Risk factors for bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm

Background: Although endoscopic submucosal dissection (ESD) is standard therapy in Japan for gastric epithelial neoplasm, the complication rate is unsatisfactory, with postoperative bleeding as the major complication. The aim of the present study was to determine risk factors for post‐ESD bleeding in patients with gastric epithelial neoplasm. Patients and Methods: The study included 764 patients in whom 924 gastric epithelial neoplasms were resected endoscopically between June 2005 and December 2009: the period during which preventative coagulation for all exposed vessels on the artificial ulcer with hemostatic forceps upon completion of ESD was performed routinely. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors. Results: The post‐ESD bleeding rate was 3.0%. Dialysis (vs no dialysis, P = 0.034), operation time ≥75 min (vs <75 min, P = 0.012) and poor control of bleeding during ESD (vs good control, P = 0.014) were significantly related to post‐ESD bleeding. Poor control of bleeding during ESD (vs good control; P = 0.04) and operation time ≥75 min (vs <75 min; P = 0.012) were significantly related to bleeding after second‐look endoscopy. Conclusions: Patients at high risk for post‐ESD bleeding in gastric epithelial neoplasm were those undergoing dialysis, those in whom operation time was ≥75 min, and those in whom bleeding during ESD was poorly controlled. The latter two are risk factors for bleeding even after second‐look endoscopy.     

Second‐look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: A meta‐analysis

Background and Aims: In the management of peptic ulcer bleeding, the benefits of second‐look endoscopic treatment with thermal coagulation or injections in controlling recurrent bleeding is unsure. This study set out to compare efficacy of routine second‐look endoscopy with treatment using either thermal coagulation or injections versus single endoscopy by pooling data from published work. Methods: Full publications in the English‐language published work as well as abstracts in major international conferences were searched over the past 10 years, and six trials fulfilling the search criteria were found. Outcome measurements included: (i) recurrent bleeding; (ii) requirement of surgical intervention; and (iii) mortality. We examined heterogeneity of trials and pooled the effects by meta‐analysis. The quality of studies was graded according to the prospective randomization, methods of patient allocation, the list of exclusion criteria, outcome definitions and the predefined salvage procedures for uncontrolled bleeding. Results: Among 998 patients recruited in these five randomized trials, 119 received routine second‐look endoscopy with thermal coagulation, and 374 received second‐look with endoscopic injection and 505 had single endoscopic therapy. Less recurrent bleeding was reported after thermal coagulation (4.2%) than single endoscopy (15.7%) (relative risk [RR] = 0.29; 95% confidence interval [CI] = 0.11–0.73), but no reduction was reported for the requirement of surgical intervention and all‐cause mortality. Injection therapy did not reduce re‐bleeding (17.6%) when compared to single endoscopy (20.8%; RR = 0.85; 95% CI = 0.63–1.14), requirement for surgery and mortality. Conclusion: Routine second‐look endoscopy with thermal coagulation, but not injection therapy, reduced recurrent peptic ulcer bleeding. There is no proven benefit in reducing surgical intervention and overall mortality.     

Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for early gastric neoplasms: analysis of 1123 lesions

Background and Aim: Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of early gastric neoplasms; however, this advanced technique has also resulted in an increase in serious complications such as perforation and delayed bleeding. This study aimed to elucidate the risk factors for these complications. Methods: A total of 1123 lesions diagnosed with early gastric neoplasms and treated by ESD at three institutions were investigated. Retrospectively, patients with or without these complications were compared on the basis of the patient characteristics and treatment results. Results: Perforation occurred in 27 lesions (2.4%) and delayed bleeding in 56 lesions (5.0%). Multivariate analysis indicated that lesions located in the upper area of the stomach (odds ratio [OR]: 4.88, 95% confidence interval [CI]: 2.21–10.75) was associated with a significantly higher risk of perforation, and that age ≥ 80 years (OR: 2.15, 95% CI: 1.18–3.90) and a long procedure time (OR: 1.01, 95% CI: 1.001–1.007) were associated with a significantly higher risk of delayed bleeding after ESD. The en bloc resection rate (74% vs 94%) and curative resection rate (48% vs 85%) of lesions with perforation were significantly lower than those without perforation. The rate of residual disease or recurrence after ESD was significantly higher in lesions with delayed bleeding than that without delayed bleeding (5.4% vs 0.84%). Conclusions: This study demonstrated risk factors for perforation and delayed bleeding associated with ESD. Furthermore, it was clarified that perforation and delayed bleeding influenced post‐procedure results and prognosis after ESD.     

