Second-look endoscopy and factors associated with delayed bleeding after endoscopic submucosal dissection

Table 1 Influence of second-look endoscopy on the incidence of bleeding following endoscopic submucosal dissection

Ref.	Year	n	Study design	Bleeding:SLE vs no SLE (%)	Risk factors for delayed bleeding	SLE benefit
Ryu et al[17]	2013	182	Prospective, single center	16.2% vs 11.1%	No risk factors	No
Mochizuki et al[8]	2014	262	Prospective, Multicenter center	5.4% vs 3.8%	Resected specimen size > 40 mm	No
Kim et al[16]	2014	437	Prospective, single center	3.6% vs 2.8%	Large tumor size (> 20 mm)	No
Park et al[14]	2015	445	Retrospective	3.0% vs 2.0%	Tumor in the upper-third of the stomach, resected specimen size > 40 mm	No
Kim et al[15]	2015	502	Retrospective	1.0% vs 2.5%	Large tumor size (> 15 mm)	No

SLE: Second-look endoscopy.

Table 2 Incidence of delayed bleeding and associated risk factors after gastric endoscopic submucosal dissection

Ref.	Year	n	Study design	Bleeding (%)	Risk factors	Remarks
Takizawa et al[5]	2008	968	Retrospective	5.8% (7.1% vs 3.1% with PEC)	Tumor location in middle and lower regions of the stomach, PEC	PEC of visible vessels in the resected area follwing ESD may lead to a decreased bleeding rate
Chung et al[30]	2009	952	Retrospective	15.60%	Upper region, size of the tumor (> 40 mm), recurrent lesion, flat morphology	A significant bleeding incidence was at 0.6%
Okada et al[10]	2011	582	Retrospective	4.81%	Resected specimen width (≥ 40 mm)	Mechanism of delayed bleeding may differ depending on the time elapsed between ESD and bleeding episodes
Toyokawa et al[11]	2012	1123	Retrospective	5.00%	Age ≥ 80 yr, extended duration of procedure	-
Goto et al[9]	2012	1814	Retrospective	5.50%	No statistical parameters	Multicenter survey clarified that post-ESD management (duration of PPI use, resumption of food intake, and performance of SLE) varied among the medical centers
Koh et al[12]	2013	1032	Retrospective	5.30%	Size of resected specimen	The incidence of delayed bleeding in patients with two risk factors was 11.6%
Choi et al[3]	2014	614	Prospective observation	Early (3.7%) Late (1.9%)	(> 40 mm), use of antithrombotic drugs (only for delay bleeding) Surface erosion, high risk of stigmata during SLE, location in the middle of the stomach	Nausea and submucosal fibrosis increase the incidence of high risk of stigmata in SLE

PEC: Post-endoscopic submucosal dissection coagulation; ESD: Endoscopic submucosal dissection; PPI: Proton pump inhibitor; SLE: Second-look endoscopy.

Table 3 Antiplatelet medication and the risk of delayed bleeding

Ref.	Year	n	Design	Method	Comparison of bleeding incidence	Comments
Lim et al[32]	2012	1591	Retrospective	ESD	No antiplatelet medication: 5.2% Antiplatelet withdrawal: 5.9% Antiplatelet continuation: 11.6%	Continuous administration of antiplatelet medication was not found to have an independent significant association with bleeding
Cho et al[33]	2012	514	Retrospective	ESD	No aspirin medication: 3.4% Aspirin withdrawal: 3.6% Aspirin continuation: 21.1%	Continuous aspirin use increases the risk of bleeding after gastric ESD
Sanomura et al[35]	2014	94	Retrospective	ESD	Aspirin interruption: 7.1% Aspirin continuation: 4.8%	Continued use of aspirin does not increase the risk of bleeding during or after ESD
Tounou et al[34]	2015	377	Retrospective	ESD	No aspirin medication: 6.1% Aspirin continuation: 14.4% Single antiplatelet: 15.5% Dual antiplatelet: 35.5%	Aspirin was not a significant risk factor for post-ESD bleeding
Ono et al[36]	2015	28	Prospective, observational	ESD/EMR	The study was terminated in accordance with predetermined safety criteria because 7 of 28 consecutive patients experienced major bleeding complications (25.0%)	Subanalysis of gastric ESD (23 lesions in 19 patients) confirmed that the administration of thienopyridine derivatives (P = 0.01) and multiple agents (P = 0.02) were the significant factors Continuation of aspirin alone during these endoscopic procedures may be acceptable

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection.