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Song S, Dou L, Liu Y, Zhang Y, He S, Wang G. A strategy combining endoscopic hand-suturing with clips for closure of rectal defects after endoscopic submucosal dissection with or without myectomy (with video). Gastrointest Endosc 2024; 99:614-624.e2. [PMID: 37993061 DOI: 10.1016/j.gie.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/11/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND AND AIMS Endoscopic hand-suturing (EHS) has been preliminarily demonstrated to be effective in closing defects after endoscopic submucosal dissection (ESD), but it is not easily performed. We proposed a strategy combining EHS with clips (EHS-Clips) and explored its effectiveness in closing rectal defects after ESD or ESD with myectomy (ESD-ME). METHODS In this observational study, data from patients with rectal defects closed using EHS-Clips were reviewed. EHS-Clips refers to a strategy where defects are sutured as much as possible by EHS first, with clips being used to close the remaining parts of defects that cannot be completely sutured. The primary endpoints included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for the sustained closure. RESULTS All 49 (100%) defects (42 ESD defects and 7 ESD-ME defects) were completely closed through the strategy of EHS-Clips, with 35 (71.4%) through EHS alone and 14 (28.6%) through EHS and additional clips. No patients experienced DB. Thirty-six (73.5%) defects remained sustained closure on postoperative days 3 to 5 (73.8% for ESD defects vs 71.4% for ESD-ME defects). The multivariate analyses identified a stitch margin of ≥5 mm (hazard ratio, 0.313; 95% confidence interval, 0.023-0.781; P = .009) as the only independent advantage factor for the sustained closure. CONCLUSIONS EHS-Clips can be used to effectively close the rectal defects after ESD or ESD-ME and prevent DB. Complete suture with a stitch margin of ≥5 mm may achieve more reliable sustained closure.
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Affiliation(s)
- Shibo Song
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lizhou Dou
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yueming Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shun He
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Arimoto J, Ohata K, Tachikawa J, Goto S, Hayashi A, Ebisawa Y, Kobayashi M, Okada N, Kuwabara H, Nakaoka M, Sakai E, Kano Y, Minato Y, Kuriyama H, Chiba H. The Management of Direct Oral Anticoagulants for Colorectal Endoscopic Submucosal Dissection: A Multicenter Observational Study. Dig Dis Sci 2024; 69:933-939. [PMID: 38340260 DOI: 10.1007/s10620-024-08316-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND There is a lack of reports on the use of direct oral anticoagulants (DOACs) during colorectal endoscopic submucosal dissection (ESD). AIMS We aimed to assess whether the use of DOACs is associated with a higher incidence of delayed bleeding (DB) after ESD. METHODS A total of 4175 colorectal neoplasms in 3515 patients were dissected at our hospitals during study period. We included 3909 lesions in the final analysis. The lesions were divided into two groups: the no-AT group (3668 neoplasms) and the DOAC group (241 neoplasms). We also compared the DOAC withdrawal group (154 neoplasms) and the DOAC continuation group (87 neoplasms). RESULTS Among the 3909 lesions, DB occurred in a total of 90 cases (2.3%). The rate of DB was 2.2% (82/3668), and 3.3% (8/241), respectively. There were no significant differences in the rate of DB between the no-AT group and the DOAC group. In the DOAC group, there were no significant differences in the rate of DB between the withdrawal group (5.2%, 8/154) and the continuation group (0%, 0/87). The multivariable analysis identified the location of the lesion in the rectum (odds ratio [OR], 4.04; 95% confidence interval [CI], 2.614-6.242; p < 0.001) and lesions ≥ 30 mm in diameter (OR, 4.14; 95% CI, 2.349-7.34; p < 0.001) as independent risk factors for DB. CONCLUSIONS Our findings suggest that DOAC use has no significant important on the rate of DB. Prospective studies are warranted to determine whether treatment with DOACs should be interrupted prior to colorectal ESD.
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Affiliation(s)
- Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan
| | - Shungo Goto
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki, Kanagawa, Japan
| | - Akimichi Hayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Yu Ebisawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Mikio Kobayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Naoya Okada
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
- Department of Gastroenterology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Eiji Sakai
- Department of Gastroenterology, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Yuki Kano
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yohei Minato
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Hitoshi Kuriyama
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki, Kanagawa, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan.
