Prospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 7, 2020; 26(41): 6475-6487
Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6475
Third-look endoscopy prevents delayed bleeding after endoscopic submucosal dissection under antithrombotic therapy
Ryosuke Ikeda, Kingo Hirasawa, Chiko Sato, Yuichiro Ozeki, Atsushi Sawada, Masafumi Nishio, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Masataka Taguri, Shin Maeda
Ryosuke Ikeda, Chiko Sato, Yuichiro Ozeki, Atsushi Sawada, Masafumi Nishio, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
Kingo Hirasawa, Endoscopy Division, Yokohama Medical University Center Hospital, Yokohama 232-0024, Japan
Masataka Taguri, Department of Data Science, Yokohama City University School of Data Science, Yokohama 236-0004, Japan
Shin Maeda, Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
Author contributions: Hirasawa K and Ikeda R contributed to conception and design; Hirasawa K, Ikeda R, Ozeki Y, Sawada A, Nishio M, Fukuchi T, Kobayashi R, Makazu M, and Sato C contributed to acquisition of data; Hirasawa K and Ikeda R contributed to analysis and interpretation of data; Hirasawa K contributed to drafting of the article; Hirasawa K and Maeda S contributed to critical revision of the article; Hirasawa K, Ikeda R, and Taguri M contributed to statistical analysis; Hirasawa K and Maeda S approved the final draft of the article; all authors listed have contributed substantially to the design, data collection and analysis, and editing of the manuscript.
Institutional review board statement: The research ethics committee in our hospital approved this research (Approval number: B170800063) in December 2016.
Clinical trial registration statement: The study was registered at UMIN Clinical Trials Registry System, using identifier 000025607. Details can be found at
Informed consent statement: All patients enrolled in this study provided written informed consent before undergoing endoscopic submucosal dissection.
Conflict-of-interest statement: The authors of this manuscript have no conflicts of interest to disclose.
Data sharing statement: There is no additional data available.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Kingo Hirasawa, MD, PhD, Chief Doctor, Endoscopy Division, Yokohama Medical University Center Hospital, 4-57, Urafune-cho, Minami-ku, Yokohama 232-0024, Japan.
Received: June 26, 2020
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
Research background

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is minimally invasive and the gold standard for treatment for endoscopic resection. However, the problem of postoperative delayed bleeding (PDB) as a major adverse event remains.

Research motivation

The PDB rate under antithrombotic therapy (ATT) is higher than non-ATT and the bleeding period tends to be a late phase. Despite several attempts against PDB have been reported, there are no effective preventive methods yet.

Research objectives

We attempted to verify the efficacy of third-look endoscopy (TLE) against PDB in patients under ATT.

Research methods

This is a prospective study in a single center. We enrolled patients with EGC receiving ATT, and TLE was added to conventional ESD, including second-look endoscopy. Additionally, we compared the PDB rate with that of a historical control group subjected to conventional ESD under ATT, using propensity score matching.

Research results

The PDB rate of patients adding TLE was lower than the threshold which we set, and it was significantly lower, especially late-onset PDB (L-PDB). Regarding the comparison with the historical control group, the L-PDB rate in the TLE group was lower.

Research conclusions

TLE is a simple method that reduces the overall PDB, especially L-PDB, in patients under ATT and is widely acceptable by endoscopists.

Research perspectives

This study is not a randomized controlled trial (RCT); therefore, we consider it necessary to investigate RCT against a larger patient sample.