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Gu Y, Zhao S. Risk factors for postoperative bleeding following endoscopic submucosal dissection in early gastric cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2024; 103:e37762. [PMID: 38608116 PMCID: PMC11018221 DOI: 10.1097/md.0000000000037762] [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: 01/04/2024] [Accepted: 03/08/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Early gastric cancer (EGC) presents a significant challenge in surgical management, particularly concerning postoperative bleeding following endoscopic submucosal dissection. Understanding the risk factors associated with postoperative bleeding is crucial for improving patient outcomes. METHODS Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review and meta-analysis were conducted across PubMed, Embase, Web of Science, and the Cochrane Library without publication date restrictions. The inclusion criteria encompassed observational studies and randomized controlled trials focusing on EGC patients undergoing endoscopic submucosal dissection and their risk factors for postoperative bleeding. The Newcastle-Ottawa Scale was utilized for quality assessment. The effect size was calculated using random or fixed-effects models based on the observed heterogeneity. We assessed the heterogeneity between studies and conducted a sensitivity analysis. RESULTS In our meta-analysis, 6 studies involving 4868 EGC cases were analyzed. The risk of postoperative bleeding was notably increased with intraoperative ulcer detection (odds ratio: 1.97, 95% confidence interval [CI]: 1.03-3.76, I2 = 61.0%, P = .025) and antithrombotic medication use (odds ratio: 2.02, 95% CI: 1.16-3.51, I2 = 57.2%, P = .039). Lesion resection size showed a significant mean difference (5.16, 95% CI: 2.97-7.98, P < .01), and longer intraoperative procedure time was associated with increased bleeding risk (mean difference: 11.69 minutes, 95% CI: 1.82-26.20, P < .05). Sensitivity analysis affirmed the robustness of these findings, and publication bias assessment indicated no significant bias. CONCLUSIONS In EGC treatment, the risk of post-endoscopic submucosal dissection bleeding is intricately linked to factors like intraoperative ulcer detection, antithrombotic medication use, the extent of lesion resection, and the length of the surgical procedure. These interwoven risk factors necessitate careful consideration and integrated management strategies to enhance patient outcomes and safety in EGC surgeries.
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Affiliation(s)
- Yuanbo Gu
- Department of Gastroenterology, Jilin Chemical Hospital, Jilin, China
| | - Shuchang Zhao
- Department of Gastroenterology, Jilin Chemical Hospital, Jilin, China
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2
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Macedo Silva V, Ferreira AI, Lima Capela T, Xavier S, Boal Carvalho P, Cotter J. BEST-J Score: Validation of a Predicting Model for Delayed Bleeding After Gastric Endoscopic Submucosal Dissection on a European Sample. Dig Dis Sci 2024; 69:1372-1379. [PMID: 38353789 DOI: 10.1007/s10620-024-08293-0] [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: 10/08/2023] [Accepted: 01/10/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The BEST-J score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in Western populations. AIMS We aimed to validate the BEST-J score on a European sample and to perform a subgroup analysis according to histological classification. METHODS Retrospective study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion to 28 days after ESD. BEST-J score was calculated in each patient and confronted with the outcome (DB). RESULTS Final sample included 161 patients. From these, 10 (6.2%) presented DB following ESD, with a median time to bleeding of 7 days (IQR 6.8). BEST-J score presented an excellent accuracy predicting DB in our sample, with an AUC = 0.907 (95%CI 0.801-1.000; p < 0.001). Subgroup analysis by histological classification proved that the discriminative power was still excellent for each grade: low-grade dysplasia-AUC = 0.970 (p < 0.001); high-grade dysplasia-AUC = 0.874 (p < 0.001); early gastric cancer-AUC = 0.881 (p < 0.001). The optimal cut-off value to predict DB was a BEST-J score ≥ 3, which matches the cut-off value for high-risk of bleeding in the original investigation. CONCLUSIONS The BEST-J score still presents excellent accuracy in risk stratification for post-ESD bleeding in European individuals. Thus, this score may help to guide which patients benefit the most from prophylactic therapies following gastric ESD in this setting.
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Affiliation(s)
- Vítor Macedo Silva
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal.
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.
- ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal.
| | - Ana Isabel Ferreira
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Sofia Xavier
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Pedro Boal Carvalho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
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3
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Geng ZH, Zhou PH, Cai MY. Submucosal Tunneling Techniques for Tumor Resection. Gastrointest Endosc Clin N Am 2023; 33:143-154. [PMID: 36375878 DOI: 10.1016/j.giec.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The concept of third space endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The mucosal flap safety valve enabled endoscopists to use submucosal space securely. The era of third space endoscopy started with peroral endoscopic myotomy for treatment of achalasia and has expanded to treat various other gastrointestinal disorders, such as mucosal lesions, submucosal tumors, extraluminal tumors, and refractory gastroparesis, Zenker diverticulum, and restoration of the completely obstructed esophageal lumen. Third space endoscopy rapidly emerged as a minimally invasive alternative to conventional surgery. Many studies discovered that this technique is safe and effective with excellent outcomes. Our review focused on the indications, techniques, clinical management, and adverse events of submucosal tunneling techniques for tumor resection.
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Affiliation(s)
- Zi-Han Geng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
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4
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Liu L, Liu H, Feng Z. A narrative review of postoperative bleeding in patients with gastric cancer treated with endoscopic submucosal dissection. J Gastrointest Oncol 2022; 13:413-425. [PMID: 35284137 PMCID: PMC8899759 DOI: 10.21037/jgo-21-466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/28/2021] [Indexed: 11/14/2023] Open
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.
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Affiliation(s)
- Li Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hongqun Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- G.I. research group, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhijie Feng
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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5
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Hakoda A, Takeuchi T, Kojima Y, Fujiwara Y, Nagami Y, Naito Y, Fukuda S, Koike T, Sugimoto M, Hamada K, Kobara H, Yoshida N, Inaba T, Nagahara A, Koizumi E, Murakami K, Furuta T, Ogasawara N, Isomoto H, Shibagaki K, Kataoka H, Suzuki H, Higuchi K. Risk factors and prediction of bleeding after gastric endoscopic submucosal dissection in patients on antithrombotic therapy: newly developed bleeding prediction application software, SAMURAI model. J Clin Biochem Nutr 2022; 70:189-196. [PMID: 35400818 PMCID: PMC8921730 DOI: 10.3164/jcbn.21-136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/20/2021] [Indexed: 12/14/2022] Open
Abstract
Bleeding after gastric endoscopic submucosal dissection (ESD) remains problematic, especially in patients receiving antithrombotic therapy. Therefore, this study aimed to identify the risk factors. In this retrospective study, patients (n = 1,207) who underwent gastric ESD while receiving antithrombotic therapy were enrolled at Osaka Medical and Pharmaceutical University Hospital and 18 other referral hospitals in Japan. Risks of post-ESD bleeding were calculated using multivariable logistic regression. The dataset was divided into a derivation cohort and a validation cohort. We created a prediction model using the derivation cohort. The accuracy of the model was evaluated using the validation cohort. Post-ESD bleeding occurred in 142 (11.8%) participants. Multivariable analysis yielded an odds ratio of 2.33 for aspirin, 4.90 for P2Y12 receptor antagonist, 1.79 for cilostazol, 0.95 for other antithrombotic agents, 6.53 for warfarin, 5.65 for dabigatran, 7.84 for apixaban, 10.45 for edoxaban, 6.02 for rivaroxaban, and 1.46 for heparin bridging. The created prediction model was called safe ESD management using the risk analysis of post-bleeding in patients with antithrombotic therapy (SAMURAI). This model had good predictability, with a C-statistic of 0.77. In conclusion, use of the SAMURAI model will allow proactive management of post-ESD bleeding risk in patients receiving antithrombotic therapy.
