Continuous Infusion versus Intermittent Dosing with Pantoprazole for Gastric Endoscopic Submucosal Dissection

Abstract

Background/aims: Proton pump inhibitors are widely used to prevent gastric endoscopic submucosal dissection (ESD)-related bleeding, but no standard administration regimens have been established. We aimed to prospectively compare the effects of continuous infusion and intermittent dosing with pantoprazole on preventing gastric ESD-related bleeding. Additionally, we analyzed the risk factors for bleeding.

Methods: From April 2012 to May 2013, patients with a gastric epithelial neoplasm scheduled for ESD in the Pusan National University Hospital were randomly assigned to one of two groups according to the pantoprazole administration regimen (continuous infusion or intermittent dosing). The primary outcomes measured were intra- and postprocedural bleeding events.

Results: The final analysis included 401 patients. The rate of significant intraprocedural bleeding was 25.4% in the C group and 24.0% in the I group, with no significant difference (p=0.419). In addition, there was no significant difference in the postprocedural bleeding rate between the C and I groups (11.7% vs 10.2%, p=0.374). Multivariate analysis showed that intraprocedural bleeding was associated with the proximal tumor location, the presence of fibrosis, and the size of the resected specimen, whereas postprocedural bleeding was associated with the size of the resected specimen and the procedure/coagulation time.

Conclusions: Intermittent dosing with pantoprazole is sufficient and cost-effective for the prevention of gastric ESD-related bleeding. Operators should consider tumor characteristics when planning ESD to minimize the risk of intraprocedural bleeding, and patients with large iatrogenic ulcers should be carefully monitored for postprocedural bleeding.

Keywords: Endoscopic mucosal resection; Gastrointestinal hemorrhage; Proton pump inhibitors; Stomach neoplasms.

Fig. 1

Study design to assess the effect of pantoprazole administration regimen regarding the prevention of intra- and postprocedural bleeding in patients who underwent endoscopic submucosal dissection (ESD) for a gastric epithelial neoplasm. Patients were randomly assigned to one of two groups depending on the pantoprazole administration regimen, namely, continuous infusion (C-group) or intermittent dosing (I-group). POD, postoperative day; IV, intravenous; PO, per oral; q.d., once a day; b.i.d., twice a day.

Fig. 2

Flow diagram of enrollment, intervention allocation, and exclusions. ESD, endoscopic submucosal dissection; EGC, early gastric cancer; UGI, upper gastrointestinal; C-group, continuous pantoprazole infusion group; I-group, intermittent pantoprazole dosing group; PPI, proton pump inhibitor.