Third-look endoscopy prevents delayed bleeding after endoscopic submucosal dissection under antithrombotic therapy

Background/Aims. Delayed bleeding is one of the most serious complications following gastric endoscopic submucosal dissection (ESD) under antithrombotic therapy. As a safety measure, for patients receiving antithrombotic therapy, we covered the ESD ulcer with autologous fibrin glue (prepared using autologous blood) alone or with polyglycolic acid (PGA) sheets. Methods. From July 2014 to November 2015, 20 patients with gastric neoplasms who were receiving antithrombotic therapy were enrolled in this study. After ESD, the ESD ulcers were covered with autologous fibrin glue alone or with PGA sheets. We prospectively evaluated the feasibility of this safety measure. Results. In total, 22 lesions in 20 patients were resected en bloc by ESD. The mean specimen size and tumor size were 31.5 ± 9.5 mm and 14.0 ± 8.8 mm, respectively. There were no cases of delayed bleeding or adverse events in this study. Attachment of autologous fibrin glue was observed in 81.8% (18/22) and 68.2% (15/22) of lesions at endoscopy performed 1 day and 7 days after ESD, respectively. Conclusion. No patient in this study had delayed bleeding or adverse events. This suggests that this measure may facilitate the safety of gastric ESD in patients receiving antithrombotic therapy. This trial is registered with UMIN000019386.

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Rebleeding in patients with delayed bleeding after endoscopic submucosal dissection for early gastric cancer

Digestive Endoscopy ◽

10.1111/den.13943 ◽

2021 ◽

Author(s):

Minami Hashimoto ◽

Waku Hatta ◽

Yosuke Tsuji ◽

Toshiyuki Yoshio ◽

Yohei Yabuuchi ◽

...

Keyword(s):

Gastric Cancer ◽

Early Gastric Cancer ◽

Endoscopic Submucosal Dissection ◽

Delayed Bleeding ◽

Submucosal Dissection

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Modified search, coagulation, and clipping with polyglycolic acid sheet and fibrin glue to reduce delayed bleeding risk after endoscopic submucosal dissection near the dentate line

Endoscopy ◽

10.1055/a-1422-2510 ◽

2021 ◽

Author(s):

Satoshi Abiko ◽

Ayumu Yoshikawa ◽

Kazuaki Harada ◽

Naoki Kawagishi ◽

Itsuki Sano ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Fibrin Glue ◽

Bleeding Risk ◽

Dentate Line ◽

Polyglycolic Acid ◽

Delayed Bleeding ◽

Polyglycolic Acid Sheet ◽

Submucosal Dissection

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Colorectal Endoscopic Submucosal Dissection in a Western Center: Analysis of Outcomes and Safety Profile

GE Portuguese Journal of Gastroenterology ◽

10.1159/000514797 ◽

2021 ◽

pp. 1-9

Author(s):

João Santos-Antunes ◽

Margarida Marques ◽

Rui Morais ◽

Fátima Carneiro ◽

Guilherme Macedo

Keyword(s):

Endoscopic Submucosal Dissection ◽

Safety Profile ◽

En Bloc Resection ◽

R0 Resection ◽

Hybrid Technique ◽

Resection Rate ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Gastrointestinal Lesions

Introduction: Endoscopic submucosal dissection (ESD) is a well-established endoscopic technique for the treatment of gastrointestinal lesions. Colorectal ESD outcomes are less reported in the Western literature, and Portuguese data are still very scarce. Our aim was to describe our experience on colorectal ESD regarding its outcomes and safety profile. Methods: We conducted a retrospective evaluation of recorded data on ESDs performed between 2015 and 2020. Only ESDs performed on epithelial neoplastic lesions were selected for further analysis. Results: Of a total of 167 colorectal ESDs, 153 were included. Technical success was achieved in 147 procedures (96%). The lesions were located in the colon (n = 24) and rectum (n = 123). The en bloc resection rate was 92% and 97%, the R0 resection rate was 83% and 82%, and the curative resection rate was 79% and 78% for the colon and the rectum, respectively. The need for a hybrid technique was the only risk factor for piecemeal or R1 resection. We report a perforation rate of 3.4% and a 4.1% rate of delayed bleeding; all the adverse events were manageable endoscopically, without the need of blood transfusions or surgery. Most of the lesions were laterally spreading tumours of the granular mixed type (70%), and 20% of the lesions were malignant (12% submucosal and 8% intramucosal cancer). Conclusion: Our series on colorectal ESD reports a very good efficacy and safety profile. This technique can be applied by endoscopists experienced in ESD.