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Affiliation(s)
- Akitoshi Hakoda
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital
| | - Toshihisa Takeuchi
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital
| | - Yuichi Kojima
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine
| | - Yuji Naito
- Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | | | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine
| | - Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital
| | - Kenta Hamada
- Departments of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine
| | - Hideki Kobara
- Department of Gastroenterology, Kagawa University Faculty of Medicine
| | - Norimasa Yoshida
- Department of Gastroenterology, Japanese Red Cross Kyoto Daiichi Hospital
| | - Tomoki Inaba
- Department of Gastroenterology, Kagawa Prefectural Central Hospital
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine
| | - Eriko Koizumi
- Department of Gastroenterology, Graduate School of Medicine, Nippon Medical School
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University
| | - Takahisa Furuta
- Center for Clinical Research, Hamamatsu University School of Medicine
| | | | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University
| | - Kotaro Shibagaki
- Department of Gastroenterology, Faculty of Medicine, Shimane University
| | - Hiromi Kataoka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Keio University School of Medicine
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital
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6
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Shiroma S, Hatta W, Tsuji Y, Yoshio T, Yabuuchi Y, Hoteya S, Tsuji S, Nagami Y, Hikichi T, Kobayashi M, Morita Y, Sumiyoshi T, Iguchi M, Tomida H, Inoue T, Mikami T, Hasatani K, Nishikawa J, Matsumura T, Nebiki H, Nakamatsu D, Ohnita K, Suzuki H, Ueyama H, Hayashi Y, Sugimoto M, Yamaguchi S, Michida T, Yada T, Asahina Y, Narasaka T, Kuribayashi S, Kiyotoki S, Mabe K, Fujishiro M, Masamune A, Fujisaki J. Timing of bleeding and thromboembolism associated with endoscopic submucosal dissection for gastric cancer in Japan. J Gastroenterol Hepatol 2021; 36:2769-2777. [PMID: 33960518 DOI: 10.1111/jgh.15536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/18/2021] [Accepted: 04/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM This study aimed to reveal the timing of bleeding and thromboembolism associated with endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). METHODS We retrospectively reviewed 10,320 patients who underwent ESD for EGC during November 2013-October 2016. We evaluated overall bleeding rates and their inter-group differences. Factors associated with early/late (cut-off 5 days) bleeding and thromboembolism frequency and its association with the intake of antithrombotic agents were investigated. RESULTS Overall, the post-ESD bleeding rate was 4.7% (489/10 320); the median time to post-ESD bleeding was 4 days. The post-ESD bleeding rates were 3.2%, 8.7%, 15.5%, and 29.9% in those not taking antithrombotic agents, those taking antiplatelet agents, those taking anticoagulants (ACs), and those taking antiplatelet agents and ACs. Warfarin (odds ratio [OR], 9.16), direct oral ACs (OR, 4.16), chronic kidney disease with hemodialysis (OR, 2.93), thienopyridine (OR, 2.25), aspirin (OR, 1.66), tumor size >30 mm (OR, 1.86), multiple tumors' resection (OR, 1.54), and tumor in the lower third of the stomach (OR, 1.40) were independent risk factors for early bleeding. The independent risk factors for late bleeding were direct oral ACs (OR, 7.42), chronic kidney disease with hemodialysis (OR, 4.99), warfarin (OR, 3.90), thienopyridine (OR, 3.09), liver cirrhosis (OR, 2.43), cilostazol (OR, 1.93), aspirin (OR, 1.92), ischemic heart disease (OR, 1.77), and male sex (OR, 1.65). There were three (0.03%) thromboembolic events (cerebral infarction = 2, transient ischemic attack = 1). CONCLUSION We revealed the timing of bleeding and risk factors for early/late bleeding and showed the thromboembolism frequency associated with ESD for EGC.
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Affiliation(s)
- Sho Shiroma
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan.,Department of Gastroenterology, Okinawa Kyodo Hospital, Naha, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University, International Clinical Cancer Research Center, Kobe, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hideomi Tomida
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan.,Department of Gastroenterology and Metabology, Graduate School of Medicine, Ehime University, Matsuyama, Japan
| | - Takuya Inoue
- Division of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Japan
| | - Jun Nishikawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Ken Ohnita
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Haruhisa Suzuki
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, School of Medicine, Juntendo University, Tokyo, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Mitsushige Sugimoto
- Division of Digestive Endoscopy, Shiga University of Medical Science Hospital, Kusatsu, Japan.,Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo, Japan
| | - Shinjiro Yamaguchi
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tomoki Michida
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Kawagoe, Japan.,Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomoyuki Yada
- Division of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshiro Asahina
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Toshiaki Narasaka
- Division of Endoscopic Center, University of Tsukuba Hospital, Tsukuba, Japan
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan.,Junpukai Health Maintenance Center Kurashiki, Okayama, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
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Abstract
With improvements in the early detection of early gastric cancer (EGC) and advances in therapeutic techniques, endoscopic resection (ER) for EGC has become widely adopted in East Asian and Western countries. Endoscopic submucosal dissection has higher rates of en bloc, complete, and curative resections with lower rates of local recurrence than that of endoscopic mucosal resection. ER is a minimally invasive method with low morbidity that provides excellent outcomes. ER for EGC is a safe, effective method, preserving organ function and thus maintaining the patient's quality of life, and is recognized as the first-line treatment of EGC in selected patients.
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Affiliation(s)
- Ga Hee Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, 88, Olympic-ro 43-gil, Songpa-gu, Seoul
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, 88, Olympic-ro 43-gil, Songpa-gu, Seoul.
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Choi J, Cho SJ, Na SH, Lee A, Kim JL, Chung H, Kim SG. Use of direct oral anticoagulants does not significantly increase delayed bleeding after endoscopic submucosal dissection for early gastric neoplasms. Sci Rep 2021; 11:9399. [PMID: 33931685 PMCID: PMC8087783 DOI: 10.1038/s41598-021-88656-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/17/2021] [Indexed: 11/09/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are widely prescribed for the prevention of stroke in elderly patients with atrial fibrillation and approved indication for DOAC has been expanded. We aimed to evaluate the risk of delayed bleeding in patients who had taken DOAC and underwent endoscopic submucosal dissection (ESD) for gastric neoplasms. We included consecutive patients who underwent ESD between January 2016 and July 2019 in Seoul National University Hospital. Patients were divided into four groups (no med; no medication, DOAC, WFR; warfarin, anti-PLT; anti-platelet agent) according to the medications they had been taken before the procedure. We defined delayed bleeding as obvious post-procedural gastrointestinal bleeding sign including hematemesis or melena combined with hemoglobin drop ≥ 2 g/dL. Among 1634 patients enrolled in this study, 23 (1.4%) patients had taken DOAC and they usually stopped the medication for 2 days before the ESD and resumed within 1 or 2 days. We compared rates of delayed bleeding between groups. Delayed bleeding rates of the groups of no med, DOAC, WFR, and anti-PLT were 2.1% (32/1499) 8.7% (2/23), 14.3% (2/14), 11.2% (11/98), respectively (P < 0.001). However, there was no difference of delayed bleeding rate between no med and DOAC group after propensity score matching (no med vs DOAC, 1.7% vs 10.0%, P = 0.160). Taking DOAC was not associated statistically with post-ESD bleeding when adjusted by age, sex, comorbidities and characteristics of target lesion (Adjusted Odds Ratio: 2.4, 95% Confidence intervals: 0.41-13.73, P = 0.335). Crude rate of bleeding in DOAC users seemed to be higher than no medication group after performing ESD with 2 days of medication cessation. When adjusted by age, sex, and comorbidity, however, this difference seems to be small, which suggests that gastric post-ESD bleeding may be influenced by patients' underlying condition in addition to medication use.
