Introduction

Delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) is major complication [1] that sometimes lead to shock vitals and the effect of mucosal defect closure for preventing DB was reported [2]. However, the thickness of the gastric mucosa and proper muscle layer makes suturing difficult [3].

Aims & Methods

The aim of this study was to investigate whether clip closure using novel anchor-pronged clip (MANTIS Clip; Boston Scientific) is effective in preventing DB after gastric ESD. Out of 70 cases (78 lesions) that underwent gastric ESD at our institution from August 2023 to February 2024, a retrospective analysis was conducted on 60 consecutive cases (65 lesions) where ≥ 50% of the wound could be closed. If the wound was small, the closure method involved initially placing at least one MANTIS Clip to achieve mucosa-to-mucosa closure. If the wound was large, it was closed according to the method we previously reported [4]. In concrete terms, one side of the mucosa was grasped with MANTIS Clip, then move the clip to the opposite muscle layer, open the clip once, and after sufficient air aspiration, grasp the muscle layer. After shrinking mucosal defect enough, complete closure was achieved by adding mucosa-mucosa and mucosa-muscle closure similar to previous report of colonic closure [5] with normal clips (Sure Clip 16mm (Micro-Tech Co., Ltd, Nanjing, China) or EZ Clip (Olympus Medical Systems, Tokyo, Japan)). The primary outcome was the actual DB rate compared with the expected DB rate calculated from the BEST-J score [1]. Secondary outcomes included the technical success rate, complete closure rate (proportion of wounds with ≥ 90% closure), and closure time.

Results

M/F=42/18. DB risk based on BEST-J score (low/intermediate/high/very high) = 46/7/6/1. The median tumor size (mm) was 10 (5-40). Adenoma/cancer = 10/55. The actual rate of DB was 0%, indicating lower tendency to the expected rate of 4.5% (p=0.244). The technical success rate was 85.7% (60/70), with a complete closure rate of 90.8% (59/65). The median closure time (min) was 9 (2-24), with a median of 1 MANTIS Clip used per lesion (range: 1-4).

Conclusion

Although further accumulation of cases is necessary, clip closure using the MANTIS Clip achieved low DB with rapid and high complete closure after gastric ESD.

References

1. Hatta W, Tsuji Y, Yoshio T et al. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut. 2021; 70: 476–484.
2. Maekawa S, Nomura R, Murase T et al. Complete closure of artificial gastric ulcer after endoscopic submucosal dissection by combined use of a single over-the-scope clip and through-the-scope clips (with videos). Surg Endosc. 2015; 29: 500–504.
3. Choi KD, Jung HY, Lee GH et al. Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding. Surg Endosc. 2008; 22: 1882–1886.
4. Okimoto K, Matsumura T, Matsusaka K et al. Successful closure of large mucosal defect with novel anchor-pronged clip after gastric endoscopic submucosal dissection. Endoscopy. 2024. Epub ahead of print.
5. Nishizawa T, Banno S, Kinoshita S et al. Feasibility of endoscopic mucosa-submucosa clip closure method (with video). Endosc Int Open. 2018; 6: E1070–E1074.

Disclosure

None

Introduction

This study aimed to compare the efficacy of combined intravenous and oral proton pump inhibitor (PPI) versus oral vonoprazan (VPZ) alone therapy in preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) in a consecutive and large case series.

Aims & Methods

A retrospective study at Chiba University Hospital included consecutive patients who underwent gastric ESD between January 2017 and July 2023. Before 2019, patients received intravenous omeprazole 20 mg in the morning and evening on the day of ESD and the day after. Thereafter, esomeprazole 20 mg was administered orally once daily, which was continued for generally 28 days (defined as the PPI group). From 2020 onward, patients received oral VPZ 20 mg once daily starting on the day of ESD, also typically continued for 28 days (defined as the VPZ group). Propensity score generation and 1:1 matching of patients between the PPI and VPZ groups were performed to minimize selection bias in treatment assignment. Matching was based on nine covariates associated with DB rates for gastric ESD, including whether patients were taking warfarin, directly acting oral anticoagulant (DOAC), P2Y12 receptor antagonist, aspirin, or cilostazol; whether it was CKD with haemodialysis, a tumour size >30 mm, lower-third in tumour location and presence of multiple tumours.