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Ogiyama H, Kato M, Yamaguchi S, Kanesaka T, Yamada T, Yamamoto M, Komori M, Nagaike K, Nakahara M, Tsutsui S, Tsujii Y, Saita R, Iijima H, Hayashi Y, Takehara T. Efficacy of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulant therapy: Multicenter prospective study. Dig Endosc 2024. [PMID: 38375544 DOI: 10.1111/den.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The high rate of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) in patients undergoing anticoagulant therapy remains a problem. Whether prophylactic clip closure reduces the rate of delayed bleeding in these patients is unclear. This study aimed to evaluate the efficacy of prophylactic clip closure in patients receiving anticoagulants. METHODS This multicenter prospective interventional trial was conducted at nine referral centers in Japan. Patients regularly taking anticoagulants, including warfarin potassium or direct oral anticoagulants, and undergoing ESD for colorectal neoplasms were enrolled. The discontinuation of anticoagulants was minimized according to recent guidelines. After the ESD, post-ESD ulcers were prophylactically closed using endoclips. The primary end-point was the incidence of delayed bleeding. The sample size was 45 lesions, and prophylactic clip closure was considered effective when the upper limit of the 90% confidence interval (CI) for delayed bleeding did not exceed 20%. RESULTS Forty-five lesions were used, and three were excluded. Complete closure was achieved in 41/42 lesions (97.6%). The overall delayed bleeding rate was low, at 4.9% (2/41; 90% [CI] 0.8-14.5), which was significantly lower than that at the prespecified threshold of 20% (P = 0.007). The median closure procedure time was 17 min, and the median number of clips was nine. No massive delayed bleeding requiring transfusion, interventional radiology, or surgery was observed, and no thromboembolic events were observed. CONCLUSION Prophylactic clip closure may reduce the risk of delayed bleeding following colorectal ESD in patients receiving anticoagulants. TRIAL REGISTRATION UMIN Clinical Trial Registry (UMIN000036734).
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Affiliation(s)
- Hideharu Ogiyama
- Departments of Gastroenterology and Hepatology, Itami City Hospital, Hyogo, Japan
- Departments of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Osaka, Japan
| | - Minoru Kato
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Osaka, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Masato Komori
- Department of Gastroenterology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Masanori Nakahara
- Departments of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Osaka, Japan
| | - Shusaku Tsutsui
- Departments of Gastroenterology and Hepatology, Itami City Hospital, Hyogo, Japan
| | - Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryotaro Saita
- Department of Medical Innovation, Osaka University Hospital, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
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Yoshida N, Hayashi Y, Togo D, Oka S, Takada K, Fukunaga S, Morita Y, Hayashi T, Kozuka K, Tsuji Y, Murakami T, Yamamura T, Komeda Y, Takeuchi Y, Shinmura K, Fukuda H, Yoshii S, Ono S, Katsuki S, Kawashima K, Nemoto D, Yamamoto H, Saito Y, Tamai N, Iwao A, Itoi Y, Tsuji S, Inagaki Y, Inada Y, Soga K, Hasegawa D, Murakami T, Yoriki H, Fukumoto K, Motoyoshi T, Nakatani Y, Sano Y, Iguchi M, Fujii S, Ban H, Harada K, Okamoto K, Nishiyama H, Sasaki F, Mizukami K, Shono T, Shimoda R, Miike T, Yamaguchi N. An Analysis of Delayed Bleeding in Cases of Colorectal Endoscopic Submucosal Dissection Due to Types of Direct Oral Anticoagulants in Japan. Clin Gastroenterol Hepatol 2024; 22:271-282.e3. [PMID: 37743040 DOI: 10.1016/j.cgh.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND & AIMS Reported rates of delayed bleeding (DB) after endoscopic resection using direct oral anticoagulants (DOACs) are high and heterogeneous. This large-scale multicenter study analyzed cases of DB after colorectal endoscopic submucosal dissection related to various types of DOACs in Japan (the ABCD-J study) with those associated with warfarin. METHODS We retrospectively reviewed 1019 lesions in patients treated with DOACs and 459 lesions in patients treated with warfarin among 34,455 endoscopic submucosal dissection cases from 47 Japanese institutions between 2012 and 2021. The DB rate (DBR) with each DOAC was compared with that with warfarin. Risk factors for DB in patients treated with DOACs or warfarin were also investigated. RESULTS The mean tumor sizes in the DOAC and warfarin groups were 29.6 ± 14.0 and 30.3 ± 16.4 mm, respectively. In the DOAC group, the DBR with dabigatran (18.26%) was significantly higher than that with apixaban (10.08%, P = .029), edoxaban (7.73%, P = .001), and rivaroxaban (7.21%, P < .001). Only rivaroxaban showed a significantly lower DBR than warfarin (11.76%, P = .033). In the multivariate analysis, heparin bridging therapy (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.27-3.73, P = .005), rectal location (2.01, 1.28-3.16, P = .002), and procedure time ≥55 minutes (2.43, 1.49-3.95, P < .001) were significant risk factors for DB in the DOAC group. The DB risk in the DOAC group (OR, (95% CI)) was 2.13 (1.30-3.50) and 4.53 (2.52-8.15) for 1 and 2 significant risk factors, respectively. CONCLUSIONS Dabigatran was associated with a higher DBR than other DOACs, and only rivaroxaban was associated with a significantly lower DBR than warfarin.