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Affiliation(s)
- Jinju Choi
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Soo-Jeong Cho
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea.
| | - Sang-Hoon Na
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ayoung Lee
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Jue Lie Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Sang Gyun Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
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9
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Li P, Li S, Liu S, Zhang D. Risk factors for complications of therapeutic endoscopy for upper gastrointestinal subepithelial lesions. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:278-282. [PMID: 33927075 PMCID: PMC10929934 DOI: 10.11817/j.issn.1672-7347.2021.190368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To study the risk factors for complications after endoscopic therapy for upper gastrointestinal subepithelial lesions (SELs). METHODS Retrospective analysis was performed on 184 patients in the Department of Gastroenterology in the Third Xiangya Hospital, Central South University after therapeutic endoscopy [endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFR), endoscopic submucosal excavation (ESE), and submucosal tunneling endoscopic resection (STER)] for the upper gastrointestinal SELs from 2014-09-01 to 2019-09-30. The clinic data were collected and risk factors for postoperative complications were analyzed. RESULTS Among the 184 patients, 22 patients were in the complication group (including 3 cases of delayed bleeding, 2 cases of delayed perforation, and 17 cases of electrocoagulation syndrome) and 162 patients were in the non-complication group. There was no significant difference between the complication group and the non-complication group in gender, age over 70 year, basic diseases, lesion location, lesion invasion layers, pathological results, endoscopic therapy, and preventive closure of wounds (all P>0.05). The differences between the two groups in lesion diameter over 40 mm, operative time over 120 minutes, and rate of intraoperative perforation were significant (all P<0.05). Logistic regression analysis showed that lesion diameter over 40 mm and operative time over 120 minutes were independent risk factors for postoperative complications. CONCLUSIONS For the patients with upper gastrointestinal SELs after endoscopic minimally invasive therapy with the lesion diameter over 40 mm and the operative time over 120 minutes, it needs to highly alert to the occurrence of postoperative complications.
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Affiliation(s)
- Peiyu Li
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
| | - Siyuan Li
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Shaojun Liu
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
| | - Decai Zhang
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
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10
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Xiang BJ, Huang YH, Jiang M, Dai C. Effects of antithrombotic agents on post-operative bleeding after endoscopic resection of gastrointestinal neoplasms and polyps: A systematic review and meta-analysis. World J Meta-Anal 2020. [DOI: 10.13105/wjma.v8.i5.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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11
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Xiang BJ, Huang YH, Jiang M, Dai C. Effects of antithrombotic agents on post-operative bleeding after endoscopic resection of gastrointestinal neoplasms and polyps: A systematic review and meta-analysis. World J Meta-Anal 2020; 8:411-434. [DOI: 10.13105/wjma.v8.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/07/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are some studies investigating the relationship between antithrombotic medication and postoperative bleeding after endoscopic resection (ER) with controversial results.
AIM To perform a meta-analysis evaluating the effects of antithrombotic therapy on postoperative bleeding after ER.
METHODS A systematic search was conducted on PubMed, Web of Science, Cochrane Library. The Newcastle-Ottawa scale was used to evaluate the quality of studies. Stata 12.0 was used for statistical analysis. The odds ratio (OR) and 95%CI were calculated and heterogeneity was quantified using Cochran’s Q test and I2.
RESULTS Total 66 studies were included in the meta-analysis. Pooled data suggested that antithrombotic therapy was significantly associated with postoperative bleeding (OR = 2.302, 95%CI: 2.057-2.577, P = 0.000) after ER. The risk of postoperative bleeding after endoscopic submucosal dissection, endoscopic mucosal resection and polypectomy in the antithrombotic group was higher than the non-antithrombotic group (OR = 2.439, 95%CI: 1.916-3.105; OR = 2.688, 95%CI: 1.098-6.582; OR = 2.112, 95%CI: 1.434-3.112).
CONCLUSION The risk of postoperative bleeding after ER correlated with the types and management of antithrombotic agents by our meta-analysis.
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Affiliation(s)
- Bing-Jie Xiang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Yu-Hong Huang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Min Jiang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Cong Dai
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
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12
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Yang CH, Qiu Y, Li X, Shi RH. Bleeding after endoscopic submucosal dissection of gastric lesions. J Dig Dis 2020; 21:139-146. [PMID: 32049422 DOI: 10.1111/1751-2980.12850] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/05/2020] [Accepted: 02/09/2020] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection (ESD) is generally used to treat gastric mucosal and submucosal lesions. Nevertheless, ESD is more difficult and complicated to perform than a traditional endoscopic mucosal resection, which can increase the incidence of various complications including hemorrhage, perforation and infection. Hemorrhage is a major post-ESD complication. Prevention and early diagnosis of post-ESD bleeding for gastric lesions are closely associated with the efficacy and safety of the operation. Many studies have reported the risks of and the preventative measures for hemorrhage after gastric ESD, but there remain some issues to be solved. We thus reviewed the risk factors, precautions and treatments for hemorrhage after ESD of gastric lesions.
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Affiliation(s)
- Chao Hu Yang
- Medical School of Southeast University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu Province, China
| | - Yu Qiu
- Medical School of Southeast University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu Province, China
| | - Xiao Li
- Medical School of Southeast University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu Province, China
| | - Rui Hua Shi
- Medical School of Southeast University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu Province, China
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13
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Komori H, Ueyama H, Nagahara A, Akazawa Y, Takeda T, Matsumoto K, Matsumoto K, Asaoka D, Hojo M, Yao T, Watanabe S. A prospective randomized trial of a potassium competitive acid blocker vs proton pump inhibitors on the effect of ulcer healing after endoscopic submucosal dissection of gastric neoplasia. J Int Med Res 2019; 47:1441-1452. [PMID: 30816056 PMCID: PMC6460617 DOI: 10.1177/0300060519828514] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background/Aims Vonoprazan is a new a potassium-competitive acid blocker (P-CAB) that was recently developed in Japan. However, vonoprazan’s efficacy in healing gastric ulcers after endoscopic submucosal dissection (ESD) remains controversial. This study aimed to compare the efficacy of P-CABs and proton pump inhibitors (PPIs) in healing post-ESD ulcers. Materials and Methods This prospective randomized controlled trial (UMIN000017386) enrolled 40 patients with gastric neoplasia, who underwent ESD at our hospital from April 2015 to January 2016. Before ESD, patients were randomly divided into the following two groups: group V, vonoprazan 20 mg/day; or group R, rabeprazole 10 mg/day. Medications were taken 1 day before to 4 weeks after ESD. The ESD-induced artificial ulcer size was measured just after ESD and 4 weeks after ESD to calculate the reduction rate as follows: (ulcer area 4 weeks after ESD)/(ulcer area just after ESD) × 100. Results Eighteen patients in group V and 15 patients in group R were analyzed. The mean reduction rate was significantly different in groups V and R (93.3% vs 96.6%, respectively). Post-ESD bleeding was observed in two patients in group R and drug-induced hepatic injury in one patient in group R. Conclusion Rabeprazole facilitated the healing process post-ESD.
