Risk factors for immediate and delayed bleeding associated with endoscopic submucosal dissection of gastric neoplastic lesions

Recent advances in endoscopic management of gastric neoplasms

The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.

Risk factors of major intraoperative bleeding and postoperative bleeding associated with endoscopic submucosal dissection for gastric neoplasms

BACKGROUND

Endoscopic resection bleeding (ERB) classification was proposed by the authors' team to evaluate the severity of intraoperative bleeding (IB) during endoscopic submucosal dissection (ESD). This study aimed to evaluate the application of ERB classification and to analyze the risk factors of major IB (MIB) and postoperative bleeding (PB) associated with ESD for gastric neoplastic lesions.

METHODS

We retrospectively enrolled a total of 1334 patients who underwent ESD between November 2006 and September 2019 at The First Medical Center of Chinese People's Liberation Army General Hospital. All patients were divided into the non-MIB group (including ERB-0, ERB-controlled 1 [ERB-c1], and ERB-c2) and the MIB group (including ERB-c3 and ERB-uncontrolled [ERB-unc]) according to the ERB classification. Risk factors of major MIB and risk factors of PB were analyzed using a logistic regression model.

RESULTS

Among the 1334 patients, 773 (57.95%) had ERB-0, 477 (35.76%) had ERB-c1, 77 (5.77%) had ERB-c2, 7 (0.52%) had ERB-c3, and no patients had ERB-unc. The rate of PB in patients with IB classifications of ERB-0, ERB-c1, ERB-c2, and ERB-c3 were 2.20% (17/773), 3.35% (16/477), 9.09% (7/77), and 2/7, respectively. In multivariate analysis, proximal location (odds ratio [OR]: 1.488; 95% confidence interval [CI]: 1.045-3.645; P = 0.047) was the only significant risk factor of MIB. Chronic kidney disease (CKD) (OR: 7.844; 95% CI: 1.637-37.583; P = 0.010) and MIB (ERB-c3) (OR: 13.932; 95% CI: 2.585-74.794; P = 0.002) were independent risk factors of PB.

CONCLUSIONS

Proximal location of lesions was a significant risk factor of MIB. Additionally, CKD and MIB (ERB-c3) were independent risk factors of PB. More attention should be paid to these high-risk patients for MIB and PB.

Prediction model for bleeding after endoscopic submucosal dissection of gastric neoplasms from a high-volume center

BACKGROUND AND AIM

Bleeding after endoscopic submucosal dissection (ESD) is a main adverse event. To date, although there have been several studies about risk factors for post-ESD bleeding, there has been few predictive model for post-ESD bleeding with large volume cases. We aimed to design a prediction model for post-ESD bleeding using a classification tree model.

METHODS

We analyzed a prospectively established cohort of patients with gastric neoplasms treated with ESD from 2007 to 2016. Baseline characteristics were collected for a total of 5080 patients, and the bleeding risk was estimated using variable statistical methods such as logistic regression, AdaBoost, and random forest. To investigate how bleeding was affected by independent predictors, the classification and regression tree (CART) method was used. The prediction tree developed for the cohort was internally validated.

RESULTS

Post-ESD bleeding occurred in 262 of 5080 patients (5.1%). In multivariate logistic regression, ongoing antithrombotic use during the procedure, cancer pathology, and piecemeal resection were significant risk factors for post-ESD bleeding. In the CART model, the decisive variables were ongoing antithrombotic agent use, resected specimen size ≥49 mm, and patient age <62 years. The CART model accuracy was 94.9%, and the cross-validation accuracy was 94.8%.

CONCLUSIONS

We developed a simple and easy-to-apply predictive tree model based on three risk factors that could help endoscopists identify patients at a high risk of bleeding. This model will enable clinicians to establish precise management strategies for patients at a high risk of bleeding and to prevent post-ESD bleeding.

The effect of PPIs Alone, PPIs plus cytoprotective agent, and H2RA plus cytoprotective agent on ulcer healing after endoscopic submucosal dissection: A prospective randomized controlled trial

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is the most effective treatment for early gastric cancer or gastric adenoma. However, ESD results in iatrogenic ulcers and postoperative bleeding from ulcers. This study aimed to evaluate the effect of using a proton pump inhibitor (PPI) alone, a PPI + rebamipide combination therapy, and an H2 receptor antagonist (H2RA) + rebamipide combination therapy on ulcer healing after ESD.

PATIENTS AND METHODS

A total of 204 patients who underwent ESD from April 2014 to July 2017 at Dong-A University Hospital were randomly assigned to the following groups: PPI-alone group, PPI + rebamipide combination therapy group, and H2RA + rebamipide combination therapy group. However, only 156 patients were studied since we excluded those who were lost to follow-up or had diseases other than early gastric cancer or gastric adenoma. Twenty-eight days after ESD, we evaluated the ulcer residual ratio, S stage rates, ulcer bleeding ratio, and gastric pH.

RESULTS

This study included 156 patients (PPI-alone group: 52 patients; PPI + rebamipide group: 52 patients; H2RA + rebamipide group: 52 patients). The ulcer residual ratios were 24.3 ± 14.2%, 17.0 ± 12.1%, and 21.0 ± 13.8% in the PPI alone, PPI + rebamipide, and H2RA + rebamipide groups, respectively (P = 0.048).

