Introduction

Clinically significant delayed bleeding (CSDB) is one of the most frequent complications after colorectal ESD (incidence 1-9%[1–4]). Delayed bleeding increase length of stay or induces new hospitalization; can lead to blood transfusion or new hemostatic colonoscopy and thereby increase costs. Few data are extant on risk prediction and risk factors of post-ESD delayed bleeding; those available are from observational Asian studies.

Aims & Methods

We performed a large western cohort study to identify risk factors of post colorectal ESD bleeding, and developed a new scoring system to accurately predict post-colorectal-ESD bleeding.
We analyzed a prospectively maintained consecutive database (IRB approval #87RI20-0021_FECCo; NCT04592003).
The patients were contacted (face to face or by telephone) after 1 month for histopathological results and verification of complications (including post-ESD delayed bleeding).
Clinically significant delayed post-ESD bleeding (CSDB) was defined as a bleeding event needing a prolongation of hospitalization, a re-admission, a new endoscopy, or a blood transfusion and occurring at least 6 hours after, and within 30 days of, the procedure.

Results

A total of 940 ESDs of large colorectal lesions were performed consecutively in 940 patients (Figure 1, Table 1).
ASA score was III or IV in 340 patients (36.2%). A total of 267 (28.4%) patients had some form of anticoagulant/antiaggregant therapy prescribed. The mean lesion size was 60.6 (25.4) mm (SD, 25.4 mm; range, 45–70 mm). Lesion location was rectum in 369 cases (39.3%), distal (sigmoid to splenic flexure) in 165 cases (17.6%), transverse in 67 (7.1%) and proximal (cecum to hepatic flexure) in 339 cases (36.1%).
CSDB occurred in 75 patients (7.98%, 95% CI: 6.36,9.95)
The factors found to be predictive in the final multivariate model and their score were age ≥ 75 years (OR 1.60; 95% CI, 0.95–2.70; p = 0.074, 1 point), antithrombotic agent (anticoagulant or antiplatelet) use during ESD (OR 1.73 95% CI, 1.01–2.95; p = 0.045, 1 point), rectum location (OR 1.55; 95% CI, 0.95–2.55; p = 0.079, 1 point), ASA classification III or IV (OR 2.29; CI 95%, 1.34–3.97, p = 0.003, 2 points) and lesion ≥ 50 mm (OR, 5.99; 95% CI, 2.76–15.70, p < 0.001, 3 points).
The multivariate model had an ROC of 0.758 (95% CI, 0.697–0.815). Calibration of the model was good according to calibration curves and to the Hosmer–Lemeshow results (X² = 8.446; p = 0.391). The discrimination slope (difference in average predictions for those with and without the outcome) was 0.08 (95% CI, 0.04–0.13).
The total CSDB score by multivariate analysis ranged from 0 (lowest risk) to 8 (highest risk). The sample was classified into low (score, 0–2; n = 232; 25% of the population); average (score, 3–5; n = 494; 53% of the population), and high (score, 6–8; n = 214; 23% of the population) risk categories. These categories had probabilities of DB of 1.2%, 5.2%, and 18.1%, respectively.

Conclusion

In conclusion, lesion size > 50 mm, antithrombotic use, age > 75 years, ASA score III/IV, and rectal location were independent risk factors for DB after ESD. Our easy-to-use risk score based on these factors enables prediction of the risk of post-colorectal ESD CSDB. After being independently validated, the CSDB score will allow provision of pre-procedural individualized information to patients, optimization of their care, and identification of patients who will benefit from new post-ESD CSDB prevention strategies.