Prospective single-arm trial of two-week rabeprazole treatment for ulcer healing after gastric endoscopic submucosal dissection

Aim: Endoscopic submucosal dissection (ESD) causes artificial ulcers, and there is no consensus regarding the degree of healing in ESD‐induced ulcers or the optimal duration of proton pump inhibitor (PPI) treatment. The aim of the present study was to investigate the healing rates of post‐ESD ulcers in response to the protective effect of 2‐week PPI treatment. Methods: Between February 2007 and March 2010, 75 patients/75 lesions and 55 patients/55 lesions were enrolled as interim and per‐protocol groups, respectively. All patients were prescribed rabeprazole (10 mg/day) orally for 16 days beginning on the day before ESD. Follow‐up endoscopy was carried out 8 weeks after ESD to evaluate ulcer healing. The primary end‐point was the healing rate of post‐ESD ulcers at 8 weeks after ESD. Secondary end‐points were the rate of post‐ESD bleeding with emergency endoscopy and the rate of other severe adverse effects during the study period. Results: The transitional rate to scarring‐stage ulcers was 80.0% (44/55). Location in the lesser curve and large resected size (>40 mm) were statistically significant predictors for delayed ulcer healing by univariate analysis and the latter was still significant by the multivariate analysis. Post‐ESD bleeding occurred within 2 weeks in two cases (2.7%), but both cases were successfully managed with endoscopic hemostasis only. Severe adverse effects did not occur. Conclusions: Two‐week administration of PPI for post‐ESD gastric ulcers may be sufficient to aid healing without increasing any adverse effects in cases where there are no possible deteriorating factors on ulcer healing, although large resection and/or resection in the lesser curve may result in delayed healing even after 8 weeks of ESD.     

A Multicenter Survey of the Management After Gastric Endoscopic Submucosal Dissection Related to Postoperative Bleeding

Background and Aims

Bleeding is a major complication after gastric endoscopic submucosal dissection (ESD). An evidence-based strategy for postoperative care related to delayed bleeding is required. We conducted a multicenter survey to assess the current status of management after gastric ESD.

Methods

A total of 1,814 gastric epithelial neoplasms in 2009 at ten tertiary referral centers were enrolled. The current status of the management after gastric ESD (use of an antisecretory drug, food intake, and second-look endoscopy) at participating hospitals was assessed. Furthermore, the rate of post-ESD bleeding and the differences in each parameter were retrospectively analyzed.

Results

Postoperative bleeding occurred in 100 cases (5.5%), which included 62 cases of bleeding within 24?h after ESD. In all of the hospitals, proton pump inhibitors (PPIs) were used. The median administration period was 56?days (range 14?C60?days). Food intake was resumed from postoperative day (POD) 1 in 4 hospitals and from POD 2 in 6 hospitals. Second-look endoscopy was performed for almost all cases, fewer cases, and rarely or none in 6, 2, and 2 hospitals, respectively. The day of second-look endoscopy varied among hospitals. There was no statistical relationship between the postoperative bleeding rate and the differences in these three parameters.

Conclusions

Post-ESD management (duration of PPI use, resumption of food intake, and performance of second-look endoscopy) varied among the medical centers; thus, randomized controlled trials are required for an optimal strategy after gastric ESD.     

A systematic review of the effectiveness of smoking relapse prevention interventions for abstinent smokers