CONCLUSIONS

PPI + rebamipide was more effective in reducing the ulcer residual ratio after ESD. There was no statistical difference in ulcer stage and delayed bleeding after ESD among the groups. These findings showed that PPI + rebamipide had limited benefits after ESD.

Diode Laser-Can It Replace the Electrical Current Used in Endoscopic Submucosal Dissection?

Background/Aims

A new medical fiber-guided diode laser system (FDLS) is expected to offer high-precision cutting with simultaneous hemostasis. Thus, this study aimed to evaluate the feasibility of using the 1,940-nm FDLS to perform endoscopic submucosal dissection (ESD) in the gastrointestinal tract of an animal model.

Methods

In this prospective animal pilot study, gastric and colorectal ESD using the FDLS was performed in ex vivo and in vivo porcine models. The completeness of en bloc resection, the procedure time, intraprocedural bleeding, histological injuries to the muscularis propria (MP) layer, and perforation were assessed.

Results

The en bloc resection and perforation rates in the ex vivo study were 100% (10/10) and 10% (1/10), respectively; those in the in vivo study were 100% (4/4) and 0% for gastric ESD and 100% (4/4) and 25% (1/4) for rectal ESD, respectively. Deep MP layer injuries tended to occur more frequently in the rectal than in the gastric ESD cases, and no intraprocedural bleeding occurred in either group.

Conclusions

The 1,940-nm FDLS was capable of yielding high en bloc resection rates without intraprocedural bleeding during gastric and colorectal ESD in animal models.

Analysis of factors associated with local recurrence after endoscopic resection of gastric epithelial dysplasia: a retrospective study

Background

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are widely used techniques for the treatment of gastric epithelial dysplasia. Previous studies have compared the clinical outcome of endoscopic resection for early gastric cancer, but few studies have focused on gastric dysplasia alone. This study aimed to evaluate the long-term prognosis following endoscopic procedures for gastric epithelial dysplasia, investigate differences in local recurrence rates according to the treatment modality, and identify risk factors associated with local recurrence.

Methods

In this retrospective study, local recurrence rates and risk factors associated with local recurrence were compared between 599 patients who underwent EMR and 306 who underwent ESD for gastric epithelial dysplasia from January 2011 to December 2015.

Results

The en bloc resection rate (32.2% vs. 100%, p < 0.001) and complete resection rate (94.8% vs. 99.0%, p = 0.003) were significantly lower in the EMR group than in the ESD group. The local recurrence rate was significantly lower in the ESD group (1.3%) than in the EMR group (4.2%; p = 0.026). There was a significantly increased risk of local recurrence, regardless of lesion location or histologic grade, in patients with lesions > 2 cm (p = 0.002) or red in color (p = 0.03). The ESD group had a significantly lower local recurrence rate, with a higher complete resection rate, than that in the EMR group (p < 0.05). In the case of recurrence after endoscopic resection, most of the recurred lesions were removed through additional endoscopic procedures; there was no difference between the two groups (p = 0.153).

Conclusions

The complete resection rate was significantly higher, and the local recurrence rate was significantly lower, in patients with gastric epithelial dysplasia treated with ESD. Therefore, ESD should be considered the preferred treatment in patients with lesions > 2 cm or showing redness due to an increased risk of local recurrence and EMR may be possible for low-grade dysplasia that is less than 2 cm without surface changes such as redness, depression and nodularity.

Hemorrhage control during gastric endoscopic submucosal dissection: Techniques using uncovered knives

Since the last decade, endoscopic submucosal dissection (ESD) has been used as the standard treatment for superficial gastrointestinal neoplasms. Trainees learning ESD frequently encounter difficulties such as vascularity, peristalsis, and fibrosis during the procedure. Because individual vascularity differs, it generally cannot be consistently avoided. Given that massive hemorrhages can prolong the procedure time and diminish treatment efficacy and that insufficient vessel handling may also increase postoperative bleeding, hemorrhage control during ESD becomes important to ensure procedure safety. This article discusses methods for controlling hemorrhage during gastric ESD. Endoscopists should have a basic understanding of the vascular architecture and the high‐density areas in blood vessels, which are susceptible to intraoperative hemorrhage. Efficient preventative coagulation should be performed in addition to mastering the techniques for hemorrhage control using hemostatic forceps. Techniques useful for preventing intraoperative hemorrhage at every step (e.g. submucosal injection, mucosal incision, and dissection) should be learned. Gaining procedural competence and learning hemorrhage control techniques not only during ESD but also in daily work would help provide safe and effective treatment.

Histamine2-Receptor Antagonists, Proton Pump Inhibitors, or Potassium-Competitive Acid Blockers Preventing Delayed Bleeding After Endoscopic Submucosal Dissection: A Meta-Analysis

Background: Endoscopic submucosal dissection (ESD) was commonly used for en bloc resection in gastric cancer and adenoma with the risk of delayed bleeding after ESD. We conducted a direct and indirect comparison meta-analysis to evaluate the best choice in preventing post-ESD bleeding among proton pump inhibitors (PPIs), histamine₂-receptor antagonists (H₂RAs), and the most widely used potassium-competitive acid blocker, vonoprazan.

