Endoscopic Closure Utilizing Endoloop and Endoclips After Gastric Endoscopic Submucosal Dissection for Patients on Antithrombotic Therapy

Abstract

Objectives Antithrombotic therapy is a well-known independent risk factor for bleeding after endoscopic submucosal dissection (ESD) of early gastric cancer (EGC). A novel method of ulcer base closure using an endoloop and endoclips has been reported. This study aimed to evaluate the effectiveness of endoscopic closure using an endoloop and endoclips in preventing post-ESD bleeding in patients undergoing gastric ESD on antithrombotic therapy. Methods This was a single center, retrospective study. Patients on antithrombotic therapy who underwent gastric ESD were divided into two groups, the closure group and the non-closure group. We analyzed procedural outcomes, post-ESD bleeding rate and factors associated with post-ESD bleeding. Results Among 400 ESDs with EGCs in 311 patients, 131 ESDs in 110 patients were in the closure group, and 269 ESDs in 217 patients were in the non-closure group (16 patients were overlapped in both groups). Post-ESD bleeding rate was 11.5% (15/131) in the closure group, and 11.9% (32/269) in the non-closure group (p = 0.89). Total sustained closure rate during second look endoscopy was 47.8% (33/69). Post-ESD bleeding rate tended to be lower in the closure group than in the nonclosure group for lesions located in the greater curvature (3.6% vs. 11.1%, p = 0.11). In addition, sustained closure rate was significantly higher in the greater curvature than in the lesser curvature (72.0% vs. 34.1%, p < 0.01). Multivariate analysis revealed resection size > 40 mm and heparin bridge were the independent risk factor for post-ESD bleeding. Conclusion Ulcer base closure using endoloop and endoclips did not prevent post-ESD bleeding in patients on antithrombotic therapy.

Endoscopic hand suturing for mucosal defect closure after gastric endoscopic submucosal dissection may reduce the risk of postoperative bleeding in patients receiving antithrombotic therapy

“…18 In addition, follow-up endoscopy has revealed that 52% (36/69) of defects closed with endoloops and hemoclips showed dehiscence. 21 On the other hand, the experiment in in vivo porcine models demonstrated that all of the post-ESD gastric mucosal defects were completely closed by EHS, remained closed without dehiscence, and healed histologically within 2 weeks. 24 In a multicenter prospective study of EHS for post-ESD gastric mucosal defects, mucosal closure by EHS was completed in 29 (97%) of 30 cases and was well maintained on POD 3 in 25 (84%) cases.…”

“…[17][18][19][20][21] In these techniques, hemoclips are typically used because of their availability; however, clip-mediated closure does not appear to be satisfactory as a complete countermeasure for postoperative bleeding, especially in gastric lesions, because it is often difficult to achieve complete closure and keep the defects closed without dehiscence. 17,18,21 We developed endoscopic hand suturing (EHS), which is a suturing technique using a needle holder and a curved needle attached to an absorbable barbed suture. 22,23 Previously, we have reported the feasibility and efficacy of EHS in porcine models and clinical studies in gastric ESD.…”

Timing of bleeding and thromboembolism associated with endoscopic submucosal dissection for gastric cancer in Japan

“…Furthermore, liver cirrhosis and ischemic heart disease were only significantly associated with late bleeding. On recognizing the risk factors for early/late bleeding, the closure of a mucosal defect would be a possible countermeasure especially for early bleeding, 26 although it has not proved enough without established technique, 27 and delaying discharge can be considered for patients at risk of late bleeding.…”

What’s New with Endoscopic Treatments for Early Gastric Cancer in the “Post-ESD Era”?

“…First, the defect closure is technically difficult by using endoscopic clips, which is the most familiar device for tissue apposition [16]. For the closure of large defects, purse-string closure with a detachable snare and clips is feasible, although it will finish a tentative closure [17]. Second, even though the defect is closed, it is easily dehisced in a short period.…”