Combined prophylactic vessel coagulation and high-density complete defect closure after colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: The optimal strategy to prevent delayed bleeding after colorectal endoscopic submucosal dissection (ESD) remains unsettled, particularly for large defects with exposed submucosal vessels and an intact muscular layer. We evaluated whether combining prophylactic vessel coagulation with high-density complete defect closure improves safety outcomes.

METHODS

We analyzed consecutive colorectal ESDs performed over 44 months at 2 tertiary referral centers. Prophylactic vessel coagulation plus complete defect closure (using standard clips or advanced closure devices, including Mantis [Boston Scientific] and X-Tack [Boston Scientific] systems) was compared with cases receiving coagulation alone. Groups were matched 1:1 using propensity score matching based on age, American Society of Anesthesiologists score, antithrombotic use, defect size, and location. Cases with intraprocedural perforation, incomplete closure, or use of hemostatic gels or powders were excluded. The primary outcome was delayed bleeding. Secondary outcomes included composite delayed adverse events (DAEs), including bleeding, perforation, and postendoscopic submucosal dissection coagulation syndrome (PECS), and hospital readmission.

RESULTS

Eighty-seven matched pairs were analyzed with comparable baseline characteristics. The combined strategy significantly reduced delayed bleeding (0% vs 6.9%; P < .05) and composite DAEs (3.5% vs 12.7%; P < .05). Rates of delayed perforation (0% vs 2.3%) and PECS (3.5% vs 3.5%) were similar (P = not significant). All bleeding and PECS events were managed endoscopically or conservatively, whereas delayed perforations required surgery. Hospital readmissions were significantly lower in the closure group (4.6% vs 16.1%; P < .05).

CONCLUSIONS

Combining prophylactic vessel coagulation with high-density complete defect closure after colorectal ESD significantly reduces delayed bleeding, composite DAEs, and unplanned readmissions, supporting its role as an effective strategy to enhance post-ESD safety.