Aims To carry out a systematic review of the effectiveness of relapse prevention interventions (RPIs) among abstinent smokers who had completed an initial course of treatment or who had abstained unassisted, pooling only outcome data from similar follow‐up time points. Methods We used the same search strategy as was used in Cochrane reviews of RPIs to identify randomized trials of behavioural and pharmacological studies of smoking RPIs published up to July 2008. Abstinence from smoking was defined as either continuous abstinence or point prevalence abstinence, measured at three follow‐up time points: short term (1–3 months post randomization), medium term (6–9 months) and long term (12–18 months). Abstinence among pregnant/postpartum women was also measured at delivery or the last follow‐up prior to delivery. Random effect meta‐analysis was used to estimate pooled odds ratios (OR) with 95% confidence intervals (CI). Results Thirty‐six studies randomizing abstainers were included. Self‐help materials appeared to be effective in preventing relapse at long‐term follow up in initially unaided quitters (pooled OR 1.52; 95% CI 1.15 to 2.01, I2 = 0%, NNT = 11, 3 studies). Other behavioural interventions for relapse prevention appeared effective in the short term only. There were positive results for the use of pharmacotherapies for relapse prevention. Bupropion was effective at long‐term follow‐up (pooled OR 1.49; 95% CI 1.10 to 2.01; I2 = 0%; NNT = 11; 4 studies). Nicotine replacement therapy (NRT) was effective at medium‐term (pooled OR 1.56; 95% CI 1.16 to 2.11; I2 = 37%; NNT = 14; 4 trials) and long‐term follow‐ups (pooled OR 1.33; 95% CI 1.08 to 1.63; I2 = 0%; NNT = 20; 4 trials). Single trials of extended treatment of Varenicline and rimonabant were also found to be effective at short‐term and medium‐term follow‐ups. Conclusions Self‐help materials appear to prevent relapse in initially unaided quitters. Use of NRT, bupropion and varenicline appears to be effective in preventing relapse following an initial period of abstinence or an acute treatment episode. There is currently no good evidence that behavioural support prevents relapse after initial unaided abstinence or following an acute treatment period.     

Uninterrupted anticoagulation with non‐vitamin K antagonist oral anticoagulants in atrial fibrillation catheter ablation: Lessons learned from randomized trials

Catheter ablation has been established as a rhythm control strategy in selected patients with atrial fibrillation (AF) who have failed or wish to avoid anti‐arrhythmic drugs. Uninterrupted oral anticoagulation with vitamin K antagonists (VKAs) peri‐ablation is associated with a lower risk of thromboembolic and bleeding complications as compared to interrupted oral anticoagulation and bridging heparin. However, a substantial portion of patients with AF are treated with non‐vitamin K antagonist oral anticoagulants (NOACs). Herein, we perform an in‐depth review and comparison of three recent randomized trials of uninterrupted oral anticoagulation with NOACs vs VKAs in patients undergoing AF catheter ablation. Furthermore, we report pooled results of these randomized trials. The pooled incidence of major bleeding was significantly lower with NOACs as compared to VKAs (2% vs 4.9%, respectively; odds ratio [OR] 0.40; 95% confidence intervals [CI] 0.16‐0.99). Similarly, cardiac tamponade was also reduced in the NOAC group (0.4% vs 1.5%; OR 0.27; 95% CI 0.07‐0.97). Thromboembolic complications were not significantly different between groups. Overall, these findings support the 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement's class I recommendation for uninterrupted NOAC use in patients undergoing AF catheter ablation.     

Ruxolitinib‐associated infections: A systematic review and meta‐analysis

Ruxolitinib exerts immunosuppressive activity that may increase the risk of infectious complications. We performed a systematic review of the literature with the aim of estimating the risk of infections in patients treated with ruxolitinib. Studies were identified by electronic search of MEDLINE and EMBASE database. Differences in the incidence of infectious events between ruxolitinib and comparison groups were expressed as odds ratios (ORs) and 95% confidence intervals (95% CI). Five phase III randomized clinical trials (RCTs) (3 phase IIIa with their extended phase and 2 phase IIIb), 6 phase IV studies and 28 case reports were included in this systematic review. Ruxolitinib was associated with a statistically significant increased risk of herpes zoster infection compared to control group in 3 RCTs including patients with polycythemia vera (OR 7.39 [1.33, 41.07]) and in a pooled analysis of the extended phase IIIa RCTs (OR 5.20 [95%CI 1.27, 21.18]). In the larger phase IV post‐marketing study, the incidence of the most frequent infections was 8% for herpes zoster, 6.1% for bronchitis and 6% for urinary tract infections. In the published case reports, the most frequent infections were tuberculosis (N = 10), hepatitis B reactivation (N = 5) and pneumocystis jeroveci infection (N = 2). Evidence is not solid enough to accurately estimate the risk of infection in ruxolitinib‐treated patients. However, published data clearly suggest that the infection risk may be clinically relevant. Well‐designed studies are warranted to evaluate the risk of ruxolitinib‐associated infection, in order to identify the most appropriate antimicrobial prophylactic strategy.     