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Affiliation(s)
- Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Yoshikazu Hayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Daichi Togo
- Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan
| | - Shiro Oka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazunori Takada
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University International Clinical Cancer Research Center, Hyogo, Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
| | - Kazuhiro Kozuka
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoriaki Komeda
- Department of Gastroenterology, Kindai University, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kensuke Shinmura
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroko Fukuda
- Department of Gastroenterology, Sasebo City General Hospital, Nagasaki, Japan
| | - Shinji Yoshii
- Department of Gastroenterology, Sapporo Medical University, Hokkaido, Japan
| | - Shoko Ono
- Department of Gastroenterology, Hokkaido University Hospital, Hokkaido, Japan
| | | | | | - Daiki Nemoto
- Department of Coloproctology, Fukushima Medical University Aizu Medical Center, Fukushima, Japan
| | - Hiroyuki Yamamoto
- Department of Gastroenterology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Naoto Tamai
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Aya Iwao
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Nihon University, Tokyo, Japan
| | - Yuki Itoi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | | | - Yutaka Inada
- Department of Gastroenterology, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Koichi Soga
- Department of Gastroenterology, Omihachiman Community Medical Center, Shiga, Japan
| | - Daisuke Hasegawa
- Department of Gastroenterology, Ayabe City Hospital, Kyoto, Japan
| | - Takaaki Murakami
- Department of Gastroenterology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Hiroyuki Yoriki
- Department of Gastroenterology, Otsu City Hospital, Shiga, Japan
| | - Kohei Fukumoto
- Department of Gastroenterology, Nara City Hospital, Nara, Japan
| | | | - Yasuki Nakatani
- Department of Gastroenterology and Hepatology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Yasushi Sano
- Gastrointestinal Center, Sano Hospital, Hyogo, Japan
| | - Mikitaka Iguchi
- Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shigehiko Fujii
- Department of Gastroenterology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Hiromitsu Ban
- Department of Gastroenterology, Omi Medical Center, Shiga, Japan
| | - Keita Harada
- Department of Gastroenterology, Okayama University, Okayama, Japan
| | - Koichi Okamoto
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hitoshi Nishiyama
- Department of Gastroenterology, Nagasaki Medical Center, Nagasaki, Japan
| | - Fumisato Sasaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kazujhiro Mizukami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Central Hospital, Kumamoto, Japan
| | - Ryo Shimoda
- Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, Saga, Japan
| | - Tadashi Miike
- Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Naoyuki Yamaguchi
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
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Sugimoto M, Murata M, Kawai T. Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants. World J Gastroenterol 2023; 29:2916-2931. [PMID: 37274799 PMCID: PMC10237096 DOI: 10.3748/wjg.v29.i19.2916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/03/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and Tmax) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.
