Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

Abstract

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

Efficacy of new hemostatic techniques in nonvariceal gastrointestinal bleeding: A systematic review and network meta‐analysis

“…However, they have a similar mechanism of action, including absorbing water, boosting the physiological clotting system, and mechanical tamponade (Supplementary Table S3). Moreover, HP can protect lesions from physical stimulation of food, digestive enzymes, and gastric acid 52 . Therefore, it may prevent rebleeding by accelerating lesion healing, although HP has a relatively short residency time within the lumen 53 .…”

“…Moreover, HP can protect lesions from physical stimulation of food, digestive enzymes, and gastric acid. 52 Therefore, it may prevent rebleeding by accelerating lesion healing, although HP has a relatively short residency time within the lumen. 53 Consequently, the rebleeding rate is lower when combining HP and other CET modalities.…”

Endoscopic Resection of Early Gastric Cancer and Pre-Malignant Gastric Lesions

“…Coagulation of visible vessels in post-ESD ulcers is also associated with reduced rates of delayed bleeding [57] and is a recommended preventive measure [22]. A network meta-analysis evaluated additional preventive measures and found that tissue shielding with polyglycolic acid significantly reduced delayed bleeding risk in high-risk patients [risk ratio (RR) 0.32; 95%CI 0.12-0.79], while hemostatic spray potentially reduced bleeding in low-risk patients, although heterogeneity was high [58]. Perforation is an uncommon adverse event of ESD and can be immediate (<3% of procedures) or delayed (<1%).…”