Second and Third-look Endoscopy for the Prevention of Post-ESD Bleeding

Abstract

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.

Efficacy of hemostatic powder in preventing bleeding after gastric endoscopic submucosal dissection in high‐risk patients

“…Similar to this study, the proportion of ulcers with a high risk for bleeding on second‐look endoscopy was reported to be 15.1% to 64.2% in several studies (Table ) . Even though patients in our study group were at high risk for post‐ESD bleeding, the proportion of ulcers with stabilized clean base was higher than that of other previous studies . Therefore, hemostatic powder application might be effective to stabilize the ulcer surface and prevent early bleeding in patients with larger resections.…”

“…Third, second‐look endoscopy and prophylactic hemostasis might affect the bleeding rate. However, previous studies reported that second‐look endoscopy did not affect bleeding rates . Indeed, in our study, two patients had delayed bleeding events even though they underwent prophylactic hemostasis on second‐look endoscopy on POD 2.…”

“…Table shows the endoscopic findings on second‐look endoscopy according to the Forrest classification after ESD in our study and recent studies . These studies were carried out on patients with an average risk of post‐ESD bleeding and were not aimed at high‐risk patients.…”

“…These studies were carried out on patients with an average risk of post‐ESD bleeding and were not aimed at high‐risk patients. Five prospective studies showed that the proportion of Forrest classification Ia, Ib, and IIa lesions ranged from 15.1% to 64.2%. The proportion of actively bleeding lesions (Forrest Ia and Ib) in previous studies ranged from 9.6% to 14.0% .…”

“…Table 3 shows the endoscopic findings on second-look endoscopy according to the Forrest classification after ESD in our study and recent studies. [23][24][25][26][27][28][29][30] These studies were carried out on patients with an average risk of post-ESD bleeding and were not aimed at high-risk patients. Five prospective studies [23][24][25]27,29 showed that the proportion of Forrest classification Ia, Ib, and IIa lesions ranged from 15.1% to 64.2%.…”