Methods: The Pubmed, Cochrane Library, and Embase were searched for randomized trials. We pooled odds ratios (OR) for preventing post-ESD bleeding using meta-analysis.

Results: Sixteen randomized trials met the inclusion criteria including 2,062 patients. Direct comparisons showed slightly significant efficacy in PPIs rather than H₂RAs in preventing post-ESD bleeding [OR: 1.83; 95% confidence interval (CI): 1.10 to 3.05] and vonoprazan was better than PPIs (OR: 0.46; 95% CI: 0.25 to 0.86). The adjusted indirect comparison indicated vonoprazan was superior to H₂RAs (OR: 0.30, 95% CI: 0.12 to 0.74). In subgroup analysis, PPIs had similar efficacy as H₂RAs in 4 weeks, while PPIs were better than H₂RAs in 8 weeks’ treatment (OR: 1.91; 95% CI: 1.08 to 3.40). The superiority of vonoprazan than PPIs was more significant in combination therapy (OR: 0.18; 95% CI: 0.04 to 0.69). There was a significant difference in vonoprazan for 8 weeks of medication (OR: 0.44; 95% CI: 0.21 to 0.92).

Conclusions: The effects of vonoprazan is better than PPIs than H₂RAs in preventing bleeding after ESD. When vonoprazan combined with mucosal protective antiulcer drug in treatment or used in 8 weeks of medication, the efficacy may be even better.

Continuous Infusion versus Intermittent Dosing with Pantoprazole for Gastric Endoscopic Submucosal Dissection

Background/Aims

Proton pump inhibitors are widely used to prevent gastric endoscopic submucosal dissection (ESD)-related bleeding, but no standard administration regimens have been established. We aimed to prospectively compare the effects of continuous infusion and intermittent dosing with pantoprazole on preventing gastric ESD-related bleeding. Additionally, we analyzed the risk factors for bleeding.

Methods

From April 2012 to May 2013, patients with a gastric epithelial neoplasm scheduled for ESD in the Pusan National University Hospital were randomly assigned to one of two groups according to the pantoprazole administration regimen (continuous infusion or intermittent dosing). The primary outcomes measured were intra- and postprocedural bleeding events.

Results

The final analysis included 401 patients. The rate of significant intraprocedural bleeding was 25.4% in the C group and 24.0% in the I group, with no significant difference (p=0.419). In addition, there was no significant difference in the postprocedural bleeding rate between the C and I groups (11.7% vs 10.2%, p=0.374). Multivariate analysis showed that intraprocedural bleeding was associated with the proximal tumor location, the presence of fibrosis, and the size of the resected specimen, whereas postprocedural bleeding was associated with the size of the resected specimen and the procedure/coagulation time.

Conclusions

Intermittent dosing with pantoprazole is sufficient and cost-effective for the prevention of gastric ESD-related bleeding. Operators should consider tumor characteristics when planning ESD to minimize the risk of intraprocedural bleeding, and patients with large iatrogenic ulcers should be carefully monitored for postprocedural bleeding.

Comparison of the effects of antithrombotic therapy on delayed bleeding after gastric endoscopic resection: a propensity score-matched case-control study

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.

Is the Reinitiation of Antiplatelet Agents Safe at 1 Week after Gastric Endoscopic Submucosal Dissection? Assessment of Bleeding Risk Using the Forrest Classification

Background/Aims

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) commonly occurs within 3 days, but it may also occur after 1 week following ESD, especially in antiplatelet agent users. We evaluated the risk of delayed bleeding in post-ESD ulcers using the Forrest classification.

Methods

Registry data on the Forrest classification of post-ESD ulcers (n=371) at 1 week or 2 weeks after ESD were retrospectively evaluated. The Forrest classification was categorized into two groups: increased risk (Forrest Ia to IIc) or low risk (Forrest III). The odds ratios (ORs) were calculated using logistic regression analysis.

Results

Among 371 post-ESD ulcers, one ulcer (0.3%) was classified as Forrest Ib, two (0.5%) as Forrest IIa, 17 (4.6%) as Forrest IIb, 172 (46.4%) as Forrest IIc, and 179 (48.2%) as Forrest III. The proportion of increased-risk ulcers was 72.2% (140/194) at 1 week after ESD, which decreased to 29.4% (52/177) at 2 weeks after ESD (p<0.001). In the multivariate analysis, a post-ESD ulcer at 1 week after ESD (OR, 7.54), younger age (OR, 2.17), and upper/middle ulcer location (OR, 2.05) were associated with increased-risk ulcers.

Conclusions

One week after ESD, ulcers still have an increased risk of bleeding when assessed using the Forrest classification. This risk should be considered when resuming antiplatelet therapy.

Splash M-knife versus Flush Knife BT in the technical outcomes of endoscopic submucosal dissection for early gastric cancer: a propensity score matching analysis

BACKGROUND

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancer. A new multi-functional ESD device was developed to achieve complete ESD with a single device. A metal plate attached to its distal sheath achieves better hemostasis during the procedure than the other needle-knife device, Flush Knife BT®, that has been conventionally used. The aim of this study was to compare the technical outcomes of ESD for early gastric cancer using the Splash M-Knife® with those using the Flush Knife BT.

