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

Abstract

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.

Comparative efficacy of esomeprazole vs. rabeprazole in post-endoscopic submucosal d i s s e c t i o n g a s t r i c u l c e r s : a p r o s p e c t i v e randomized trial

“…ESD has eliminated the size limitation of early gastric tumors, the objective of endoscopic treatment, and has expanded its indication. [16,17] As a result, ESD produces a large PESDGU, and the risk of bleeding and perforation from PESDGU is higher than from gastric ulcers induced by conventional EMR. [18] It also became clear that it took time for the ulcers to heal.…”

Present situation of minimally invasive surgical treatment for early gastric cancer

“…Due to longer surgical time and greater invasiveness, the incidence of intraoperative bleeding in ESD is significantly higher than that in EMR. The review first defines post-ESD bleeding and elaborates on its management, including methods for coagulation of potential bleeding points during surgery, lesion closure, lesion shielding, and the application of gastric acid secretion inhibitors[ 23 ].…”

Temporary sutures using reopenable clips and barbed threads

“…Closing a large mucosal defect after endoscopic submucosal dissection (ESD) using an endoclip is a challenge. However, the closure of the mucosal defect is desirable to prevent post‐ESD bleeding 1,2 . We developed a temporary suture method using reopenable clips and barbed threads.…”

“…However, the closure of the mucosal defect is desirable to prevent post‐ESD bleeding. 1 , 2 We developed a temporary suture method using reopenable clips and barbed threads.…”