Is a Second-Look Endoscopy Necessary after Endoscopic Submucosal Dissection for Gastric Neoplasm?

Background/Aims

Second-look endoscopy is performed to check for the possibility of post-endoscopic submucosal dissection (ESD) bleeding and to perform prophylactic hemostasis in most hospitals; however, there is little evidence about the efficacy of second-look endoscopy. We investigated whether second-look endoscopy after ESD is useful in the prevention of post-ESD bleeding.

Methods

A total of 550 lesions with gastric epithelial neoplasms in 502 patients (372 men and 130 women) were treated with ESD between August 18, 2009 and August 18, 2010. After the exclusion of three lesions of post-ESD bleeding within 24 hours, 547 lesions (335 early gastric cancers and 212 gastric adenomas) were included for the final analysis.

Results

The occurrence rate of delayed post-ESD bleeding was not significantly different between the second-look group and the no second-look group (1% vs 2.5%, p>0.05). The only predictor of delayed bleeding was tumor size, regardless of second-look endoscopy after ESD (22.8±9.87 vs 15.1±10.47, p<0.05). There was no difference between the prophylactic hemostasis and nonprophylactic hemostasis groups, including the occurrence rate of delayed bleeding. In the second-look group with prophylactic hemostasis, the hospital stay was more prolonged than in the second-look group without prophylactic hemostasis, but there was no significant difference (p=0.08).

Conclusions

Second-look endoscopy to prevent delayed bleeding after ESD provides no significant medical benefits.     

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: A meta-analysis

Abstract

Objective. Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. Materials and methods. Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). Results. Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85–8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24–0.74, p < 0.01), and a trend for less units of blood transfused (WMD ?0.48; 95% CI ?0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. Conclusions. Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.     

Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis

BACKGROUND: Endoscopic therapy for GI bleeding is highly effective. Nevertheless, bleeding recurs in 10% to 25% of cases, irrespective of the method of treatment used. Whether a second-look endoscopy with retreatment after initial hemostasis is of clinical value is controversial. A meta-analysis was performed to assess whether systematic second-look endoscopy with retreatment reduces the risks of recurrent bleeding, salvage surgery, and death in patients with peptic ulcer bleeding. METHODS: A systematic review was performed of randomized controlled studies of the value of second-look endoscopy in patients with peptic ulcer bleeding published between 1990 and 2000. Four studies were selected according to predefined criteria. Two investigators extracted the data independently. Pooled risk estimates and number need to treat were calculated for each procedure. Heterogeneity of effects was tested. RESULTS: The absolute risk reduction in clinical recurrent bleeding was 6.2% (p < 0.01). Absolute risk reduction for surgery and mortality were, respectively, 1.7% and 1.0% (not significant). The second look with retreatment significantly reduced the risk of recurrent bleeding compared with control patients (OR 0.64; 95% CI [0.44, 0.95]; p < 0.01), with a number needed to treat of 16. There was no heterogeneity among studies. The risk of surgery as well as the risk of death were not significantly influenced by the second-look endoscopy with retreatment (number needed to treat, respectively, 58 and 97). CONCLUSIONS: Systematic second-look endoscopy with retreatment significantly reduces the risk of recurrent bleeding in patients with peptic ulcer bleeding compared with control patients, but it does not substantially reduce the risk of salvage surgery or mortality.     

Two-week treatment with proton pump inhibitor is sufficient for healing post endoscopic submucosal dissection ulcers

AIM:To investigate the optimum period of treatment for post endoscopic submucosal dissection(ESD)ulcers.METHODS:Patients who underwent ESD for gastric cancer were randomized to two groups and treated with esomeprazole 20 mg per day for 4 wk(4W group)or 2 wk(2W group).At 4 wk after ESD,we measured the size of the artificial ulcers by endoscopy and determined the ulcer healing rate,compared with the size of the ESD specimens.This randomized controlled trial study was approved by our ethics committee and registered in the UMIN Clinical Trial Registry.RESULTS:A total of 60 consecutive patients were included in the study.All patients received rebamipide 300 mg per day for 4 wk.One patient in 2W group who showed bleeding within two weeks and received endoscopic treatment was excluded from further analysis.The numbers of patients with ulcers in the healing/scar stage in the 2W and 4W groups at 4 wk after ESD were 20/6 and 28/5,respectively,with no significant difference.The ulcer healing rate in the 2W and 4W groups were 96.1%[95%confidence interval(CI):94.6%-97.55]vs 94.8%(95%CI:92.6%-97.1%),respectively,with no statistical difference(UMIN000006951).CONCLUSION:Two-wk treatment with a proton pump inhibitor is as effective as four-week treatment for healing post ESD ulcers.     