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Affiliation(s)
- Hiroyuki Komori
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Hiroya Ueyama
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Yoichi Akazawa
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Tsutomu Takeda
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Kohei Matsumoto
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Kenshi Matsumoto
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Daisuke Asaoka
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Mariko Hojo
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Takashi Yao
- 2 Department of Human Pathology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Sumio Watanabe
- 1 Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
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14
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So S, Ahn JY, Kim N, Na HK, Jung KW, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Comparison of the effects of antithrombotic therapy on delayed bleeding after gastric endoscopic resection: a propensity score-matched case-control study. Gastrointest Endosc 2019; 89:277-285.e2. [PMID: 30145315 DOI: 10.1016/j.gie.2018.08.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Antithrombotic (AT) therapy has been known to increase post-endoscopic resection (ER) bleeding risk; however, there are few studies quantifying the effect of AT agents. This study aimed to analyze the incidence of delayed bleeding (DB) based on AT agents administered and to identify the proper timing of drug cessation. METHODS Between January 2011 and March 2017, 7752 patients with 8242 lesions underwent ER for single gastric neoplasm. After a 2:1 propensity score matching using age, sex, specimen size, tumor location, diagnosis, chronic kidney disease, and liver cirrhosis, 798 and 399 lesions were classified as belonging to the matched control (MC) group and AT group, respectively. The clinical outcomes were compared between the 2 groups. RESULTS The DB rate of the MC and AT groups was 6.3% and 10.0%, respectively. There was no significant difference in the early DB rate between the 2 groups; however, the late DB rate of the AT group was higher than the MC group. The continuation group of the AT group had a higher incidence of DB than their matched control subjects (15.9% vs 5.1%; odds ratio, 3.55; 95% confidence interval, 1.24-10.14; P = .018). In patients taking anticoagulants, heparin bridging therapy (HBT) increased the incidence of DB compared with non-HBT (35.7% vs 10.0%; odds ratio, 5.00; 95% confidence interval, 1.11-22.50; P = .036). No thromboembolic events were observed in patients taking AT agents. CONCLUSIONS Patients receiving AT therapy had a higher incidence of DB than those not receiving AT therapy, especially with the continued administration of AT agents and HBT.
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Affiliation(s)
- Seol So
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Nayoung Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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15
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Kono Y, Obayashi Y, Baba Y, Sakae H, Gotoda T, Miura K, Kanzaki H, Iwamuro M, Kawano S, Kawahara Y, Tanaka T, Okada H. Postoperative bleeding risk after gastric endoscopic submucosal dissection during antithrombotic drug therapy. J Gastroenterol Hepatol 2018; 33:453-460. [PMID: 28696019 DOI: 10.1111/jgh.13872] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The safety of gastric endoscopic submucosal dissection (ESD) in the antithrombotic drug users remains controversial. METHODS Patients who underwent gastric ESD at Okayama University Hospital between March 2006 and February 2016 were enrolled. This study investigated the risk of post-ESD bleeding according to the management of the antithrombotic drugs. RESULTS One thousand twenty lesions (872 patients) were enrolled. In a multivariate analysis, heparin replacement (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.8-14), multiple antithrombotic drug use (OR 2.9, 95% CI 1.1-6.9), a resected specimen of ≥ 33 mm in diameter (OR 2.7, 95% CI 1.5-5.4), Helicobacter pylori negativity (OR 2.2, 95% CI 1.3-3.7), and tumors located in the lower third of the stomach (OR 1.7, 95% CI 1.0-2.9) were significant risk factors for post-ESD bleeding, while the continuation of aspirin or cilostazol was not (OR 2.6, 95% CI 0.72-7.8). The bleeding rate of the continuation group was comparable with that of the all cessation group among single antithrombotic drug users (4.5% vs 4.4%, P = 1.0); however, the rate of the continuation group was significantly higher than that of the all cessation group among multiple antithrombotic drug users (67% vs 15%, P = 0.020). CONCLUSIONS The risk of post-ESD bleeding differed according to the management of the antithrombotic drugs. The gastric ESD under the cessation or continuation of aspirin or cilostazol monotherapy was acceptable. However, multiple antithrombotic drug use or heparin replacement was associated with a higher risk of post-ESD bleeding.
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Affiliation(s)
- Yoshiyasu Kono
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuka Obayashi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Baba
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tatsuhiro Gotoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ko Miura
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromitsu Kanzaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshiro Kawahara
- Department of Endoscopy, Okayama University Hospital, Okayama, Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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16
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The fourth space surgery: endoscopic subserosal dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc 2017; 32:2575-2582. [DOI: 10.1007/s00464-017-5985-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/13/2017] [Indexed: 02/07/2023]
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17
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Dong J, Wei K, Deng J, Zhou X, Huang X, Deng M, Lü M. Effects of antithrombotic therapy on bleeding after endoscopic submucosal dissection. Gastrointest Endosc 2017; 86:807-816. [PMID: 28732709 DOI: 10.1016/j.gie.2017.07.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Bleeding is the most common adverse event after endoscopic submucosal dissection (ESD). Although several studies have reported on the use of antithrombotic agents and post-ESD bleeding, many issues remain controversial. We conducted a meta-analysis and systematic review to evaluate the effects of antithrombotic therapy on post-ESD bleeding. METHODS The published literature was searched on online databases, and all studies were included up to January 2017. Standard forms were used to extract data by 2 independent reviewers. The Newcastle-Ottawa Scale score was used to assess the quality of studies. The pooled odds ratio (OR) was computed for the effect of antithrombotic agents. Publication bias was assessed by funnel plots. Heterogeneity was assessed by the Cochran Q test and I2 statistic. RESULTS Sixteen retrospective articles were included. Regardless of discontinuation (OR, 1.66; 95% confidence interval [CI], 1.15-2.39; P = .007) or continuation (OR, 8.39; 95% CI, 4.64-15.17; P < .00001), antithrombotic therapy was significantly associated with post-ESD bleeding, particularly for delayed bleeding (OR, 2.66; 95% CI, 1.42-4.98; P = .002). The bleeding rate was higher in the discontinued multiple antithrombotics group (OR, 5.17; 95% CI, 3.13-8.54; P < .00001) than in the discontinued a single antithrombotic group (OR, 2.23; 95% CI, 1.29-3.85; P = .004) and single antiplatelet group (OR, 2.08; 95% CI, 0.93-4.63; P = .07). In the subgroup analysis, resuming antithrombotics within 1 week (OR, 2.46; 95% CI, 1.54-3.93; P = .0002) and using heparin replacement (OR, 4.20; 95% CI, 1.94-9.09; P= .0003) significantly increased post-ESD bleeding risk. Continued use of low-dose aspirin (OR, 1.22; 95% CI, 0.17-8.61; P = .84) did not significantly increase the bleeding risk. CONCLUSIONS Antithrombotic therapy is a risk factor for post-ESD bleeding, especially for delayed bleeding. Using multiple antithrombotic drugs, resuming antithrombotics within 1 week, and heparin replacement were significantly associated with post-ESD bleeding; but continuous low-dose aspirin was not. However, much larger prospective studies are required.