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Affiliation(s)
- Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo 160-0023, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo 160-0023, Japan
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Gopakumar H, Vohra I, Sharma NR, Puli SR. Efficacy of self-assembling peptide in mitigating delayed bleeding after advanced endoscopic resection of gastrointestinal lesions: A meta-analysis. Endosc Int Open 2023; 11:E553-E560. [PMID: 37251794 PMCID: PMC10219783 DOI: 10.1055/a-2057-4505] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/22/2023] [Indexed: 05/31/2023] Open
Abstract
Background and study aims Advanced endoscopic resection techniques carry a risk of delayed bleeding (DB). A novel fully synthetic self-assembling peptide (SAP) has shown promising results in mitigating this risk. In this meta-analysis, we evaluated all available data and analyzed the effectiveness of SAP in reducing DB after advanced endoscopic resection of gastrointestinal luminal lesions. Patients and methods Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the use of SAP solution in patients undergoing advanced endoscopic resection of gastrointestinal lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. Results The initial search identified 277 studies, of which 63 relevant articles were reviewed. The final analysis included data from six studies comprising 307 patients that met inclusion criteria. The pooled rate of DB was 5.73 % (95 % confidence interval [CI] = 3.42-8.59). Mean patient age was 69.40 years ± 1.82. The weighted mean size of resected lesions was 36.20 mm (95 % CI = 33.37-39.02). Endoscopic submucosal dissection was used in 72.69 % (95 % CI = 67.62-77.48), while endoscopic mucosal resection was used in 26.42 % (95 % CI = 21.69-31.44) of the procedures. Among the 307 patients, 36 % were on antithrombotic medications. No adverse events (AEs) were attributable to using SAP, with a pooled rate of 0.00 % (95 % CI = 0.00-1.49). Conclusions SAP solution appears promising in reducing post-procedural DB after advanced endoscopic resection of high-risk gastrointestinal lesions with no reported AEs.
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Affiliation(s)
- Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
| | - Ishaan Vohra
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
| | - Neil R. Sharma
- Parkview Cancer Institute, Interventional Oncology & Surgical Endoscopy (IOSE) division, GI Oncology Tumor Site Team, Fort Wayne, Indiana, United States
| | - Srinivas R. Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
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Nakajima Y, Nemoto D, Nemoto T, Takahata Y, Aizawa M, Utano K, Isohata N, Endo S, Lefor AK, Togashi K. Short‐term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions. DEN OPEN 2023; 3:e136. [PMID: 35898832 PMCID: PMC9307737 DOI: 10.1002/deo2.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022]
Abstract
Objectives Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients. Methods Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events. Results A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors. Conclusions No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.
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Affiliation(s)
- Yuki Nakajima
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Daiki Nemoto
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Tetsutaro Nemoto
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Yosuke Takahata
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Masato Aizawa
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Kenichi Utano
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Noriyuki Isohata
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | - Shungo Endo
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
| | | | - Kazutomo Togashi
- Department of Coloproctology, Aizu Medical Center Fukushima Medical University Fukushima Japan
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Kawasaki K, Torisu T, Esaki M, Eizuka M, Kawatoko S, Kumei T, Hirai M, Kondo M, Fujioka S, Fuyuno Y, Matsuno Y, Umeno J, Moriyama T, Kitazono T, Sugai T, Matsumoto T. Continuous use of antithrombotic medications during peri-endoscopic submucosal dissection period for colorectal lesions: A propensity score matched study. J Gastroenterol Hepatol 2023. [PMID: 36808767 DOI: 10.1111/jgh.16149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND AND AIM The aim of this study was to elucidate the continuous use of antithrombotic medications during the peri-colorectal endoscopic submucosal dissection (ESD) period. METHODS This study included 468 patients with colorectal epithelial neoplasms treated by ESD, consisting of 82 under antithrombotic medications and 386 patients without the medications. Among patients taking antithrombotic medications, antithrombotic agents were continued during the peri-ESD period. Clinical characteristics and adverse events were compared after propensity score matching. RESULTS Before and after propensity score matching, post-colorectal ESD bleeding rate was higher in patients continuing antithrombotic medications (19.5% and 21.6%, respectively) than in those not taking antithrombotic medications (2.9% and 5.4%, respectively). In the Cox regression analysis, continuation of antithrombotic medications was associated with post-ESD bleeding risk (hazard ratio, 3.73; 95% confidence interval, 1.2-11.6; P < 0.05) compared with patients without antithrombotic therapy. All patients who experienced post-ESD bleeding were successfully treated by endoscopic hemostasis procedure or conservative therapy. CONCLUSIONS Continuation of antithrombotic medications during the peri-colorectal ESD period increases the risk of bleeding. However, the continuation may be acceptable under careful monitoring for post-ESD bleeding.