METHODS

We conducted a retrospective review of the case records of 149 patients with early gastric cancer treated with ESD using the needle-type ESD knives between January 2012 and August 2016 at Kitakyushu Municipal Medical Center. Lesions treated with ESD using the Splash M-knife (ESD-M) and the Flush Knife BT (ESD-F) were compared. Multivariate analyses and propensity score matching were used to compensate for the differences in age, gender, underlying disease, antithrombotic drug use, lesion location, lesion position, macroscopic type, tumor size, presence of ulceration, operator level and types of electrosurgical unit used. The primary endpoint was the requirement to use hemostatic forceps in the two groups. The secondary endpoints of procedure time, en bloc and complete resection rates, and adverse events rates were evaluated for the two groups.

RESULTS

There were 73 patients in the ESD-M group, and 76 patients in the ESD-F group. Propensity score matching analysis created 45 matched pairs. Adjusted comparisons between the two groups showed a significantly lower usage rate of hemostatic forceps in the ESD-M group than in the ESD-F group (6.7% vs 84.4%, p < 0.001). Treatment outcomes showed an en bloc resection rate of 100% in both groups; complete resection rate of 95.6% vs 100%, p = 0.49; median procedure time of 74.0 min vs 71.0 min, p = 0.90; post-procedure bleeding of 2.2% vs 2.2%, p = 1, in the ESD-M and ESD-F groups, respectively. There were no perforations in either group.

CONCLUSIONS

ESD-M appeared to reduce the usage of hemostatic forceps during ESD for early gastric cancer without increasing the adverse effects. Thus, it may contribute to a reduction in the total ESD cost.

Oral esomeprazole vs injectable omeprazole for the prevention of hemorrhage after endoscopic submucosal dissection

AIM

To evaluate the effectiveness of oral esomeprazole (EPZ) vs injectable omeprazole (OPZ) therapy to prevent hemorrhage after endoscopic submucosal dissection (ESD).

METHODS

A case-control study was conducted using a quasi-randomized analysis with propensity score matching. A total of 258 patients were enrolled in this study. Patients were treated with either oral EPZ or injectable OPZ. The endpoint was the incidence of hemorrhage after ESD.

RESULTS

Data of 71 subjects treated with oral EPZ and 172 subjects treated with injectable OPZ were analyzed. Analysis of 65 matched samples revealed no difference in the incidence of hemorrhage after ESD between the oral EPZ and injectable OPZ groups (OR = 0.89, 95%CI: 0.35-2.27, P ≥ 0.99).

CONCLUSION

We conclude that oral EPZ therapy is a useful alternative to injectable PPI therapy for the prevention of hemorrhage after ESD.

Expression of microRNA-328 Functions as a Biomarker for Recurrence of Early Gastric Cancer (EGC) After Endoscopic Submucosal Dissection (ESD) by Modulating CD44

Background

This study investigated the molecular mechanism of the effect of CD44 on the recurrence of EGC after ESD, including the potential regulator and signaling pathways of CD44.

Material/Methods

We searched the miRNA online database (www.mirdb.org) with the “seed sequence” located within the 3′-UTR of the target gene, and performed luciferase assay to test the miRNA/mRNA relationship. We also determined the expression of CD44 in the EGC and control samples. In addition, statistical analysis was used to explore the role of miR-328 as a biomarker to predict the recurrence after ECD.

Results

We validated CD44 to be the direct gene via luciferase reporter assay system. We also established the negative regulatory relationship between miR-328 and CD44 via studying the relative luciferase activity at different concentrations of miR-328 mimics. We also conducted real-time PCR and Western blot analysis to study the mRNA and protein expression level of CD44 among different groups (recurrence-positive and recurrence-negative) or cells treated with different concentrations of miR-328 mimics/inhibitors, indicating the negative regulatory relationship between miR-328 and CD44. We also investigated the relative viability of EGC cells when transfected with miR-328 mimics (50 nM and 100 nM) and miR-328 inhibitors (100 nM) to validate miR-328 to be negatively interfering with the viability of EGC cells. miR-328 was also recognized as a potential biomarker to predict recurrence after ESD in EGC patients via analysis of the recurrence-free rate among different groups of EGC patients.

Conclusions

The expression level of miR-328 can function as a predictive biomarker of recurrence after ECD in patients with EGC via targeting CD44.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Clinical effects of endoscopic submucosal dissection in treatment of upper gastrointestinal submucosal tumors

AIM: To explore the therapeutic efficiency of endoscopic submucosal dissection (ESD) in the treatment of upper gastrointestinal submucosal tumors and the risk factors for complications.

METHODS: Seventy-three patients with upper gastrointestinal submucosal tumors were collected from Chengdu Military Medical Hospital from May 2009 to March 2014. All the patients underwent ESD and were followed by endoscopy. The complete resection rate, the frequency of complications and the risk factors for complications were analyzed.

RESULTS: The overall rate of R0 resection was 98.6% (68/69), with six endoscopic failures. Complete resection was achieved in all submucosal tumor (SMT) cases. The median procedure time was 100.9 min (range, 30.0-275.0 min). Perforation occurred in 7 patients. Bleeding occurred in 15 patients. No death occurred. No recurrence cases were noted.

