gross type, lesion diameter (>2 cm), the resected tumor size of >40 mm and Helicobacter pylori infection were independently associated with late delayed bleeding after ESD, while flat gross type, ulcer, the resected tumor size of >40 mm and artificial ulcer diameter >3 cm were independently associated with early delayed bleeding. Thus, the data of the present study indicates that second-look endoscopy following gastric ESD may be useful in preventing post-ESD delayed bleeding and should be performed on the second day.

Role of second-look endoscopy and prophylactic hemostasis after gastric endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND

Although several studies have shown that second-look endoscopy does not affect the incidence of bleeding after gastric endoscopic submucosal dissection (ESD), the potential roles of second-look endoscopy have not been fully evaluated. This study aimed to determine the role of second-look endoscopy after ESD through a systematic review and meta-analysis.

METHODS

This study conducted a systematic literature search of MEDLINE, EMBASE, and the Cochrane Library through March 2016 using the keywords "second-look," "prophylactic hemostasis," "prophylactic haemostasis," "prevention," "prophylaxis," and "endoscopic submucosal dissection." Studies were included if they evaluated the incidence of post-ESD bleeding according to second-look endoscopy or prophylactic hemostasis during second-look endoscopy.

RESULTS

Four randomized controlled trials on post-ESD bleeding between second-look endoscopy and no second-look endoscopy and 12 non-randomized studies with a cohort design on post-ESD bleeding were included. On meta-analysis, second-look endoscopy did not affect delayed post-ESD bleeding (odds ratio [95% confidence interval] = 1.27 [0.80-2.00], I²  = 0%). During second-look endoscopy, patients who were considered as high-risk for post-ESD bleeding underwent prophylactic hemostasis. Delayed post-ESD bleeding was more common in patients who were treated with hemostasis during second-look endoscopy compared with those who were not (odds ratio [95% confidence interval] = 3.40 [1.87-6.18], I²  = 62%). In patients who underwent prophylactic hemostasis, the number needed to prolong a hospitalization period to avoid one additional post-ESD bleeding after discharge was 25.

CONCLUSION

Second-look endoscopy after ESD could not reduce the risk of delayed post-ESD bleeding. Delayed post-ESD bleeding was more common in patients who underwent prophylactic hemostasis than in those who did not.

Second-look endoscopy after endoscopic submucosal dissection for gastric neoplasms

Routine second-look endoscopy after gastric endoscopic submucosal dissection (ESD) remains controversial. The aim of the present study was to systematically evaluate the efficacy of second-look endoscopy for gastric ESD. PubMed, the Cochrane library, and the Igaku-chuo-zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data were combined to calculate a pooled odds ratio (OR) for developing post-ESD bleeding. The database search yielded three randomized trials (854 patients). Compared with second-look endoscopy, the pooled OR for post-ESD bleeding without second-look endoscopy was 0.69 (95% confidence interval [CI]: 0.38-1.26, P = 0.228), without significant heterogeneity. There were no significant differences between second-look endoscopy and no second-look endoscopy with regard to large tumor size (>20 mm). This systematic review and meta-analysis showed that second-look endoscopy had no advantage for the prevention of post-ESD bleeding in patients without a high risk of bleeding.

Second-look endoscopy is not associated with better clinical outcomes after gastric endoscopic submucosal dissection: a prospective, randomized, clinical trial analyzed on an as-treated basis

BACKGROUND

The efficacy of routine second-look endoscopy (SLE) to detect or prevent bleeding after gastric endoscopic submucosal dissection (ESD) has not yet been validated.

OBJECTIVE

The aim of this study was to determine whether SLE affects clinical outcomes including bleeding and morbidity after gastric ESD.

DESIGN

A prospective, randomized, controlled study with consecutive data analyzed on an as-treated basis.

SETTING

A single, tertiary-care referral center.

PATIENTS

A total of 182 patients.

INTERVENTION

Gastric ESD and SLE.

MAIN OUTCOME MEASUREMENTS

Incidence of and risk factors related to bleeding after ESD and outcomes by univariate or multivariate analysis.

RESULTS

Among 182 patients enrolled, 74 and 81 patients were assigned to the SLE and no-SLE groups, respectively. Two groups were observed closely for 4 weeks. Bleeding occurred after ESD in 21 patients (13.5%). Hemoglobin loss (≥2.0 g/dL) was observed in 20 patients, and melena developed in 1 patient after ESD. However, only 1 patient needed a transfusion. Twelve patients (16.2%) in the SLE group and 9 in the no-SLE group (11.1%) experienced bleeding after ESD. The frequency of bleeding after ESD was not significantly different between the 2 groups (P = .66). There were no risk factors related to bleeding after ESD.

LIMITATIONS

Single-center analysis.

CONCLUSION

SLE is not routinely necessary because it does not affect clinical outcomes, including bleeding and morbidity after ESD. (

CLINICAL TRIAL REGISTRATION NUMBER

KCT0000146.).