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Affiliation(s)
- Keisuke Kawasaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Yahaba, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Makoto Eizuka
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Yahaba, Japan.,Department of Diagnostic Pathology, Iwate Medical University, Yahaba, Japan
| | - Shinichiro Kawatoko
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomo Kumei
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Yahaba, Japan
| | - Minami Hirai
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Yahaba, Japan
| | - Masahiro Kondo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shin Fujioka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Matsuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohiko Moriyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tamotsu Sugai
- Department of Diagnostic Pathology, Iwate Medical University, Yahaba, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Yahaba, Japan
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9
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Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023; 35:216-231. [PMID: 35778927 DOI: 10.1111/den.14397] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/30/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.
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Affiliation(s)
- Hideki Kobara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Naoya Tada
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shintaro Fujihara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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10
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朱 睿, 马 翠, 闵 敏. [Research Progress in Delayed Bleeding after Endoscopic Submucosal Dissection of Early-Stage Gastrointestinal Cancer]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2022; 53:381-385. [PMID: 35642142 PMCID: PMC10409415 DOI: 10.12182/20220560503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Indexed: 06/15/2023]
Abstract
Endoscopic submucosal dissection (ESD) has been widely used in the clinical treatment of early-stage and precancerous lesions of the digestive tract. Compared with traditional open surgery, the procedure has a number of advantages, including low postprocedural recurrence rate, the location and scope of lesions not posing much restrictions on the procedure, and quick patients recovery afterwards. The procedure has hence become one of the minimally-invasive procedures commonly performed with gastrointestinal endoscope. However, due to the influence of various factors, complications such as intraoperative and postoperative bleeding, perforation, electrocoagulation syndrome and lumen stenosis may occur. Delayed postoperative bleeding, in particular, may induce cardiovascular and other related diseases due to the insidious nature of its onset, resulting in serious consequences. It is critically important for the further development of ESD that we should acquire thorough understanding and mastery of the relevant influencing factors and preventive measures of delayed bleeding after ESD of early-stage gastrointestinal cancer. We herein summarized and discussed the latest research findings in the preventative and treatment measures.
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Affiliation(s)
- 睿 朱
- 解放军总医院第五医学中心 消化内科 (北京 100853)Department of Gastroenterology, Fifth Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 翠云 马
- 解放军总医院第五医学中心 消化内科 (北京 100853)Department of Gastroenterology, Fifth Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 敏 闵
- 解放军总医院第五医学中心 消化内科 (北京 100853)Department of Gastroenterology, Fifth Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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11
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Yoshida A, Kurumi H, Ikebuchi Y, Kawaguchi K, Yashima K, Kamitani Y, Yasui S, Nakada Y, Kanda T, Takata T, Isomoto H. New Closure Method Using Loop and Open-Close Clips after Endoscopic Submucosal Dissection of Stomach and Colon Lesions. J Clin Med 2021; 10:jcm10153260. [PMID: 34362044 PMCID: PMC8348124 DOI: 10.3390/jcm10153260] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/11/2021] [Accepted: 07/22/2021] [Indexed: 12/28/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) and en bloc resection of stomach and colon tumors have become common. However, mucosal defects resulting from ESD may cause delayed bleeding and perforation. To prevent adverse events, we developed a new clip closure technique, namely, the loop and open–close clip closure method (LOCCM), and aimed to examine its efficacy after ESD for stomach and colon tumors. The LOCCM uses loop and open–close clips. Here, the open–close clip was used to grasp the loop to bring it to the edge of the post-ESD mucosal defect. Another clip with a loop was then inserted into the opposite edge and clipped to the contralateral mucosa to pull both edges together. Once apposed, additional clips facilitated complete closure. The LOCCM was performed in 19 patients after ESD at Tottori University between October 2020 and March 2021. The outcomes retrospectively analyzed were the LOCCM success and adverse event rates. The complete closure rate using LOCCM was 89.5% and none of the patients had post-ESD bleeding or perforation. The results show that LOCCM is an effective and safe closure technique for mucosal defects after stomach and colon ESD to prevent bleeding and perforation.
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