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Controlled hypertension under hemostasis prevents post-gastric endoscopic submucosal dissection bleeding: a prospective randomized controlled trial

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Abstract

Background

Endoscopic submucosal dissection (ESD) is a prominent minimally invasive operative technique for treating early gastrointestinal tumors but can result in postoperative bleeding. We conducted a randomized controlled trial to determine whether increasing blood pressure under hemostasis during gastric ESD to identify potential bleeding spots reduces the risk of post-ESD bleeding.

Methods

In this randomized, controlled, single-blinded clinical trial, 309 patients with early gastric cancer who were admitted to a hospital to undergo ESD were recruited from March 2017 to February 2018 and were randomized into intervention and control groups. In the control group, patients underwent normal ESD. In the intervention group, we increased patients’ blood pressure to 150 mmHg for 5 min using a norepinephrine pump (0.05 μg/kg/min initial dose) after the specimen was extracted during the ESD operation to identify and coagulate potential bleeding spots with hot biopsy forceps. Our primary outcome was the incidence of postoperative bleeding over 60-day follow-up.

Results

The incidence of post-ESD bleeding was lower in the intervention group (1.3%, 2/151) than in the control group (10.1%, 16/158, p = 0.01). Deeper tumor invasion was associated with a higher risk of post-ESD bleeding (5.3% in mucosal/submucosal layer 1 group vs. 12.5% in submucosal layer 2/muscularis propria group, p < 0.001). Multi-factor but not univariate analysis showed that proton pump inhibitor administration three times per day may be a better choice than twice per day.

Conclusion

Increasing blood pressure under hemostasis during ESD to identify and coagulate potential bleeding spots could reduce the risk of delayed bleeding after gastric ESD.

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Funding

This study was supported by the grants from the Natural Science Foundation of Shanghai (Grant No. 18441901100) and the National Natural Science Foundation of China (Grant No. 82000623).

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Author notes

  1. Sheng-Li Lin, Ping-Ting Gao and Wen-Kai Ni shared co-first authorship.

Authors and Affiliations

  1. Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People’s Republic of China

    Sheng-Li Lin, Ping-Ting Gao, Wen-Kai Ni, Quan-Lin Li, Wei-Feng Chen, Yi-Qun Zhang, Jian-Wei Hu, Wen-Zheng Qin, Ming-Yan Cai, Zhong Ren, Yun-Shi Zhong, Li-Qing Yao, Shi-Yao Chen, Li-Li Ma & Ping-Hong Zhou

  2. Endoscopy Center, East Hospital, Tongji University School of Medicine, Shanghai, China

    Mei-Dong Xu

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Correspondence to Li-Li Ma or Ping-Hong Zhou.

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Disclosures

Drs. Sheng-Li Lin, Ping-Ting Gao, Wen-Kai Ni, Quan-Lin Li, Wei-Feng Chen, Yi-Qun Zhang, Jian-Wei Hu, Wen-Zheng Qin, Ming-Yan Cai, Zhong Ren, Yun-Shi Zhong, Li-Qing Yao, Shi-Yao Chen, Mei-Dong Xu, Li-Li Ma, and Ping-Hong Zhou have no conflicts of interest or financial ties to disclose.

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Lin, SL., Gao, PT., Ni, WK. et al. Controlled hypertension under hemostasis prevents post-gastric endoscopic submucosal dissection bleeding: a prospective randomized controlled trial. Surg Endosc 35, 5675–5685 (2021). https://doi.org/10.1007/s00464-020-08256-2

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