Ikeda Ryosuke, Hirasawa Kingo, Sato Chiko, Ozeki Yuichiro, Sawada Atsushi, Nishio Masafumi, Fukuchi Takehide, Kobayashi Ryosuke, Makazu Makomo, Taguri Masataka, Maeda Shin
Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan.
Endoscopy Division, Yokohama Medical University Center Hospital, Yokohama 232-0024, Japan.
World J Gastroenterol. 2020 Nov 7;26(41):6475-6487. doi: 10.3748/wjg.v26.i41.6475.
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, = 0.005], while the late-and early-onset PDB rates (L-PDB and E-PDB) were 5.3% [90%CI: 2.7-9.9, < 0.0001] and 2.6% [90%CI: 1.1-6.4, = 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% 20.7%, = 0.12), whereas L-PDB occurrence significantly differed (5.2% 17.2%, = 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% 23.1% and 5.0% 29.4%, respectively).
TLE for gastric ESD reduces overall PDB, and especially L-PDB incidence, among patients receiving antithrombotics.
即使进行二次内镜检查，接受抗栓治疗的患者在胃内镜黏膜下剥离术（ESD）后发生术后延迟出血（PDB）仍是最常见的不良事件。此外，随着老龄化人口中心血管和脑血管疾病以及相关生活方式相关疾病患病率的增加，接受抗栓治疗的患者数量也在增加。已经进行了几次尝试来预防老年人群中的PDB；然而，尚未达成共识。
研究第三次内镜检查（TLE）预防PDB的疗效。
前瞻性纳入100例接受抗栓治疗的早期胃肿瘤患者，并于2017年2月至2019年7月期间接受ESD及TLE。主要终点是PDB发生率，并与我们预设的阈值进行比较。此外，我们将出血期分为早期和晚期PDB（分别为E-PDB和L-PDB）并分析其发生率。作为次要分析，我们使用倾向评分匹配将PDB发生率与历史对照组进行比较，并计算每组中每种抗栓药物使用的PDB发生率。
总共最终评估了96例患者和114个标本。总体PDB发生率为7.9%（9/114）[90%CI：4.7-13.1，P = 0.005]，而晚期和早期PDB发生率（L-PDB和E-PDB）分别为5.3%[90%CI：2.7-9.9，P < 0.0001]和2.6%[90%CI：1.1-6.4，P = 0.51]。倾向评分匹配为TLE组和对照组生成了58对匹配对。总体PDB发生率无差异（10.3%对20.7%，P = 0.12），而两组之间L-PDB的发生有显著差异（5.2%对17.2%，P = 0.04）。考虑抗栓药物的使用，对照组中直接口服抗凝剂和多种抗栓药物的总体PDB发生率较高，而TLE组中这些药物的L-PDB发生率较低（分别为8.7%对23.1%和5.0%对29.4%）。
对于接受抗栓治疗的患者，胃ESD的TLE可降低总体PDB发生率，尤其是L-PDB发生率。