CONCLUSION: ESD is an effective treatment in SMT patients with a high success rate and a low incidence of complications.

High Dose Proton Pump Inhibitor Infusion Versus Bolus Injection for the Prevention of Bleeding After Endoscopic Submucosal Dissection: Prospective Randomized Controlled Study

BACKGROUND

A high dose of continuous intravenous infusion of proton pump inhibitor (PPI) is the standard treatment for peptic ulcer bleeding. The optimal dose for the prevention of bleeding after endoscopic submucosal dissection (ESD) is unclear.

AIM

The purpose of this study was to determine whether stronger acid suppression more effectively prevents bleeding and high risk ulcer stigma (HRS) after gastric ESD.

METHODS

A total of 273 patients who underwent ESD were randomly assigned to one of two treatment groups: the continuous infusion group and the bolus injection group. Second-look endoscopy was performed on the following day after ESD. The incidences and risk factors of HRS identified by second-look endoscopy and delayed bleeding were analyzed.

RESULTS

There were no differences in the incidences of HRS and delayed bleeding between two treatment groups. The incidence of HRS was 15.8 % (43/273) and the gross morphology (flat or depressed) was identified as a significant factor associated with HRS. The incidence of delayed bleeding was 8.4 % (23/273) and the gross morphology (flat) and the presence of submucosal invasive cancer were identified as the associated risk factors for delayed bleeding.

CONCLUSION

The incidences of delayed bleeding and HRS identified by second-look endoscopy were not affected by PPI infusion methods. Flat or depressed morphologic lesions and submucosal invasive cancer should be closely monitored.

Risk factors and correlations of immediate, early delayed, and late delayed bleeding associated with endoscopic resection for gastric neoplasms

BACKGROUND

Bleeding is a major complication following endoscopic resection (ER) of gastric mucosal lesions. We aimed to determine the risk factors for post-ER bleeding and their correlations according to the time elapsed since the procedure.

METHODS

We retrospectively enrolled 670 lesions in 610 patients who underwent ER between March 2009 and December 2010. We classified these lesions into three types in accordance with the bleeding time, i.e., immediate bleeding (IB), early delayed bleeding (EDB), and late delayed bleeding (LDB). We analyzed the risk factors for each bleeding type according to baseline patient characteristics, procedure-related factors, and correlations between the occurrence of each bleeding type.

RESULTS

There were 408 post-ER bleeding events in our study cohort: 302 IB events, 88 EDB events, and 18 LDB events. In multivariate analysis, a histologic finding of carcinoma and the resection time were significant predictors of IB (p < 0.001). Of the 302 IB events, 13.9% showed EDB. Additionally, LDB occurred in 2.4% of lesions with EDB and 4.6% of lesions without EDB. Similar to the IB group, of 368 lesions without IB, 12.5% showed EDB. In addition, LDB occurred in 2.2% of lesions with EDB and 1.2% of lesions without EDB. IB was associated with a higher risk of EDB (p < 0.001) and LDB (p < 0.001), whereas EDB was not related to an increased risk of LDB (p = 0.997).

CONCLUSION

IB significantly increases the risk of EDB and LDB, but EDB does not increase the risk of LDB. Histologically confirmed carcinoma or a prolonged time for resection increases the risk of post-ER IB. We recommend careful follow-up approaches following ER of a gastric mucosal lesion in high-risk patients to prevent a potentially critical occurrence of delayed bleeding.

Endoscopic submucosal dissection for early gastric neoplasms in elderly patients

OBJECTIVE

To retrospectively evaluate the safety and feasibility of endoscopic submucosal dissection (ESD) for the treatment of early gastric cancer (EGC) in elderly patients ≥75 years of age.

PATIENTS AND METHODS

One hundred seventy-one patients (187 lesions) treated with ESD from January 2010 to September 2013 were enrolled in our study. Subjects were classified into two groups: elderly (age ≥75 years) or non-elderly (age <75 years). Clinicopathological characteristics, resectability, curability, complications, rates of local recurrence, and residual disease were evaluated. Association of clinicopathological characteristics of the lesions with immediate bleeding was analyzed.

RESULTS

No significant differences in clinical characteristics were observed. The incidences of comorbidity were significantly different between the elderly group and the non-elderly group (P<.001). Of the elderly patients, 54.3% had two or more underlying diseases compared with 18.4% of the non-elderly patients (P<.001). Of the 98.0% of elderly patients and 97.1% of younger patients who received en bloc resection, curative resection reached 94.1% and 96.3%, respectively. Immediate bleeding occurred in 15.2% of the elderly group and 4.8% of the non-elderly group (P=.044). Operation time differed significantly (P=.039). No apparent discrepancy was observed in perforation and delayed bleeding. The differences in the invasion depth were considered between the two groups (P=.001). Logistic regression analysis revealed that the rate of immediate bleeding was associated with invasion depth (P=.003). There were no differences in the follow-up period and rates of local recurrence and residual disease.

CONCLUSIONS

ESD is safe and feasible for elderly patients in the era of a graying population. Higher risk of immediate bleeding and longer operation time should be concerned.

