Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection - An analysis of risk factors[*]

Background and study aim: Endoscopic submucosal dissection (ESD) has been reported to be associated with a higher complication rate than standard endoscopic mucosal resection. We aimed to clarify the risk factors for delayed bleeding after ESD for early gastric cancer (EGC).

Methods: 1083 EGCs in 968 consecutive patients undergoing ESD during a 4-year period were reviewed. Post-ESD coagulation (PEC) preventive therapy of visible vessels in the resection area, using a coagulation forceps, was introduced and mostly performed during the later 2 years. Various factors related to patients, tumors, and treatment including PEC were investigated using univariate and multivariate analysis with regard to delayed post-ESD bleeding, evidenced by hematemesis or melena, that required endoscopic treatment.

Results: Delayed bleeding occurred after ESD of 63 lesions (5.8 % of all lesions and 6.5 % of patients), controlled in all cases by endoscopic hemostasis; blood transfusion was required in only one case. Tumor location in the upper third of the stomach and PEC were independent factors indicating a lower rate of delayed bleeding according to both univariate and multivariate analysis.

Conclusions: This retrospective study suggested that preventive coagulation of visible vessels in the resection area after ESD may lead to a lower bleeding rate.

1 Presented at the 13th United European Gastroenterology Week, UEGW 2005, Copenhagen, Denmark, 15 - 19 October 2005.

References

• 1 Oda I, Gotoda T, Hamanaka H. et al . Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series.  Dig Endosc. 2005;  17 54-58
• 2 Eguchi T, Gotoda T, Oda I. et al . Is endoscopic one-piece mucosal resection essential for early gastric cancer?.  Dig Endosc. 2003;  15 113-116
• 3 Hirao M, Masuda K, Asanuma T. et al . Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine.  Gastrointest Endosc. 1988;  34 264-269
• 4 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 5 Gotoda T, Kondo H, Ono H. et al . A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions.  Gastrointest Endosc. 1999;  50 560-563
• 6 Yamamoto H, Kawata H, Sunada K. et al . Successful one-piece resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood.  Endoscopy. 2003;  35 690-694
• 7 Oyama T, Kikuchi , Y . Aggressive endoscopic mucosal resection in the upper GI tract - hook knife EMR method.  Min Invas Ther Allied Technol. 2002;  11 291-295
• 8 Yamamoto H, Kawata H, Sunada K. et al . Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate.  Gastrointest Endosc. 2002;  56 507-12
• 9 Miyamoto S, Muto M, Hamamoto Y. et al . A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms.  Gastrointest Endosc. 2002;  55 576-581
• 10 Minami S, Gotoda T, Ono H. et al . Complete endoscopic closure using endoclips for gastric perforation during endoscopic resection for early gastric cancer can avoid emergent surgery.  Gastrointest Endosc. 2008;  in press
• 11 Lin H-J, Lee F-Y, Kang W-M. et al . A controlled study of therapeutic endoscopy for peptic ulcer with non-bleeding visible vessel.  Gastrointest Endosc. 1986;  32 319-323
• 12 Chung S C, Leong H T, Can A C. et al . Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial.  Gastrointest Endosc. 1996;  43 591-595
• 13 Amano Y, Moriyama N, Suetsugu H. et al . Which types of non-bleeding visible vessels in gastric peptic ulcers should be treated by endoscopic hemostasis?.  J Gastroenterol Hepatol. 2004;  19 13-17
• 14 Okano A, Hajiro K, Takakuwa H. et al . Predictors of bleeding after endoscopic mucosal resection of gastric tumors.  Gastrointest Endosc. 2003;  57 687-690
• 15 Japanese Gastric Cancer Association . Japanese classification of gastric carcinoma. 2nd English edition.  Gastric Cancer. 1998;  1 11
• 16 Hirao M, Asanuma T, Masuda K. et al . Endoscopic resection of early gastric cancer following locally injecting hypertonic saline-epinephrine.  [In Japanese with English abstract.] Stomach Intest. 1988;  23 399-409
• 17 Narimiya N, Sato H, Joki M. et al . An experimental study of submucosal vascular structure of the stomach after endoscopic mucosal resection. [In Japanese with English abstract.]  Gastroenterol Endosc. 1994;  36 958-963

1 Presented at the 13th United European Gastroenterology Week, UEGW 2005, Copenhagen, Denmark, 15 - 19 October 2005.