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

Abstract

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.

Propensity score matching analysis to evaluate efficacy of polyethylene oxide adhesive on preventing delayed bleeding after gastric endoscopic submucosal dissection

“…After propensity score matching, the resected specimen size in both the PEO and control groups was larger than 40 mm, which made the statistics insignificant. Second, in contrast to antithrombotic drugs, resection size was more related to early-phase delayed bleeding 36 – 38 . However, as mentioned above, the application of PEO may decrease bleeding events that occur before POD 3.…”

Efficacy of vonoprazan against bleeding from endoscopic submucosal dissection-induced gastric ulcers under antithrombotic medication: A cross-design synthesis of randomized and observational studies

“…Second-look endoscopy (SLE) has been performed after ESD to evaluate the ulcer condition and to perform preventive hemostatic treatment for high-risk bleeding ulcers [ 35 ]. However, SLE cannot suppress bleeding after ESD, and bleeding prevention procedures performed during SLE may be harmful [ 36 , 37 ]. Therefore, other methods are necessary to suppress post-ESD bleeding in antithrombotic drug users.…”

Bleeding Risk Factors after Endoscopic Submucosal Dissection in Early Gastric Cancer and the Necessity of “Second-Look” Endoscopic Examination on the following Day

“…The next day, during second-look endoscopy, APC and clipping were mainly used for hemostasis [18]. A proton pump inhibitor (PPI) was infused twice daily on the day of the surgery and on the day after the surgery [19][20][21][22][23][24][25]. If there was no bleeding, patients resumed eating 2 days after resection, and the route of PPI administration was switched from intravenous to oral.…”