Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6475
Peer-review started: June 26, 2020
First decision: September 12, 2020
Revised: September 22, 2020
Accepted: October 20, 2020
Article in press: October 20, 2020
Published online: November 7, 2020
Postoperative delayed bleeding (PDB) after gastric endoscopic submucosal dissection (ESD) is the most common adverse event in patients receiving antithrombotics even with second-look endoscopy. Moreover, with the increasing prevalence of cardiovascular and cerebrovascular diseases in an aging population with associated lifestyle-related diseases, an increasing number of patients receive antithrombotics. Several attempts have been made to prevent PDB in aging population; however, a consensus has yet to be reached.
To examine the efficacy of third-look endoscopy (TLE) for PDB prevention.
One hundred patients with early gastric neoplasms receiving antithrombotics were prospectively enrolled and subjected to ESD with TLE between February 2017 and July 2019. The primary endpoint was PDB rate, which was compared with our preset threshold. Furthermore, we divided the bleeding period into early-and late-onset PDB (E-PDB and L-PDB, respectively) and analyzed its rate. As a secondary analysis, we compared PDB rates with those of a historical control group, using propensity score matching, and calculated the PDB rates per antithrombotic agent use in each group.
In total, 96 patients and 114 specimens were finally evaluated. The overall PDB rate was 7.9% (9/114) [90%CI: 4.7-13.1, P = 0.005], while the late-and early-onset PDB rates (L-PDB and E-PDB) were 5.3% [90%CI: 2.7-9.9, P < 0.0001] and 2.6% [90%CI: 1.1-6.4, P = 0.51], respectively. Propensity score matching generated 58 matched pairs for TLE and control groups. No differences were found in overall PDB incidence (10.3% vs 20.7%, P = 0.12), whereas L-PDB occurrence significantly differed (5.2% vs 17.2%, P = 0.04) between groups. Considering antithrombotics’ use, the overall PDB rate was higher for direct oral anticoagulants and multiple antithrombotics in the control group, while L-PDB incidence was lower in the TLE group for these agents (8.7% vs 23.1% and 5.0% vs 29.4%, respectively).
TLE for gastric ESD reduces overall PDB, and especially L-PDB incidence, among patients receiving antithrombotics.
Core Tip: The major adverse event after endoscopic submucosal dissection for early gastric cancer under antithrombotic therapy is post-operative delayed bleeding (PDB). We verified the effectiveness of third-look endoscopy (TLE) before discharge in a phase II trial. Our results suggest that TLE significantly reduced PDB incidence among patients who continued to receive antithrombotic drugs. We concluded that TLE which is manageable for every endoscopist is a simple and effective method for preventing PDB under antithrombotic therapy.