Risk of delayed bleeding after colorectal endoscopic submucosal dissection: the Limoges Bleeding Score

Abstract

Background and Aims: Clinically significant delayed bleeding (CSDB) is a frequent, and sometimes severe, adverse event after colorectal endoscopic submucosal dissection (ESD). We evaluated risk factors of CSDB after colorectal ESD. Methods: We analyzed a prospective registry of 940 colorectal ESDs performed from 2013 to 2022. The incidence of bleeding was evaluated up to 30 days. Risk factors for delayed bleeding were evaluated by multivariate logistic regression. A Korean scoring model was tested, and a new risk-scoring model was developed and internally validated. Results: CSDB occurred in 75 patients (7.98%). The Korean score performed poorly in our cohort, with an ROC of 0.567. In the multivariate analysis, risk factors were age ≥ 75 years (OR, 1.60; 95% CI, 0.95,2.7; 1 point), use of antithrombotics (OR, 1.72; 95% CI, 1.01, 2.94; 1 point), rectal location (OR, 1.51; 95% CI, 0.92, 2.48; 1 point), size > 50mm (OR, 3.63; 95% CI, 2.02, 7.14; 3 points), and ASA score of III or IV (OR, 2.26; 95% CI, 1.32, 3.92; 2 points). The model showed a fair calibration and good discrimination, with an ROC curve of 0.751 (95% CI, 0.690–0.812). The score was used to define two groups of patients, those with low-medium (0 to 4 points) and high (5 to 8 points) risks of CSDB (respective bleeding rates 4.1% and 17.5%). Conclusion: A score based on five simple and meaningful variables is predictive of CSDB.

Clip Closure and PuraStat for Prevention of Clinically Significant Delayed Bleeding after Colorectal Endoscopic Submucosal Dissection: A Prospective, Observational Study

“…We found a higher CSDB incidence of 7.9% (3 events out of 38 cases, 95% CI [1.7-21.4%]) versus 2.8-4.3% as reported by the ESGE ESD technical guidelines [2]. Other authors have also found similar higher incidences of delayed bleeding of 4.1 to 17.5% [10]. We included only three patients with CSDB for whom endoscopic evaluation with hemostasis by thermocoagulation was necessary.…”

“…Even though statistical significance was not attained, the protective effect may be clinically meaningful, and further validation is necessary (0 events in 14 cases with clips versus 3 events in 24 cases without clips, p = 0.283). Note that clip closure was not protective for CSDB in the large prospective cohort of colorectal ESD lesions, validating the Limoges bleeding score (odds ratio = 1.59, 95% CI [0.73-4.18], p = 0.26) [10].…”

“…The risk factors for CSDB after ESD were included in the following predictive scores: the Korean risk score (rectosigmoid location, lesion diameter > 30 mm, use of antiaggregants) and the Limoges score (rectal location, lesion diameter > 50 mm, antiaggregants/anticoagulants, age > 75, and an American Society of Anesthesiology (ASA) risk score of III or IV) [10,11]. In our series, no predictive risk factors for CSDB were found in the univariate analysis (Table 4).…”

“…CSDB was defined as post-ESD bleeding necessitating the prolongation of hospitalization or readmission, with a new endoscopic evaluation or a blood transfusion and occurring at least 6 h after the ESD [10].…”