Results

There were 720 cases (856 tumors) of gastric ESD during the study period, of which 352 (409 tumors) were in the PPI group and 368 (447 tumors) in the VPZ group. Propensity score matching for 9 covariates related to DB rates for gastric ESD ultimately produced 334 best matches. There was no significant difference in DB rates between the two groups (3.6% vs 3.6%. p = 1.000).

Conclusion

Though further prospective studies are needed to draw definitive conclusions, it was suggested that the easily administered oral VPZ can be an important option for acid suppression after gastric ESD.

Introduction

Post-procedural bleeding (PPB) is the most common adverse event after gastric endoscopic submucosal dissection (ESD). The BEST-J score was created to predict PPB risk following gastric ESD.

Aims & Methods

We aimed to evaluate predictive factors of PPB and validate the BEST-J score in a large European cohort. We conducted a retrospective cohort study including consecutive gastric epithelial lesions removed by ESD between January of 2005 and June of 2024. Incomplete ESD and patients with missing information that prevented the score calculation were excluded. PPB was defined as presence of compatible clinical picture in the 28 days following the procedure. Univariate and multivariate analysis were used to identify predictive factors of PPB, and the diagnostic ability of the BEST-J score was calculated in this cohort.

Results

From 990 ESD, 874 were included in the final analysis. PPB occurred in 53 patients (6.1%), with a median time after procedure of 2 days (P25-P75: 1-7). PPB was significantly superior in patients with higher risk as evaluated by the BEST-J score (PPB rate of 3.7%, 3.9%, 19.2% and 35.7% for low, intermediate, high and very-high risk, respectively). The area under the curve for PPB prediction using the BEST-J score was 0.684 (IC95% 0.598-0.679). For a score ≥ 3 (high and very-high risk), the sensitivity and specificity for PPB detection were 47.2% (IC95% 34.2-60.5) e 88.7% (IC95% 86.4-90.7), respectively. In this sample, the following predictive factors for PPB were identified: ischemic cardiopathy [adjusted Odds Ratio (aOR) 4.351; IC95% 1.660-11.404], medication with warfarin (aOR 18.339; IC95% 4.541-74.064) or direct oral anticoagulants (aOR 7.596; IC95% 2.666-21.641) and lesion size > 20mm (aOR 2.563; IC95% 1.246-5.272).

Conclusion

The BEST-J score presented moderate discrimination for PPB following gastric ESD in our cohort. The identified factors may assist the decision of implementing prophylactic measures in high-risk patients and the creation of more precise prediction models.

References

Vasconcelos AC, et al. Endoscopic Resection of Early Gastric Cancer and Pre-malignant Gastric Lesions. Cancers, 2023 Jun 7;15(12):3084. doi: 10.3390/cancers15123084.
Hatta W, et al. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut, 2021 Mar;70(3):476-484. doi: 10.1136/gutjnl-2019-319926

Introduction

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) is one of the most frequent complications (up to 7%). The BEST-J score is a risk predictive model for delayed bleeding following gastric ESD. We aim to assess potential risk factors associated with bleeding and validate the BEST-J score in a population of patients undergoing ESD.

Aims & Methods

Prospective cohort study, single centre, of patients who underwent gastric ESD between 2017 and 2023. The characteristics of the lesion were evaluated, and logistic regression of risk factors associated with bleeding after ESD was performed. The BEST-J score was calculated for each patient and the discriminative ability was evaluated through the area under the receiver operating characteristic curve (AUC-ROC).