A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding

GOALS: We hypothesized that large volume gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding would improve the quality of endoscopic examination. BACKGROUND: Blood retained in the stomach can impair visualization during esophagogastroduodenoscopy. Patients with acute upper gastrointestinal bleeding and a retained gastric fundic pool during endoscopy may have worse outcomes than patients without a retained fundic pool. No trials to date have evaluated if large volume gastric lavage prior to endoscopy improves visualization during acute upper gastrointestinal bleeding. STUDY METHODS: Patients with acute upper gastrointestinal bleeding were randomized to esophagogastroduodenoscopy alone or large volume tap water gastric lavage prior to esophagogastroduodenoscopy. The quality of endoscopic visualization was assessed using a 5-point scale. Clinical outcomes were compared for lavaged and nonlavaged patients. RESULTS: A total of 39 patients were randomized. In 1 patient, lavage was unsuccessful. The quality of visualization was not significantly different between groups for the esophagus, gastric antrum, or duodenum but was significantly better for the gastric fundus for patients randomized to lavage (P = 0.02). There was no significant difference between groups for ability to define a bleeding source, achieve hemostasis, recurrent bleeding, need for repeat endoscopy, and length of stay or death. There were no complications. CONCLUSIONS: Large volume gastric lavage prior to esophagogastroduodenoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus.     

Administration of Erythromycin Before Endoscopy in Upper Gastrointestinal Bleeding: A Meta-analysis of Randomized Controlled Trials

Background/Aim:

Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB.

Methods:

Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration).

Results:

Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01).

Conclusions:

Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.     

Risk of Bleeding on Triple Antithrombotic Therapy After Percutaneous Coronary Intervention/Stenting: A Systematic Review and Meta-analysis

Background

There are no reported randomized controlled trials of triple antithrombotic therapy (TT; aspirin plus a thienopyridine plus vitamin K antagonist) vs dual antiplatelet therapy (DAPT; aspirin plus a thienopyridine) among patients undergoing percutaneous coronary intervention with stenting (PCI-S). A systematic review and meta-analysis was undertaken to assess the risk of bleeding among patients receiving TT after PCI-S.

Methods

Electronic databases were searched for studies reporting bleeding among patients receiving TT after PCI-S. Of the 4108 articles screened, 18 met study inclusion criteria and underwent detailed data extraction: of these, 6 reported in-hospital outcomes, 14 reported 30-day outcomes, and 9 reported 6-month outcomes. At each time point, pooled estimates of bleeding with TT were ascertained and where possible summary odds ratios (ORs) for comparative risks vs DAPT were calculated.

Results

The pooled estimate of major bleeding rate with TT post PCI-S was 2.38% by 30 days postprocedure (95% confidence interval [CI], 0.98-3.77%) and 4.55% by 6 months postdischarge (95% CI, 0.56-8.53%). At 30 days and 6 months the rates of major bleeding with TT were significantly higher than those observed with DAPT: OR, 2.38 at 30 days (95% CI, 1.05-5.38) and OR, 2.87 at 6 months (95% CI, 1.47-5.62).

Conclusions

This systematic review and meta-analysis of reports of triple therapy with a vitamin K antagonist, aspirin, and clopidogrel after PCI-S provides precise and valid bleeding risk data. Based on existing observational studies the rates of major and any bleeding associated with TT are clinically important and significantly greater than those reported with DAPT.     

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

Endoscopic submucosal dissection(ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy(SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.     