Risk factors for non-curative resection of early gastric neoplasms with endoscopic submucosal dissection: Analysis of 1,123 lesions

Although the frequency of residual disease and recurrence following endoscopic submucosal dissection (ESD) has markedly decreased, a few cases of residual disease and recurrence following ESD are still observed. The aims of the present study were to clarify the causes of non-curative resection and to investigate the risk factors. A total of 1,123 early gastric neoplasm lesions treated by ESD were investigated. Non-curative resection was defined as histological positivity of the resected margins, vascular invasion or failure of en bloc resection. Cases of non-curative resection were classified as being caused by one of three reasons: Inadequate technique, pre-procedural misdiagnosis or problems in the histological diagnosis. Following classification, the cases of non-curative and curative resection were compared based on a range of patient characteristics: Procedure time, and size, type and location of the lesions. The frequency of non-curative resection was 16% (182 lesions). Non-curative resection occurred due to inadequate technique in 59 cases, pre-procedural misdiagnosis in 88 cases and problems in the histological diagnosis in 35 cases. Multivariate analysis revealed that a large lesion size, long procedure time and inexperienced endoscopist were associated with a significantly higher risk of non-curative resection due to an inadequate technique. Furthermore, it was found that lesions located in the upper area of the stomach and cancer with submucosal invasion were associated with a significantly higher risk of non-curative resection due to pre-procedural misdiagnosis. In conclusion, the present study has shown that the major reasons for non-curative resection are an inadequate technique and pre-procedural misdiagnosis. The risk factors for these problems have been clarified.

Second and third-look endoscopy for the prevention of post-ESD bleeding

The efficacy of 2nd-look esophagogastroduodenoscopy (EGD) with endoscopic hemostatic therapy (EHT) for the prevention of postendoscopic submucosal dissection (ESD) clinical bleeding remains controversial. The aim of this study was to estimate post-ESD bleeding rate using 2nd and 3rd-look strategy, and to determine risk factors for clinical bleeding, and for EHT at 2nd and 3rd-look EGDs.Three hundred forty-four consecutive patients with early gastric cancer or adenoma underwent ESD from January 2006 through March 2012. Second and 3rd-look EGDs were performed on day 1 (D1) and day 7 (D7), respectively, with EHT as needed.Post-ESD clinical bleeding rate was 2.6% (95% confidence interval [CI] 1.2%-4.9%). For clinical bleeding, adjusted odds ratios (ORs) for age <65 years and antithrombotic drug uses were 4.40 (95% CI 1.07-19.93) and 7.34 (95% CI 1.80-32.48), respectively. For D1 EHT, adjusted ORs of tumor location in the lower part of the stomach and maximum tumor diameter ≥60 mm were 2.16 (95% CI 1.35-3.51) and 2.20 (95% CI 1.05-4.98), respectively. For D7 EHT, adjusted OR of D1 EHT was 4.65 (95% CI 1.56-20.0).Post-ESD clinical bleeding rate was relatively low using 2nd and 3rd-look strategy. Age <65 years and antithrombotic drug use are significant risk factors for clinical bleeding. Regarding EHT, tumor location in the lower part of the stomach and maximum diameter of resected specimen ≥60 mm are significant predictors for D1 EHT. D1 EHT in turn is a significant risk factor for D7 EHT. The efficacy of sequential strategy for preventing post-ESD bleeding is promising.

A second-look endoscopy may not reduce the bleeding after endoscopic submucosal dissection for gastric epithelial neoplasm

Background

Gastric endoscopic submucosal dissection (ESD) has gradually come to be recommended as the optimal treatment for early gastric cancer; however, one of the primary issues is postoperative bleeding. Although second-look endoscopy is conventionally performed to reduce the risk of postoperative bleeding, its benefit has not yet been clearly elucidated. The objective of this study was to elucidate the benefit of second-look endoscopy.

Methods

A total of 459 lesions in patients were underwent gastric ESD from May 2004 to April 2013 at our hospital were included in the analysis. The patients were divided into those who had bleeding within 24 hours after ESD (immediate bleeding) and those in whom bleeding occurred 24 hours or more after the procedure (delayed bleeding); the underlying disease, age, lesion site, diameter of the resected specimen, and lesion diameter were analyzed to identify the risk factors for postoperative bleeding after ESD.

Results

Post-ESD immediate or delayed bleeding occurred in 23 of the 459 cases (5.0%). Second-look endoscopy was performed in 210 of 447 cases (47.0%) excluding 12 cases with immediate bleeding; in the remaining 237 of the 447 cases (53.0%), it was not performed. Post-ESD delayed bleeding occurred in 6 of the 210 cases (2.9%) and 5 of the 237 cases (2.1%), with no statistically significant difference between the two groups. Overall, the following factors were identified as the risk factors for postoperative bleeding: young age (P = 0.005), lesions in the L segment (P = 0.042), and large size of the resected specimen (P = 0.005). The risk factors identified in the immediate bleeding group were lesions in the L segment (P = 0.032), large size of the resected specimen (P < 0.001), and large tumor size (P = 0.011), and those in the delayed bleeding group were young age (P = 0.013) and concomitant renal disease (P = 0.011).