Results

Included 101 gastric ESDs (63.4% female), with a mean age of 69.7 ± 8 years. 17.8% of patients were on antiplatelet therapy and 13.9% were on anticoagulant therapy. Among the analyzed lesions: 43.6% measured between 0-20mm, 56.4% were ≥ 20mm; 13.9% were sessile, 60.4% flat, 14.9% depressed and 10.9% subepithelial; 22.8% were located in the cardia, fundus, or body, 17.8% in the incisura angularis and 59.4% in the antrum. The most frequent histological results were: 38.6% low-grade dysplasia, 26.7% high-grade dysplasia and 19.8% intramucosal adenocarcinoma. The mean procedure duration was 87±43 minutes. Delayed bleeding after ESD occurred in 5.9% (n=6) of cases. In the univariate analysis of risk factors, the lesion size ≥ 20mm showed statistical significance (10.5% vs. 0%; p=0.034), but not the location in the antrum (6.7% vs. 4.9%; p=0.5), lesion nature (7.1% vs. 8.2% vs. 0% vs. 0%; p=0.5) or procedure duration ≥60 minutes (5% vs. 9.5%; p=0.3). The BEST-J score predicted the risk of delayed bleeding after gastric ESD with an AUC of 0.70 (95% CI: 0.53-0.87; p=0.1).

Conclusion

The use of bleeding predictive scores may be useful in identifying high-risk patients; in our series, the BEST-J score was not very effective, with only lesion size ≥ 20mm being a relevant factor for bleeding after ESD.

Introduction

Endoscopic submucosal dissection (ESD) is widely implemented in Asia. BEST J-score is a clinically useful prediction model validated in 2021, based on this population, to stratify the risk of delayed bleeding (DB) after gastric ESD. Experience from the Western world is still scarce.

Aims & Methods

The aim of our study is to validate BEST-J score in a Western sample.
Retrospective analysis with a prospectively maintained database of all patients undergoing ESD at a Western tertiary center from June 2016 to December 2022.
Gastric ESD performed by a single operator were included in this study. BEST-J score was applied for all procedures, which comprised 10 variables (intake of warfarin, direct oral anticoagulant (DOAC), chronic kidney disease with haemodialysis, intake of P2Y12 receptor antagonist, aspirin, cilostazol, tumour size >30 mm, lower-third in tumour location, presence of multiple tumours and interruption of each kind of antithrombotic agents). The primary endpoint was to validate BEST-J score accuracy in predicting DB (up to 28 days after ESD).

Results

Of 477 ESD performed, a total of 252 ESD met the inclusion criteria; 56.5% were male, with a mean age of 68 years (SD 8 years). Of this, 30 patients (15.3%) were under anticoagulant therapy, 19 of them (63.3%) with DOAC. Antiplatelet agents were taken by 48 patients (19%). From these, 5 (2.0%) presented DB following ESD, with a median time to bleeding of 11 days.
According to BEST-J score, bleeding risk was low (0-1 points) in 205 procedures (81,3%), intermediate (2 points) in 18 (7.1%), high (3-4 points) in 26 (10.3%) and very high (≥5 points) in 3 (1.2%).
BEST-J score presented an acceptable accuracy predicting DB in our sample, with an AUC=0.777 (p=0.034, CI 95%, 0.58-0.975). The optimal cut-off value to predict DB was a BEST-J score ≥ 3, which matches the cut-off value for high-risk of bleeding in the original investigation. This value had a sensitivity of 60.0%, specificity of 88.7% and a negative predictive value of 99.1%.

Conclusion

The BEST-J score presents an acceptable accuracy for post-ESD bleeding and it is particularly useful in identifying low risk DB patients. Therefore, this model is a good clinical decision-making support tool in the Western population.

Introduction

Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The Bleeding after ESD Trend from Japan (BEST-J) score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in non-Asiatic populations.