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Affiliation(s)
- Jiaqi Dong
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; Department of Gastroenterology, People's Hospital of Deyang, Deyang, Sichuan, P.R. China
| | - Kunyan Wei
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Jiaqi Deng
- School of Foreign Languages, Southwest Medical University, Luzhou, Sichuan, China
| | - Xi Zhou
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiaomei Huang
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - MingMing Deng
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Muhan Lü
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Yoshio T, Nishida T, Hayashi Y, Iijima H, Tsujii M, Fujisaki J, Takehara T. Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms. World J Gastrointest Endosc 2016; 8:756-762. [PMID: 28042389 PMCID: PMC5159673 DOI: 10.4253/wjge.v8.i20.756] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/12/2016] [Accepted: 09/22/2016] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms, particularly for patients with comorbidities. Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation. With appropriate cessation, antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients. However, high thrombosis-risk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy (HBT) in the perioperative period. Dual antiplatelet therapy (DAPT), a representative combination therapy, is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding. In patients receiving DAPT, gastric ESD may be postponed until DAPT is no longer required. HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk. The continuous use of warfarin or direct oral anticoagulants may be possible alternatives. Here, we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD, whereas most antithrombotic therapies do not. The management of high thrombosis-risk patients is crucial for improved outcomes.
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19
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Libânio D, Costa MN, Pimentel-Nunes P, Dinis-Ribeiro M. Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis. Gastrointest Endosc 2016; 84:572-86. [PMID: 27345132 DOI: 10.1016/j.gie.2016.06.033] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 06/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD. METHODS Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I(2). RESULTS Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12). CONCLUSIONS Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.
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Affiliation(s)
- Diogo Libânio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Mariana Nuno Costa
- Gastroenterology Department, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal
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20
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Igarashi K, Takizawa K, Kakushima N, Tanaka M, Kawata N, Yoshida M, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H, Ono H. Should antithrombotic therapy be stopped in patients undergoing gastric endoscopic submucosal dissection? Surg Endosc 2016; 31:1746-1753. [PMID: 27530896 DOI: 10.1007/s00464-016-5167-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/30/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The management of antithrombotic therapy in the patients undergoing gastric endoscopic submucosal dissection (ESD) is of concern. This study aimed to assess delayed bleeding rate after gastric ESD in the patients receiving antithrombotic therapy. METHODS This study was a retrospective observational study held in a single institute. The patients undergoing gastric ESD from January 2009 to October 2014 were reviewed. Delayed bleeding rate in the patients receiving antithrombotic therapy was compared with that in matched controls. We also compared delayed bleeding rate in the patients continuing antithrombotic therapy with that in the patients with heparin bridging or cessation of antithrombotic therapy. Among 2388 lesions resected by gastric ESD, 367 lesions were resected in the patients with antithrombotic therapy, and 722 lesions were selected as controls. The lesions in the patients receiving antithrombotic therapy were divided into three subgroups: 54 lesions without preoperative cessation (continuation group), 37 lesions with heparin bridging (heparin group), and 276 lesions with cessation of antithrombotic therapy (cessation group). RESULTS The incidence of delayed bleeding was significantly higher in the patients receiving antithrombotic therapy (9.5 % [35/367] vs. 4.2 % [30/722]; p < 0.01). Delayed bleeding rate in continuation group, heparin group, and cessation group was 9.2 % (5/54), 10.8 % (4/37), and 9.4 % (26/276), respectively, and no significant difference was observed. Thrombosis occurred only in cessation group (1.6 %). CONCLUSIONS Delayed bleeding rate associated with gastric ESD is significantly higher in the patients receiving antithrombotic therapy. No significant difference in delayed bleeding rate was observed among patients with and without cessation of antithrombotic therapy. To prevent thrombosis, gastric ESD without cessation may be feasible.
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Affiliation(s)
- Kimihiro Igarashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
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Akintoye E, Obaitan I, Muthusamy A, Akanbi O, Olusunmade M, Levine D. Endoscopic submucosal dissection of gastric tumors: A systematic review and meta-analysis. World J Gastrointest Endosc 2016; 8:517-532. [PMID: 27606044 PMCID: PMC4980641 DOI: 10.4253/wjge.v8.i15.517] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/11/2016] [Accepted: 07/13/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To systematically review the medical literature in order to evaluate the safety and efficacy of gastric endoscopic submucosal dissection (ESD).
METHODS: We performed a comprehensive literature search of MEDLINE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of gastric ESD.
RESULTS: Twenty-nine thousand five hundred and six tumors in 27155 patients (31% female) who underwent gastric ESD between 1999 and 2014 were included in this study. R0 resection rate was 90% (95%CI: 87%-92%) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in region (P = 0.02) and sample size (P = 0.04). Endoscopic en bloc and curative resection rates were 94% (95%CI: 93%-96%) and 86% (95%CI: 83%-89%) respectively. The rate of immediate and delayed perforation rates were 2.7% (95%CI: 2.1%-3.3%) and 0.39% (95%CI: 0.06%-2.4%) respectively while rates of immediate and delayed major bleeding were 2.9% (95%CI: 1.3-6.6) and 3.6% (95%CI: 3.1%-4.3%). After an average follow-up of about 30 mo post-operative, the rate of tumor recurrence was 0.02% (95%CI: 0.001-1.4) among those with R0 resection and 7.7% (95%CI: 3.6%-16%) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 0.75% (95%CI: 0.42%-1.3%).
CONCLUSION: Our meta-analysis, the largest and most comprehensive assessment of gastric ESD till date, showed that gastric ESD is safe and effective for gastric tumors and warrants consideration as first line therapy when an expert operator is available.
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Shindo Y, Matsumoto S, Miyatani H, Yoshida Y, Mashima H. Risk factors for postoperative bleeding after gastric endoscopic submucosal dissection in patients under antithrombotics. World J Gastrointest Endosc 2016; 8:349-356. [PMID: 27076874 PMCID: PMC4823674 DOI: 10.4253/wjge.v8.i7.349] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 12/27/2015] [Accepted: 01/31/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the risk factors for postoperative bleeding after gastric endoscopic submucosal dissection (ESD) based on the latest guidelines.
METHODS: A total of 262 gastric neoplasms were treated by ESD at our center during a 2-year period from October 2012. We analyzed the data of these cases retrospectively to identify the risk factors for post-ESD bleeding.
RESULTS: Of the 48 (18.3%) cases on antithrombotic treatment, 10 were still receiving antiplatelet drugs perioperatively, 13 were on heparin replacement after oral anticoagulant withdrawal, and the antithrombotic therapy was discontinued perioperatively in 25 cases. Postoperative bleeding occurred in 23 cases (8.8%). The postoperative bleeding rate in the heparin replacement group was 61.5%, significantly higher than that in the non-antithrombotic therapy group (6.1%). Univariate analysis identified history of antithrombotic drug use, heparin replacement, hemodialysis, cardiovascular disease, diabetes mellitus, elevated prothrombin time-international normalized ratio, and low hemoglobin level on admission as risk factors for post ESD bleeding. Multivariate analysis identified only heparin replacement (OR = 13.7, 95%CI: 1.2-151.3, P = 0.0329) as a significant risk factor for post-ESD bleeding.
CONCLUSION: Continued administration of antiplatelet agents, based on the guidelines, was not a risk factor for postoperative bleeding after gastric ESD; however, heparin replacement, which is recommended after withdrawal of oral anticoagulants, was identified as a significant risk factor.
