Feasibility of a modified search, coagulation, and clipping method with and without the use of polyglycolic acid sheets and fibrin glue for preventing delayed bleeding after gastric endoscopic submucosal dissection

Abstract

Background Methods have been developed for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (GESD). However, none of the methods can completely prevent DB. We hypothesized that DB could be prevented by a modified search, coagulation, and clipping (MSCC) method for patients at low risk for DB and by combining the use of polyglycolic acid sheets and fibrin glue with the MSCC method (PMSCC method) for patients at high risk for DB (antibleeding [ABI] strategy). This study assessed the technical feasibility of this novel strategy. Method We investigated 123 lesions in 121 consecutive patients who underwent GESD in Kushiro Rosai Hospital between April 2018 and January 2020. The decision for continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment. Results Oral antithrombotic agents were administered to 28 patients (22.8%). The en bloc R0 resection rate was 98.4%. The MSCC method and the PMSCC method for preventing DB were performed in 114 and 9 lesions, respectively. The median time of the MSCC method was 16 min, and the median speed (the resection area divided by the time of method used) was 3.6 cm2/10 min. The median time of the PMSCC method was 59 min, and the median speed was 1.3 cm2/10 min. The only delayed procedural adverse event was DB in 1 (0.8%) of the 123 lesions. Conclusions The ABI strategy is feasible for preventing DB both in patients at low risk and in those at high risk for DB after GESD, whereas the PMSCC method may be necessary for reduction of time.

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

“…A recent meta-analysis carried out by Li and colleagues [60] concluded that PGA sheets effectively reduced the post-ESD bleeding rate in patients receiving antithrombotic agents (RR 0.39; 95% CI, 0.18-0.83). In our study, with systematic search updated to May 2022, and including data from Kikuchi et al [46] and Abiko et al [43], the results were similar to that of Li's work, further validating the potential of endoscopic application for post-ESD bleeding prevention. PGA was one of the initial, degradable polymers researched for biomedical application, and its use has now been extended to wound healing and adhesives for soft tissues [17].…”

“…However, in studies comparing the efficacy of prevention of delayed bleeding using endoscopic closure (RR 0.60, 95% CI 0.27-1.32; I 2 = 43%, p = 0.150) with control groups, no statistically significant difference was found (Figure 2). [32,33,38,41]; (B) Tissue shielding group vs. control group [10,[43][44][45][46]; (C) Hemostatic spray group vs. control group. Block and whisker: point estimate and 95% confidence interval (CI) of the primary study.…”

“…Of the total, 54 proved potentially relevant for full-text review. Of these, 31 articles on the management of ESD-induced ulcers via endoscopic closure (hemoclips, endoclips, endoloop + endoclips, detachable snare + clips, OTSC + through-the-scope clips [TTSC], overstitch suturing, handsewn suturing) [31][32][33][34][35][36][37][38][39][40][41][42], tissue shielding methods (PGA sheets-based) [10,[43][44][45][46][47][48][49], and hemostatic powder/gel spray [18,19,[50][51][52][53][54][55][56][57][58], matched the selection criteria and were included in the systematic review. The key characteristics of each included study appear in Table 1.…”

“…Thus, a network was created among the nodes of the three categorized endoscopic approaches (endoscopic closure, tissue shielding method, and hemostatic spray) with a control group node (Figure 3A). Overall, 2742 lesions were randomly assigned to one of [32,33,38,41]; (B) Tissue shielding group vs. control group [10,[43][44][45][46]; (C) Hemostatic spray group vs. control group. Block and whisker: point estimate and 95% confidence interval (CI) of the primary study.…”

“…Figure 2.The efficacy of different endoscopic approaches for the prevention of delayed bleeding after gastric ESD, according to pair-wise meta-analysis: (A) Endoscopic closure group vs. control group[32,33,38,41]; (B) Tissue shielding group vs. control group[10,[43][44][45][46]; (C) Hemostatic spray group vs. control group. Block and whisker: point estimate and 95% confidence interval (CI) of the primary study.…”