Aims & Methods

We aimed to apply and validate the BEST-J score on a European sample.
We have conducted a longitudinal study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as a hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion of ESD to 28 days after ESD.
BEST-J score (use of vitamin K antagonists +4, direct oral anticoagulants +4, aspirin or P2Y12R antagonists +2; withdrawing antithrombotic drugs -1; chronic kidney disease +3; multiple lesions +1; lesion ≥30mm +1; lesion in lower-third of the stomach +1) was calculated in each patient and confronted with the outcome (DB).

Results

Final sample included 161 patients, 102 (63.4%) male, with a mean age of 68±8 years. From these, 10 (6.2%) presented DB following ESD, with a median time to bleeding of 7 days (IQR 6.8).
According to BEST-J score, bleeding risk was low (0-1 points) in 111 (68.9%), intermediate (2 points) in 29 (18.0%), high (3-4 points) in 16 (9.9%) and very high (≥5 points) in 5 (3.1%) patients.
BEST-J score presented an excellent accuracy predicting DB in our sample, with an AUC=0.907 (95%CI=0.801-1.000; p<0.001). The optimal cut-off value to predict DB was a BEST-J score ≥3, which matches the cut-off value for high-risk of bleeding in the original investigation. This value had a sensitivity of 90% and specificity of 92%.

Conclusion

The BEST-J score still presents excellent accuracy in risk stratification for post-ESD bleeding in European individuals. Thus, this score may help to guide which patients benefit the most from prophylactic therapies following gastric ESD in this setting.

Introduction

In intraoperative bleeding during endoscopic submucosal dissection (ESD) by using a needle-tip type electrocautery knife, spray coagulation is considered helpful compared to swift coagulation. In this study, we compared the hemostatic effect of two coagulation modes (swift coagulation and spray coagulation) on intraoperative bleeding during gastric ESD in a propensity score analysis.

Aims & Methods

In an intraoperative bleeding strategy, we changed “swift-dependent” hemostasis to “spray-switching” one in 2021. Therefore, 202 bleeding events before April 2020 (33 lesions, Swift group) and 203 bleeding events after April 2022(36 lesions, Spray group) were consecutively collected. In the Swift group, hemostasis was attempted firstly by swift coagulation by using a retracted tip of the needle-type knife, and if hemostasis was not achieved, hemostatic forceps were used. In the Spray group, when hemostasis was attempted several times by swift coagulation but hemostasis was not achieved or when hemostasis was not expected by swift coagulation, spray coagulation was used. If hemostasis was not achieved by spray coagulation, hemostatic forceps were finally used. The two coagulation modes were determined by one endoscopist who retrospective observed the difference of sparks that occurred in hemostasis on video. We performed a post-hoc propensity score-matched analysis to compare the two groups.

Results

In comparison of patient background (age, gender, whether or not intraoperative antithrombotic medication was taken) and lesion background (site of lesion occupation, resection diameter, depth, presence or absence of ulcer, histological type, etc.) between the two groups, the larger number of patients in the Swift group had antithrombotic agents on ESD (p=0.016), while no significant differences were observed in other parameters. A propensity score matching was performed in defining intraoperative administration of antithrombotic agents, location, resection size, pathology, and presence or absence of ulcer as covariates. A total of 106 events were matched per event in the two group, respectively. There was no significant difference in the hemostatic duration per event in the two group (Swift vs. Spray: 48.2 sec. vs. 55.3 sec., p=0.22). The number of coagulations per event in the Swift group was less than that of Spray group (4.3 times vs. 5.8 times, p=0.008). The hemostatic forceps was significantly less frequently used in the Spray group than in the Swift group (31.1% vs. 17.0%, p=0.016). The cumulative success rate of hemostasis with electrocautery knives was likely to be higher in the Spray group (p=0.104), although there was no significant difference between the two groups. In the Swift group, two patients had postoperative hemorrhage and one patient had delayed perforation, whereas no adverse events were observed in the Spray group.

Conclusion

The data suggested that spray coagulation by the tip of the needle-type knife could reduce the use of hemostatic forceps. In gastric ESD, spray coagulation may facilitate the hemostasis of intraoperative bleeding.