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Feasibility of a modified search, coagulation, and clipping method with and without the use of polyglycolic acid sheets and fibrin glue for preventing delayed bleeding after gastric endoscopic submucosal dissection

BMC Gastroenterology ◽

10.1186/s12876-020-01539-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Satoshi Abiko ◽

Soichiro Oda ◽

Akimitsu Meno ◽

Akane Shido ◽

Sonoe Yoshida ◽

...

Keyword(s):

High Risk ◽

Endoscopic Submucosal Dissection ◽

Median Time ◽

Fibrin Glue ◽

Polyglycolic Acid ◽

Low Risk ◽

R0 Resection ◽

Antithrombotic Agents ◽

Delayed Bleeding ◽

Submucosal Dissection

Abstract Background Methods have been developed for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (GESD). However, none of the methods can completely prevent DB. We hypothesized that DB could be prevented by a modified search, coagulation, and clipping (MSCC) method for patients at low risk for DB and by combining the use of polyglycolic acid sheets and fibrin glue with the MSCC method (PMSCC method) for patients at high risk for DB (antibleeding [ABI] strategy). This study assessed the technical feasibility of this novel strategy. Method We investigated 123 lesions in 121 consecutive patients who underwent GESD in Kushiro Rosai Hospital between April 2018 and January 2020. The decision for continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment. Results Oral antithrombotic agents were administered to 28 patients (22.8%). The en bloc R0 resection rate was 98.4%. The MSCC method and the PMSCC method for preventing DB were performed in 114 and 9 lesions, respectively. The median time of the MSCC method was 16 min, and the median speed (the resection area divided by the time of method used) was 3.6 cm2/10 min. The median time of the PMSCC method was 59 min, and the median speed was 1.3 cm2/10 min. The only delayed procedural adverse event was DB in 1 (0.8%) of the 123 lesions. Conclusions The ABI strategy is feasible for preventing DB both in patients at low risk and in those at high risk for DB after GESD, whereas the PMSCC method may be necessary for reduction of time.

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Vonoprozan: potentially new first-line treatment for delayed upper gastrointestinal bleeds following endoscopic procedures? A letter to the editor

Journal of the Pakistan Medical Association ◽

10.47391/jpma.4136 ◽

2022 ◽

Vol 71 (12) ◽

pp. 2838-2838

Author(s):

Muhammad Umer ◽

Syed Wasif Bukhari

Keyword(s):

Endoscopic Submucosal Dissection ◽

Gastrointestinal Diseases ◽

High Dose ◽

First Line ◽

Gastroesophageal Varices ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Significant Difference ◽

H Pylori ◽

Line Of Therapy

Endoscopy nowadays is widely used as a diagnostic and therapeutic tool for various gastrointestinal diseases due to it being less invasive and safer. However, amongst some adverse events is delayed bleeding. The definition of delayed bleeding requires endoscopic hemostasis and/or blood transfusion after at least two days of treatment. (1) Oesophageal cancer is comparatively more common in Pakistan, being 7th most common malignancy in men and 6th most common in women in Karachi. (2) Oesophageal endoscopic submucosal dissection (E-ESD) employed in the treatment of the above- mentioned cancer has an incidence of delayed bleeding of about 1.3-6.7%. (1) The prevalence of gastric cancer across Pakistan was about 2-18% (3), for which endoscopic submucosal dissection is often used has an incidence of delayed bleeding of 4.7-15.6%. (1) Endoscopic therapy for gastroesophageal varices can also result in delayed bleeding, the incidence of which easily reaches up to 10%. (1) In a retrospective cohort study of 124,422 patients conducted in Japan, it was found that vonoprazan was more effective in reducing the risk of delayed bleeding compared to omeprazole. (OR= 0.75) (1) Vonoprazan works by competitively inhibiting the potassium-acid channel resulting in strong and sustained acid inhibition. (4) It was also found to have a superior effect in the eradication of H Pylori and an equal effect in acid-related disorders. (5) In the retrospective study mentioned above, it is also worth noting that the efficacy of vonoprazan was variable with respect to procedures and was most prominent with gastroduodenal endoscopic submucosal dissection (OR=0.70). (1) Other procedures did not elicit any significant difference. In addition, standard/high dose vonoprazan proved to be most efficacious in reducing the risk of delayed bleeding compared with standard/high-dose PPI and low-dose vonoprazan. It was also observed that patients taking anti-thrombotic medications at a higher risk of delayed bleeding also benefited from high-dose vonoprazan. (OR=0.74) (1) The findings above compel the conclusion that high dose vonoprazan should be ideal for reducing the risk of delayed bleeding in patients who have undergone gastroduodenal endoscopic submucosal dissection and/or are on anti-thrombotics. Though high-dose vonoprazan does look promising, it is imperative that more randomized controlled trials on more diverse populations be conducted to further explore its efficacy and safety as the drug might be a potential first line of therapy.

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