Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions

Abstract

Aim: To assess risk factors for bleeding after gastric endoscopic submucosal dissection (ESD) and to develop preventive measures.

Methods: This retrospective study was performed in a tertiary referral center. A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009. The main outcome was association between post-ESD bleeding and the following: age; sex; comorbidities; daily use of medicine potentially related to gastric injury/bleeding; location, size, and histological depth of lesions; ulceration; experience of operator coagulating the ulcer floor, and duration of operation. We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.

Results: Univariate analysis revealed significant risk factors: tumor location [odds ratio (OR), 2.86; 95% CI: 1.21-6.79, P = 0.024], coagulator experience (OR, 4.29; 95% CI: 1.43-12.86, P = 0.009), and medicine potentially related to gastric injury/bleeding (OR, 2.80; 95% CI: 1.14-6.90, P = 0.039). Multivariate logistic regression analysis confirmed significant, independent risk factors: tumor in lower third of stomach (OR, 2.47; 95% CI: 1.02-5.96, P = 0.044), beginner coagulator (OR, 3.93; 95% CI: 1.29-11.9, P = 0.016), and medicine (OR, 2.76; 95% CI: 1.09-6.98, P = 0.032). We classified cases of post-ESD bleeding into two groups (bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts (OR, 16.00; 95% CI: 1.22-210.59, P = 0.040).

Conclusion: Beginner coagulators, tumor in the antrum, and medicines were significant risk factors for post-ESD bleeding. Bleeding at the ulcer margin frequently occurred with beginner operators.

Figures

Figure 1

Flow chart summarizing the cessation and restart of antithrombotic drugs in endoscopic submucosal dissection (ESD)[6]. Warfarin is discontinued before ESD and heparin is initiated if needed. PT-INR is checked 3 to 4 d later; if PT-INR ≤ 1.5, ESD can be performed. After surgery warfarin is immediately restarted, and heparin is co-administered in patients at high risk for disease. Antiplatelet drugs are discontinued before ESD as well (aspirin, 3 d before ESD; ticlopidine, 5 d before ESD); they are immediately restarted after the procedure. PT-INR: Prothrombin time-international normalized ratio.

Figure 2

The margin and center areas of the ulcer floor. The margin includes the outer 5 mm edge of the ulcer, and the remaining area is defined as the center.