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Jung YS, Kim KO, Lee SH, Jang BI, Kim TN. Comparison on Oral versus Intravenous Proton Pump Inhibitors for Prevention of Bleeding after Endoscopic Submucosal Dissection of Gastric Lesions. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 67:74-80. [DOI: 10.4166/kjg.2016.67.2.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Yeoun Su Jung
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Kim ER, Kim JH, Kang KJ, Min BH, Lee JH, Rhee PL, Rhee JC, Kim JJ. Is a second-look endoscopy necessary after endoscopic submucosal dissection for gastric neoplasm? Gut Liver 2015; 9:52-8. [PMID: 25071070 PMCID: PMC4282857 DOI: 10.5009/gnl13422] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Second-look endoscopy is performed to check for the possibility of post-endoscopic submucosal dissection (ESD) bleeding and to perform prophylactic hemostasis in most hospitals; however, there is little evidence about the efficacy of second-look endoscopy. We investigated whether second-look endoscopy after ESD is useful in the prevention of post-ESD bleeding. Methods A total of 550 lesions with gastric epithelial neoplasms in 502 patients (372 men and 130 women) were treated with ESD between August 18, 2009 and August 18, 2010. After the exclusion of three lesions of post-ESD bleeding within 24 hours, 547 lesions (335 early gastric cancers and 212 gastric adenomas) were included for the final analysis. Results The occurrence rate of delayed post-ESD bleeding was not significantly different between the second-look group and the no second-look group (1% vs 2.5%, p>0.05). The only predictor of delayed bleeding was tumor size, regardless of second-look endoscopy after ESD (22.8±9.87 vs 15.1±10.47, p<0.05). There was no difference between the prophylactic hemostasis and nonprophylactic hemostasis groups, including the occurrence rate of delayed bleeding. In the second-look group with prophylactic hemostasis, the hospital stay was more prolonged than in the second-look group without prophylactic hemostasis, but there was no significant difference (p=0.08). Conclusions Second-look endoscopy to prevent delayed bleeding after ESD provides no significant medical benefits.
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Affiliation(s)
- Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Ha Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Joo Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Hoon Min
- Department of Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Chul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Risk factors for bleeding evaluated using the Forrest classification in Japanese patients after endoscopic submucosal dissection for early gastric neoplasm. Eur J Gastroenterol Hepatol 2015; 27:1022-9. [PMID: 26075810 DOI: 10.1097/meg.0000000000000419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND/AIMS Bleeding remains a serious complication after endoscopic submucosal dissection (ESD). Second-look endoscopy for hemostasis helps prevent post-ESD bleeding. We investigated the relationships between patient characteristics, tumor characteristics, and the Forrest classification for exposed vessels on artificial ulcers after ESD and evaluated whether hemostasis during second-look endoscopy was useful for preventing post-ESD bleeding. PATIENTS AND METHODS We analyzed 250 patients (265 lesions) who underwent ESD for gastric neoplasms. Vessels classified by Forrest classifications during scheduled second-look endoscopy were analyzed for associations with patient characteristics, tumor characteristics, and recurrent bleeding. RESULTS Two of 250 patients (0.8%) underwent emergency hemostatic endoscopy before scheduled second-look endoscopy. The remaining 248 patients (99.2%) underwent scheduled second-look endoscopy on the day after ESD. Patients with Forrest classification Ia, Ib, or IIa vessels had a significantly higher risk for recurrent bleeding after scheduled second-look endoscopy compared with patients with IIb or III vessels according to univariate analysis (P<0.05) and multivariate logistic regression analysis (odds ratio: 3.45; 95% confidence interval: 1.04-11.41; P=0.042). Univariate analysis indicated that hemodialysis correlated significantly with the presence of Ia, Ib, or IIa vessels compared with that of IIb or III vessels found during second-look endoscopy (P<0.05). Multivariate analysis indicated a significant relationship between hemodialysis and recurrent bleeding after second-look endoscopy (odds ratio: 10.05; 95% confidence interval: 1.97-51.26; P=0.006). CONCLUSION Hemodialysis is a risk factor for post-ESD bleeding. Proper classification of exposed vessels within post-ESD ulcers according to the Forrest classification using second-look endoscopy might help predict or prevent recurrent bleeding.
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Matsumoto M, Mabe K, Tsuda M, Ono M, Omori S, Takahashi M, Yoshida T, Ono S, Nakagawa M, Nakagawa S, Shimizu Y, Kudo T, Sakamoto N, Kato M. Multicenter study on hemorrhagic risk of heparin bridging therapy for periendoscopic thromboprophylaxis. BMC Gastroenterol 2015. [PMID: 26215103 PMCID: PMC4515926 DOI: 10.1186/s12876-015-0315-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background For endoscopic interventions, heparin bridging therapy is recommended in patients who are at high risk from interruption of antithrombotic therapy. Although heparin bridging has been reported to be effective in preventing thrombosis, several reports have raised concerns about increased risk of bleeding. The aim of this study was to clarify complications of hepari bridging therapy in therapeutic endoscopy. Methods A nationwide multicenter survey using questionnaire was performed about patients undergoing therapeutic endoscopy with heparin bridging. Patients who underwent therapeutic endoscopy without heparin bridging therapy were considered as controls. Compliance scores of heparin bridging therapy guideline were employed, and association was analyzed between the score and occurrence of post-procedural bleeding. Results The incidence of post-procedural bleeding was significantly higher (13.5 %, 33/245) in the heparin group compared with the control group (2.7 %, 299/11102)(p < 0.001). Thrombosis occurred in 1 patient each in the two groups. In the heparin group, post-procedural bleeding was more likely to be delayed bleeding. Dose adjustment of heparin was a significant factor contributing to bleeding. The compliance score of heparin bridging therapy guideline was significantly higher in those who suffered bleeding. Conclusions Heparin bridging therapy significantly increased the risk of post-procedural bleeding compared with the control. The bleeding risk was associated with greater adherence with guidelines for heparin bridging therapy.
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Affiliation(s)
- Mio Matsumoto
- Department of Gastroenterology, Sapporo Medical Center NTT EC, 〒060-0061 South 1 West 15, Chuo-ku, Sapporo, Hokkaido, Japan.
| | - Katsuhiro Mabe
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Momoko Tsuda
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Masayoshi Ono
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Saori Omori
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Masakazu Takahashi
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Takeshi Yoshida
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Manabu Nakagawa
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Soichi Nakagawa
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Yuichi Shimizu
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Takahiko Kudo
- Department of Gastroenterology, Sapporo City General Hospital, 〒060-8604 North 11, West 13, Chuo-ku, Sapporo, Hokkaido, Japan.
| | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Mototsugu Kato
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
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Polyglycolic acid sheets and fibrin glue decrease the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms (with video). Gastrointest Endosc 2015; 81:906-12. [PMID: 25440679 DOI: 10.1016/j.gie.2014.08.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 08/25/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevention of bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasms is still an important problem. OBJECTIVE To investigate the efficacy and safety of a shielding method that uses polyglycolic acid (PGA) sheets and fibrin glue to prevent post-ESD bleeding in high-risk patients. DESIGN A nonrandomized trial with historical control subjects. SETTING A single academic hospital in Japan. PATIENTS From July 2013 to February 2014, 45 ESD-induced ulcers in 41 patients with a high risk of bleeding were enrolled in a study group. Forty-one consecutive ESD-induced ulcers in 37 control subjects with a high risk of bleeding were treated in 2013 before the first enrollment. INTERVENTIONS We placed PGA sheets on the mucosal defect and fixed with fibrin glue in the study group. MAIN OUTCOME MEASUREMENTS The post-ESD bleeding rate. RESULTS The post-ESD bleeding occurred at a rate of 6.7% in the study group (3/45 lesions) and 22.0% in the historical control group (9/41 lesions). There was a significant difference in the post-ESD bleeding rate between the 2 groups (P = .041). LIMITATIONS A nonrandomized trial with historical control subjects; a single-center analysis; small sample size. CONCLUSIONS The endoscopic tissue shielding method with PGA sheets and fibrin glue appears to be promising for the prevention of post-ESD bleeding. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000011058.).
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Zhou DJ, Dai ZB, Wells MM, Yu DL, Zhang J, Zhang L. Submucosal tunneling and endoscopic resection of submucosal tumors at the esophagogastric junction. World J Gastroenterol 2015; 21:578-583. [PMID: 25593479 PMCID: PMC4294169 DOI: 10.3748/wjg.v21.i2.578] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 07/14/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the safety and efficacy of submucosal tunneling and endoscopic resection (STER) for treating submucosal tumors (SMTs).
METHODS: Between August 2012 and October 2013, 21 patients with SMTs originating from the muscularis propria (MP) layer at the esophagogastric junction were treated by STER of their tumors. Key steps of the procedure include: (1) mucosal incision: a 2-cm longitudinal mucosal incision was made 5 cm proximal to the tumor; (2) submucosal tunneling: a submucosal tunnel was created 5 cm proximal to and 1 to 2 cm distal to the tumor; (3) tumor resection: the SMT was resected under direct endoscopic viewing; (4) hemostasis: while finishing the tumor resection, careful hemostasis of the MP defect and the tunnel was performed; and (5) mucosal closure: the mucosal incision site was closed by using hemostatic clips. During the operation, equipment used included a cap-fitted endoscope, an insulated-tip knife, a hook knife, hemostatic forceps, an injection needle, a snare, an endoclip, and a high-frequency generator. Carbon dioxide (CO2) insufflation was achieved by using a CO2 insufflator.
RESULTS: The median age of the patients was 46.2 years (range, 35-59 years), and the majority were male (18 male vs 3 female). Complete resection rate was 100% (21/21). Eighteen lesions were resected en bloc. Mean tumor size was 23 mm (range, 10-40 mm), and mean procedure time was 62.9 min (range, 45-90 min). Pathological diagnosis of these tumors included leiomyoma (15 out of 21) and gastrointestinal stromal tumor (6 out of 21). Full-thickness MP resection was performed in 9 of 21 patients (42.9%), with mediastinal and subcutaneous emphysema occurring in all nine. At the completion of the procedure, all patients received closure of the incision with hemoclips. One patient required percutaneous drainage. The remaining 20 patients required no further endoscopic or surgical intervention. There were no incidents of massive or delayed bleeding. The median follow-up period after the procedure was 6 mo (range, 2-14 mo). During follow-up, no patients were found to have residual or recurrent tumor or esophageal stricture.
CONCLUSION: STER is safe, effective and feasible, which provides accurate histopathologic evaluation and curative treatment for SMTs originating from the MP layer at the esophagogastric junction.
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Ahn SY, Jang SI, Lee DW, Jeon SW. Gastric endoscopic submucosal dissection is safe for day patients. Clin Endosc 2014; 47:538-43. [PMID: 25505720 PMCID: PMC4260102 DOI: 10.5946/ce.2014.47.6.538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/18/2013] [Accepted: 11/28/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIMS Although the advantages of endoscopic submucosal dissection (ESD) are well established, there are important limitations that relate to its higher cost and higher rate of complications compared with endoscopic mucosal resection. This study assessed the therapeutic safety and efficacy of ESD in the treatment of small gastric dysplasia and early gastric cancer (EGC) located within the antrum in an outpatient setting, and it compared the results with those from patients admitted to hospital for ESD treatment. METHODS This study was a retrospective analysis of a prospectively maintained database. We reviewed consecutive patients with EGC or gastric dysplasia who underwent ESD between October 2007 and May 2008. The lesions were smaller than 2 cm and were located in the antrum. We analyzed 105 lesions in 105 patients. The patients were assigned to two groups according to each patient's preference. RESULTS The overall rates of complete resection were 98.1% in the inpatients group and 94.3% in the outpatients group. Immediate bleeding occurred in four inpatients, which included one patient in the outpatient group. Delayed bleeding occurred in one inpatient within 24 hours of the procedure. Macroperforations did not occur in either group. A microperforation was found in one outpatient. CONCLUSIONS The safety and efficacy of ESD used to treat small gastric tumors in the antrum in an outpatient setting appeared to be similar to the safety and efficacy of ESD used to treat patients who were admitted to the hospital.
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Affiliation(s)
- Sun Young Ahn
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sun Ik Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Seong Woo Jeon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
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Zhang Y, Huang Q, Zhu LH, Zhou XB, Ye LP, Mao XL. Endoscopic excavation for gastric heterotopic pancreas: an analysis of 42 cases from a tertiary center. Wien Klin Wochenschr 2014; 126:509-14. [PMID: 25015880 DOI: 10.1007/s00508-014-0563-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 05/05/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Because of the difficulty associated with making an accurate diagnosis of gastric heterotopic pancreas (HP) before surgery, surgical resection is usually performed in suspected cases. However, this is an invasive procedure and prone to certain surgical complications. AIMS This study was designed to evaluate the feasibility of endoscopic excavation for gastric HP, as well as the value of endoscopic ultrasonography (EUS) in diagnosing gastric HP. METHODS Between January 2007 and January 2013, 42 consecutive patients with gastric HP were enrolled in this retrospective study. Key steps: (1) Injection of a solution (100 ml saline + 2 ml indigo carmine + 1 ml epinephrine) into the submucosal layer after making several dots around the lesion; (2) Incision of the mucosa outside the marker dots with a needle-knife, and then circumferential excavation until complete resection of the lesion; (3) Closure of the artificial ulcer with several clips after tumor removal. RESULTS In this study, 18 cases (42.9%) were suspected as gastric HP (assessed by two experienced endoscopists before endoscopic excavation), 8 (19.0%) were suspected as gastrointestinal stromal tumors, 7 (16.7%) as gastric polyp, and the remaining 9 cases (21.4%) were still unknown. The mean procedure duration was 28.6 min. En bloc resection by endoscopic excavation was achieved in 40 cases (95.2%), and no massive bleeding, delayed bleeding, perforation, or other severe complication occurred in these patients. Among the 42 lesions, a tube echo could be detected in 11 cases by EUS. Those 11 cases were diagnosed as gastric HP by histopathology. CONCLUSIONS Endoscopic excavation appears to be a safe and feasible procedure for accurate histopathologic evaluation and curative treatment in gastric HP. Use of EUS has some value in the diagnosis of gastric HP before the procedure
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Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria. Surg Endosc 2014; 28:1978-83. [PMID: 24619327 DOI: 10.1007/s00464-014-3421-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 01/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS This retrospective study evaluated the safety and efficacy of endoscopic full-thickness resection (eFTR) with defect closure using clips and an endoloop for the treatment of gastric subepithelial tumors (SETs) arising from the muscularis propria (MP). METHODS From January 2009 to December 2012, 51 patients with gastric SETs arising from the MP underwent eFTR with defect closure using clips and an endoloop. The key steps were (1) several milliliters of mixture solution was injected into the submucosa after dots were marked around the tumor; (2) a cross incision was made in the mucosa to reveal the tumor; (3) subsequently, circumferential excavation was performed as deep as the muscularis propria, and full-thickness resection of the tumor was performed with an insulated-tip knife, including its underlying MP and serosa; (4) the gastric wall defect was closed with clips and an endoloop was then placed to fix and tighten all of the clips together. RESULTS Successful complete resection by eFTR was achieved in 50 cases (98.0%). One case failed and was converted into a laparoscopic resection due to the tumor falling into the peritoneal cavity during the procedure. The mean procedure time was 52 min. No patients had severe complications, such as massive bleeding, delayed bleeding, peritonitis, or gastrointestinal tract leakage. The mean tumor length was 2.4 cm. Pathological diagnoses of the tumors were leiomyomas (21/51) and gastrointestinal stromal tumors (30/51). The median follow-up period after the procedure was 22.4 months (range 1-48 months), and no residual tumor or tumor recurrence was detected during the follow-up period. CONCLUSIONS eFTR with defect closure with clips and an endoloop appears to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP, especially for those with extraluminal growth or adhesions to the MP.