Conclusions

The results of this study suggest that second-look endoscopy after gastric ESD may not be useful for preventing postoperative bleeding.

A pilot study using an infrared imaging system in prevention of post-endoscopic submucosal dissection ulcer bleeding

BACKGROUND

Endoscopic submucosal dissection (ESD) for superficial gastric neoplasm is a curative method. The aim of this study was to detect potential nonbleeding visible vessels (NBVVs) by using an infrared imaging (IRI) system.

METHODS

A total of 24 patients (25 lesions) were consecutively enrolled between March 2010 and December 2010. The day after ESD, endoscopist A (K.M.), who was blinded to the actual procedure of ESD, performed esophagogastroduodenoscopy (EGD) of the post-ESD ulcer base using the IRI system. Endoscopist A marked gray/blue points in the hard-copy images with the IRI system. After the first procedure, endoscopist B (Y.Y.), who was blinded to the results recorded by endoscopist A, performed a second EGD with white light endoscopy and administered water-jet pressure with the maximum level of an Olympus flushing pump onto the post-ESD ulcer base. This test can cause iatrogenic bleeding via application of pressure to NBVV in the post-ESD ulcer.

RESULTS

The IRI system detected 58 gray points and 71 blue points. The post-ESD ulcer was divided into the central area and the peripheral area. There were 14 gray points (24 %) in the central area and 44 gray points (76 %) in the peripheral area. There were 19 blue points (27 %) in the central area and 52 blue points (73 %) in the peripheral area. There was no significant difference when comparing the distribution of gray points and blue points. Bleeding occurred with a water-jet pressure in 11 of 58 gray points and in none of the blue points (P = 0.000478). Among the gray points, bleeding in response to a water-jet pressure occurred in 2 points in the central area and in 9 points in the peripheral area.

CONCLUSION

The IRI system detects visible vessels (VVs) that are in no need of coagulation as blue points, and VVs have a potential risk of bleeding as gray points.

Preventing and controlling bleeding in gastric endoscopic submucosal dissection

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.

Endoscopy in the patient on antithrombotic therapy

PURPOSE OF REVIEW

The management of antithrombotics during the periendoscopic period is a common clinical problem. This review focuses on recent literature addressing this issue, primarily on articles published from 2009 to 2012.

RECENT FINDINGS

A large proportion of the studies retrieved focused on the effect of antithrombotics on bleeding risk following diagnostic endoscopy, polypectomy, endoscopic mucosal resection, and submucosal dissection, whereas studies involving other endoscopic procedures were scarce. Recent American and European guidelines direct the management of antithrombotic therapy in patients undergoing endoscopy according to the procedure's risk of bleeding and the patient's thromboembolic risk. The difficulty in determining a priori the need for endotherapy and hence appropriate classification of risk of bleeding prior to the procedure is a potential limitation of such classification. Moreover, most studies have primarily addressed the risk of immediate or early bleeding by proposing interruption of antithrombotic therapy prior to endotherapy, and few have focused on the risk of delayed bleeding and the optimal time for resumption of these agents following high-risk procedures.

SUMMARY

Management of patients on antithrombotics remains complex, especially in high-risk settings. Existing guidelines are valuable but should not be a substitute for a careful personalized risk assessment strategy involving patient and physician.

Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for early gastric neoplasms: analysis of 1123 lesions

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of early gastric neoplasms; however, this advanced technique has also resulted in an increase in serious complications such as perforation and delayed bleeding. This study aimed to elucidate the risk factors for these complications.

METHODS

A total of 1123 lesions diagnosed with early gastric neoplasms and treated by ESD at three institutions were investigated. Retrospectively, patients with or without these complications were compared on the basis of the patient characteristics and treatment results.

RESULTS

Perforation occurred in 27 lesions (2.4%) and delayed bleeding in 56 lesions (5.0%). Multivariate analysis indicated that lesions located in the upper area of the stomach (odds ratio [OR]: 4.88, 95% confidence interval [CI]: 2.21-10.75) was associated with a significantly higher risk of perforation, and that age ≥ 80 years (OR: 2.15, 95% CI: 1.18-3.90) and a long procedure time (OR: 1.01, 95% CI: 1.001-1.007) were associated with a significantly higher risk of delayed bleeding after ESD. The en bloc resection rate (74% vs 94%) and curative resection rate (48% vs 85%) of lesions with perforation were significantly lower than those without perforation. The rate of residual disease or recurrence after ESD was significantly higher in lesions with delayed bleeding than that without delayed bleeding (5.4% vs 0.84%).

CONCLUSIONS

This study demonstrated risk factors for perforation and delayed bleeding associated with ESD. Furthermore, it was clarified that perforation and delayed bleeding influenced post-procedure results and prognosis after ESD.

[Endoscopic submucosal dissection: only for expert endoscopists?]

Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.

