Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

Abstract

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

Keywords: delayed bleeding; endoscopic closure; endoscopic submucosal dissection; hemostatic spray; polyglycolic acid; polymers.

Figure 1

Study identification and selection.

Figure 2

The efficacy of different endoscopic approaches for the prevention of delayed bleeding after gastric ESD, according to pair-wise meta-analysis: (A) Endoscopic closure group vs. control group [32,33,38,41]; (B) Tissue shielding group vs. control group [10,43,44,45,46]; (C) Hemostatic spray group vs. control group. Block and whisker: point estimate and 95% confidence interval (CI) of the primary study. Its relative size and proximity to the meta-analysis pooled estimate are proportional to primary study relative weight. Grey diamond: Pooled estimate of effect size. Its width corresponds to its 95% CI [19,52,53,55,56,57].

Figure 3

Network graph of the included studies: (A) in patients overall; (B) in high-risk patients; (C) in low-risk patients. The size of the node is proportional to the number of participants in the group (in (A), as the number of patients in the control group is much larger than the number in other groups, the control group node size is collapsed for graph neatness), and the width of the edge is proportional to the number of studies comparing two approaches.

Figure 4

The efficacy of different endoscopic approaches for the prevention of delayed bleeding after gastric ESD, according to network meta-analysis: (A) in patients overall; (B) in high-risk patients; (C) in low-risk patients.