How I do it: Flexible 3‐D endoscope for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is technically challenging as a result of a lack of depth perception. The present article investigated the 3‐D endoscope for carrying out ESD and translated the technique from bench to clinical use. In a preclinical porcine experiment, ESD using a 3‐D endoscope was compared between an experienced and a novice endoscopist. All ESD were completed without perforation. Median operative time per surface area was significantly lower for the experienced endoscopist than for the novice (197.9 s/cm² vs 434.7 s/cm²; P = 0.05). The second part was a prospective clinical experience to evaluate use of the 3‐D endoscope for carrying out ESD. Ten patients received ESD using the 3‐D endoscope. Four patients had gastric ESD, two had duodenal ESD and four had sigmoid and rectal ESD. There were no complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Mean operative time was 99.4 min, and operative time per surface area resection was 391 s/cm². The operating endoscopist did not complain of motion sickness, whereas the assistants had some dizziness upon prolonged ESD procedure. This study showed that carrying out ESD was safe and effective using a 3‐D endoscope with an excellent 3‐D view enhancing depth perception. Future study should be conducted to compare 3‐D against 2‐D endoscopes for ESD.     

Management of gastric epithelial neoplasia in patients requiring esophagectomy for esophageal cancer

Esophageal squamous cell carcinoma is occasionally associated with malignancies located in other regions of the alimentary tract, as well as in the head, neck, and upper respiratory tract. The stomach is most commonly used for reconstruction of the alimentary tract after esophagectomy for esophageal cancer. When synchronous tumors are located in the stomach, it is often unsuitable for use in esophageal reconstruction. In such cases, an invasive procedure involving anastomosis between the esophagus and the colon must be performed. However, this procedure is associated with a high incidence of mortality and morbidity. Seven patients with synchronous esophageal cancer and gastric epithelial neoplasia were encountered. First, endoscopic submucosal dissection (ESD) was performed for the gastric epithelial neoplasia. Then, following successful ESD, Ivor‐Lewis esophagectomy for esophageal cancer was planned 1 to 2 weeks later. A total of 11 gastric epithelial lesions were found in seven patients. En bloc resection by ESD was possible in all 11 lesions and histologically complete resection was achieved in all 11 lesions. Follow‐up endoscopy was done 1–2 weeks after ESD; six patients with well‐healing ulcers underwent esophagectomy the next day (8 or 15 days after ESD). In one patient with a poorly healed ulcer, a second follow‐up endoscopy was done 1 week later and then esophagectomy was performed the next day (22 days after ESD). Post‐surgical complications related to ESD, such as bleeding or mediastinal leak, were not seen in any of the seven patients. In patients with synchronous esophageal cancer and gastric epithelial neoplasia, ESD for gastric epithelial neoplasia followed by Ivor‐Lewis esophagectomy 1 to 2 weeks later is an effective choice of treatment.     

Routine second look endoscopy: ineffective, costly and potentially misleading.

Despite the best medical and endoscopic efforts, some patients with nonvariceal upper gastrointestinal bleeding suffer recurrences. Because high risk stigmata (visible vessels, active bleeders and adherent clots) often persist despite apparently successful initial hemostasis and have a variable natural history, it would seem reasonable to at least consider a routine second look endoscopy. However, a review of the literature revealed six randomized trials that, in aggregate, do not support such a strategy. In fact, a second look does not appear to be effective and is associated with an increased number of procedures, treatment sessions and possibly retreatment-related complications. In addition, the cointerventions in these trials are already out of date and the potential absolute risk reductions are low when a second look is used with intravenous proton pump inhibitors and/or the application of endoscopic hemoclips or combination endoscopic therapy. Finally, the Forrest classification may provide dangerously misleading estimates of prognosis because it is being used out of context. This review critically analyzes routine second look endoscopy.     

Bleeding after endoscopic submucosal dissection of gastric lesions

Endoscopic submucosal dissection (ESD) is generally used to treat gastric mucosal and submucosal lesions. Nevertheless, ESD is more difficult and complicated to perform than a traditional endoscopic mucosal resection, which can increase the incidence of various complications including hemorrhage, perforation and infection. Hemorrhage is a major post‐ESD complication. Prevention and early diagnosis of post‐ESD bleeding for gastric lesions are closely associated with the efficacy and safety of the operation. Many studies have reported the risks of and the preventative measures for hemorrhage after gastric ESD, but there remain some issues to be solved. We thus reviewed the risk factors, precautions and treatments for hemorrhage after ESD of gastric lesions.