Analysis of delayed bleeding after endoscopic submucosal dissection for gastric epithelial neoplasms

Aim. Delayed bleeding after endoscopic submucosal dissection (ESD) for gastric epithelial neoplasms is a major complication. We investigated factors related to post-ESD bleeding to identify preventive measures. Methods. The study included 161 gastric epithelial neoplasms in 142 patients from June 2007 to September 2010. Post-ESD bleeding was defined as an ulcer with active bleeding or apparent exposed vessels diagnosed by an emergency endoscopy or a planned follow-up endoscopy. We analyzed associations between bleeding and the following factors: age, sex, morphology, pathology, tumor depth, ulcer presence/absence, location, size of the resected lesion, duration of the procedure, the number of times bleeding occurred during ESD, and the use of anticoagulants and/or antiplatelet drugs. Subsequently, we examined characteristics of bleeding cases. Results. Post-ESD bleeding occurred in 21 lesions. Univariate analysis of these cases showed that ulcer presence/absence (P < 0.001), middle or lower third lesions (P = 0.036), circumference (P = 0.014), and a post-ESD ulcer with an extended lesser curve (P = 0.009) were significant predictors of bleeding. Multivariate analysis showed that ulcer presence/absence (OR 9.73, 95% CI 2.28–41.53) was the only significant predictor. Conclusion. Ulcer presence/absence was considered the most significant predictor of post-ESD bleeding.

Proton Pump Inhibitor Therapy before and after Endoscopic Submucosal Dissection: A Review

Endoscopic submucosal dissection (ESD) is a novel endoscopic procedure first developed in the 1990s which enables en bloc resection of gastric neoplastic lesions that are difficult to resect via conventional endoscopic mucosal resection. However, given that ESD increases the risk of intra- and post-ESD delayed bleeding and that platelet aggregation and coagulation in artificial ulcers after ESD strongly depend on intragastric pH, faster and stronger acid inhibition via proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H(2)RAs) as well as endoscopic hemostasis by thermocoagulation during ESD have been used to prevent ESD-related bleeding. Because PPIs more potently inhibit acid secretion than H(2)RAs, they are often the first-line drugs employed in ESD treatment. However, acid inhibition after the initial infusion of a PPI is weaker in the early phase than that achievable with H(2)RAs; further, PPI effectiveness can vary depending on genetic differences in CYP2C19. Therefore, optimal acid inhibition may require tailored treatment based on CYP2C19 genotype when ESD is performed, with a concomitant infusion of PPI and H(2)RA possibly most effective for patients with the rapid metabolizer CYP2C19 genotype, while PPI alone may be sufficient for those with the intermediate or poor metabolizer genotypes.

Clinical outcomes of ESD for early gastric neoplasms in elderly patients

BACKGROUND

Endoscopic submucosal dissection (ESD) is a standard treatment in Japan for early gastric neoplasms. With an increase in elderly population, the number of elderly patients in whom ESD performed has also steadily increased.

AIMS AND METHODS

 The aim of study was to evaluate the effectiveness of and problems associated with ESD for early gastric neoplasms in elderly patients. Subjects were 514 patients (586 lesions) with early gastric neoplasms performed ESD at two institutions. The patients were classified into an elderly group (age ≥ 75 years) and a nonelderly group (age < 75 years). We compared the characteristics of patients and lesions, treatment results, ESD-related complications and prognosis between the two groups.

RESULTS

The elderly group included 200 patients (229 lesions), and the nonelderly group included 314 patients (357 lesions). The incidences of underlying disease, such as hypertension and heart disease, and the rate of antiplatelet agents use were significantly higher in the elderly group. En bloc and curative resection rates were high in both groups. The bleeding rate was significantly higher in the elderly group. Residual disease or recurrence rates were very low in both groups. The death rate due to other diseases was significantly higher in the elderly group.

CONCLUSIONS

This study demonstrates the efficacy of ESD in both elderly and nonelderly patients. However, we must be attentive to ESD-related bleeding, death caused by other diseases, and underlying diseases when we perform ESD in elderly patients.

Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions

AIM: To assess risk factors for bleeding after gastric endoscopic submucosal dissection (ESD) and to develop preventive measures.

METHODS: This retrospective study was performed in a tertiary referral center. A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009. The main outcome was association between post-ESD bleeding and the following: age; sex; comorbidities; daily use of medicine potentially related to gastric injury/bleeding; location, size, and histological depth of lesions; ulceration; experience of operator coagulating the ulcer floor, and duration of operation. We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.

RESULTS: Univariate analysis revealed significant risk factors: tumor location [odds ratio (OR), 2.86; 95% CI: 1.21-6.79, P = 0.024], coagulator experience (OR, 4.29; 95% CI: 1.43-12.86, P = 0.009), and medicine potentially related to gastric injury/bleeding (OR, 2.80; 95% CI: 1.14-6.90, P = 0.039). Multivariate logistic regression analysis confirmed significant, independent risk factors: tumor in lower third of stomach (OR, 2.47; 95% CI: 1.02-5.96, P = 0.044), beginner coagulator (OR, 3.93; 95% CI: 1.29-11.9, P = 0.016), and medicine (OR, 2.76; 95% CI: 1.09-6.98, P = 0.032). We classified cases of post-ESD bleeding into two groups (bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts (OR, 16.00; 95% CI: 1.22-210.59, P = 0.040).

CONCLUSION: Beginner coagulators, tumor in the antrum, and medicines were significant risk factors for post-ESD bleeding. Bleeding at the ulcer margin frequently occurred with beginner operators.