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HIKICHI TAKUTO, SATO MASAKI, WATANABE KO, NAKAMURA JUN, TAKAGI TADAYUKI, SUZUKI REI, SUGIMOTO MITSURU, WARAGAI YUICHI, KIKUCHI HITOMI, KONNO NAOKI, OHIRA HIROMASA, OBARA KATSUTOSHI. ORAL RABEPRAZOLE ADMINISTRATION ON A PROCEDURE DAY SUPPRESSES BLEEDING AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC NEOPLASMS. Fukushima J Med Sci 2014; 60:68-74. [DOI: 10.5387/fms.2013-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Park CH, Lee SK. Preventing and controlling bleeding in gastric endoscopic submucosal dissection. Clin Endosc 2013; 46:456-62. [PMID: 24143302 PMCID: PMC3797925 DOI: 10.5946/ce.2013.46.5.456] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 07/04/2013] [Indexed: 02/06/2023] Open
Abstract
Although techniques and instruments for endoscopic submucosal dissection (ESD) have improved, bleeding is still the most common complication. Minimizing the occurrence of bleeding is important because blood can interfere with subsequent procedures. Generally, ESD-related bleeding can be divided into intraprocedural and postprocedural bleedings. Postprocedural bleeding can be further classified into early post-ESD bleeding which occurs within 48 hours after ESD and late post-ESD bleeding which occurs later than 48 hours after ESD. A basic principle for avoiding intraprocedural bleeding is to watch for vessels and coagulate them before cutting. Several countertraction devices have been designed to minimize intraprocedural bleeding. Methods for reducing postprocedural bleeding include administration of proton-pump inhibitors or prophylactic coagulation after ESD. Medical adhesive spray such as n-butyl-2-cyanoacrylate is also an option for preventing postprocedural bleeding. Various endoscopic treatment modalities are used for both intraprocedural and postprocedural bleeding. However, hemoclipping is infrequently used during ESD because the clips interfere with subsequent resection. Bleeding that occurs as a result of ESD can usually be managed easily. Nonetheless, more effective ways to prevent bleeding, including reliable ESD techniques, must be developed.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc 2013; 28:524-30. [PMID: 24013472 DOI: 10.1007/s00464-013-3197-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/13/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND This prospective study was designed to evaluate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for small (≤3 cm) upper gastrointestinal (GI) subepithelial tumors (SETs) originating from the muscularis propria (MP) layer. METHODS Between August 2011 and February 2013, a total of 85 patients with upper GI SETs originating from the MP layer were treated with STER. The key steps were as follows: (1) locating the tumor by injection of methylene blue or indigo carmine and then creating a submucosal tunnel from 5 cm above the tumor between the submucosal and muscular layers; (2) resecting the tumor by endoscopic resection techniques; (3) closing the mucosal incision site with several clips after the tumor is removed. RESULTS Of the 85 SETs, 60 were located in the esophagus, 16 in the cardia, and 9 in the stomach. STER was successfully performed in all cases (success rate: 100 %). The mean tumor size was 19.2 mm. The mean procedure time was 57.2 min. The average hospital stay after the procedure was 5.9 days. Pathological diagnosis of the tumors were leiomyoma (65/85), gastrointestinal stromal tumor (GIST) (19/85), and calcifying fibrous tumor (1/85). During the procedure, eight patients developed pneumothorax, subcutaneous emphysema, and/or pneumoperitoneum. These patients recovered after conservative treatment. The rate of all complications was significantly higher for lesions originating in the deeper MP layer (70 %) than in the superficial MP layer (1.3 %; p < 0.001). The total complication rate for different histological diagnoses was also significantly different (26.3 % for GISTs, 4.6 % for leiomyomas, 0 % for calcifying fibrous tumors, p < 0.05). No residual or recurrent tumors were detected during the follow-up period (median: 8 months). CONCLUSIONS Submucosal tunneling endoscopic resection appears to be a feasible, safe, and effective procedure for treatment of small (≤3 cm) upper GI SETs originating from the MP layer.
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Endoscopic muscularis excavation for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer. Dig Dis Sci 2013. [PMID: 23192645 DOI: 10.1007/s10620-012-2487-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Because of complicating anatomic factors, endoscopic submucosal dissection is seldom performed in subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer. AIM This study was designed to evaluate the feasibility of endoscopic muscularis excavation for treating subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer. METHODS Between December 2008 and December 2011, 68 patients with subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer were treated with endoscopic muscularis excavation. Key steps of the procedure included the following: (1) injecting a mixture solution into the submucosal layer after making several dots around the tumor; (2) making a cross incision of the overlying mucosa, and excavating the tumor from the muscularis propria layer; (3) closing the artificial ulcer with clips after tumor removal. RESULTS The mean tumor size was 16.2 mm (range 7-35 mm). Endoscopic muscularis excavation was successfully performed in 65 out of 68 cases (success rate 95.6 %). Pathological diagnosis of these tumors included leiomyoma (39 out of 68) and gastrointestinal stromal tumor (29 out of 68). Perforation occurred in seven patients (10.3 %). No massive bleeding or delayed bleeding occurred. The median follow-up period after the procedure was 23 months (range 6-42 months). No residual or recurrent tumor was detected and no stricture occurred in patients during the follow-up period. CONCLUSIONS Endoscopic muscularis excavation is a safe, effective and feasible procedure for providing accurate histopathologic evaluation and curative treatment for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.
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Park HJ, Kim HS, Kim BR, Park SY, Hong JH, Jo KW, Kim JW. Half-dose rabeprazole has an equal efficacy to standard-dose rabeprazole on endoscopic submucosal dissection-induced ulcer. Dig Dis Sci 2013; 58:1054-61. [PMID: 23065090 DOI: 10.1007/s10620-012-2436-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/21/2012] [Indexed: 02/15/2023]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD)-induced ulcers heal faster and recur less often than non-iatrogenic gastric ulcers, the optimal dosage and duration of proton pump inhibitor treatment for ESD-induced ulcers remain unclear. AIMS To evaluate the efficacy of half-dose rabeprazole on endoscopic submucosal dissection-induced ulcer compared with standard dose rabeprazole. METHODS The study was a prospective randomized controlled double-blind trial at a single tertiary hospital. A total of 80 patients who underwent ESD for gastric neoplasia were enrolled. Of these patients, 10 were not followed to completion. Final analysis included the remaining 70 patients. Rabeprazole 20 or 10 mg, depending on randomization, was given orally for 4 weeks after ESD. RESULTS Of the 70 patients, 45 (64 %) were men, and the median age was 65.2 ± 9.7 years. The mean ESD-induced ulcer area was 673 mm(2). No significant differences in ulcer area reduction ratio (p = 0.49) or ulcer-related symptoms (p = 0.91) were observed between the two groups at 4 weeks after ESD. CONCLUSION For ESD-induced ulcers, treatment with 10 mg of rabeprazole daily produces a similar outcome as 20 mg of rabeprazole with regard to healing efficacy and symptom resolution.
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Affiliation(s)
- Hong Jun Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine and Institute of Lifelong Health, Wonju College of Medicine, Yonsei University, 162, Ilsan-dong, Gangwon-do, Wonju 220-701, Korea
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