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

Abstract

Background 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 (8.0%). The Korean score performed poorly in our cohort, with a receiver operating characteristic (ROC) curve of 0.567. In the multivariate analysis, risk factors were age ≥75 years (odds ratio [OR] 1.63; 95%CI 0.97–2.73; 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 >50 mm (OR 3.67; 95%CI 2.02–7.14; 3 points), and American Society of Anesthesiologists (ASA) score of III or IV (OR 2.26; 95%CI 1.32–3.92; 2 points). The model showed fair calibration and good discrimination, with an area under the 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 risk (0 to 4 points) and high risk (5 to 8 points) for CSDB (respective bleeding rates 4.1% and 17.5%).

Conclusion A score based on five simple and meaningful variables was predictive of CSDB.

Publication History

Received: 30 March 2023

Accepted after revision: 10 October 2023

Accepted Manuscript online:
10 October 2023

Article published online:
20 December 2023

• References

• 1 Saito H, Igarashi K, Hirasawa D. et al. The risks and characteristics of the delayed bleeding after endoscopic submucosal dissection for early gastric carcinoma in cases with anticoagulants. Scand J Gastroenterol 2020; 55: 1253-1260
• 2 Boda K, Oka S, Tanaka S. et al. Clinical outcomes of endoscopic submucosal dissection for colorectal tumors: a large multicenter retrospective study from the Hiroshima GI Endoscopy Research Group. Gastrointest Endosc 2018; 87: 714-722
• 3 Bordillon P, Pioche M, Wallenhorst T. et al. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021; 94: 333-343
• 4 Probst A, Ebigbo A, Märkl B. et al. Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center. Endoscopy 2017; 49: 222-232
• 5 Seo M, Song EM, Cho JW. et al. A risk-scoring model for the prediction of delayed bleeding after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2019; 89: 990-998.e2
• 6 Burgess NG, Bassan MS, McLeod D. et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2017; 66: 1779-1789
• 7 Pimentel-Nunes P, Libânio D, Bastiaansen BAJ. et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54: 591-622
• 8 Lugli A, Kirsch R, Ajioka Y. et al. Recommendations for reporting tumor budding in colorectal cancer based on the International Tumor Budding Consensus Conference (ITBCC) 2016. Mod Pathol 2017; 30: 1299-1311
• 9 Veitch AM, Radaelli F, Alikhan R. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53: 947-969
• 10 Steyerberg EW. Statistical models for prediction. In: Steyerberg EW. Clinical prediction models: a practical approach to development, validation, and updating. New York, NY: Springer; 2009: 53-82
• 11 Albéniz E, Fraile M, Ibáñez B. et al. A scoring system to determine risk of delayed bleeding after endoscopic mucosal resection of large colorectal lesions. Clin Gastroenterol Hepatol 2016; 14: 1140-1147
• 12 Conti Bellocchi MC, Crinò SF, Fioravante M. et al. Development and validation of a risk score for prediction of clinical success after duodenal stenting for malignant gastric outlet obstruction. Expert Rev Gastroenterol Hepatol 2022; 16: 393-399
• 13 Moons KGM, Harrell FE, Steyerberg EW. Should scoring rules be based on odds ratios or regression coefficients?. J Clin Epidemiol 2002; 55: 1054-1055
• 14 Collins GS, Reitsma JB, Altman DG. et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BMJ 2015; 350: g7594
• 15 Burgess NG, Metz AJ, Williams SJ. et al. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12: 651-661.e1–3
• 16 Jacques J, Wallenhorst T, Chevaux J-B. et al. Endoscopic submucosal dissection (ESD) versus piece-meal endoscopic mucosal resection (PM-EMR) for large laterally spreading lesions: French randomized controlled trial Resect-Colon. Gastrointestinal Endoscopy 2022; 95: AB138
• 17 Kobara H, Tada N, Fujihara S. et al. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: literature review over one decade. Dig Endosc 2023; 35: 216-231
• 18 Ogasawara N, Yoshimine T, Noda H. et al. Clinical risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal tumors in Japanese patients. Eur J Gastroenterol Hepatol 2016; 28: 1407-1414
• 19 Suzuki S, Chino A, Kishihara T. et al. Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms. World J Gastroenterol 2014; 20: 1839-1845
• 20 Terasaki M, Tanaka S, Shigita K. et al. Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms. Int J Colorectal Dis 2014; 29: 877-882
• 21 Albéniz E, Gimeno-García AZ, Fraile M. et al. Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions. Gastrointest Endosc 2020; 91: 868-878.e3
• 22 Gupta S, Sidhu M, Shahidi N. et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7: 152-160
• 23 Pohl H, Grimm IS, Moyer MT. et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; 157: 977-984.e3
• 24 Albéniz E, Álvarez MA, Espinós JC. et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 2019; 157: 1213-1221.e4
• 25 Bi D, Zhang LY, Alqaisieh M. et al. Novel through-the-scope suture closure of colonic endoscopic mucosal resection defects. Gastrointest Endosc 2023;
• 26 Abe S, Saito Y, Tanaka Y. et al. A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study. Endoscopy 2020; 52: 780-785
• 27 Farha J, Ramberan H, Aihara H. et al. A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study. Endoscopy 2023;
• 28 Jung DH, Moon HS, Park CH. et al. Polysaccharide hemostatic powder to prevent bleeding after endoscopic submucosal dissection in high risk patients: a randomized controlled trial. Endoscopy 2021; 53: 994-1002