Risk-stratified evaluation of prophylactic strategies for delayed bleeding after gastric ESD: a multicenter retrospective study on clipping efficacy in the low-risk category

Background and study aims: Delayed bleeding (DB) remains a major complication after gastric endoscopic submucosal dissection (ESD), and risk-stratified preventive strategies are not well established. This study evaluated the efficacy of the modified search, coagulation, and clipping (MSCC) method and MSCC combined with polyglycolic acid sheets and fibrin glue (PMSCC) using the Bleeding after ESD Trend from Japan (BEST-J) score.

Patients and methods: We retrospectively analyzed 303 patients who underwent gastric ESD with MSCC or PMSCC between April 2018 and March 2024. DB was defined as bleeding requiring emergency endoscopic hemostasis or transfusion, or a hemoglobin decrease ≥ 2 g/dL. Observed DB rates were compared with threshold rates derived from the BEST-J score.

Results: In the low-risk category (MSCC/PMSCC: 237/0), no DB occurred in the MSCC group (0%; 95% confidence interval [CI]: 0.00–1.54%), with the upper CI limit below the threshold rate (2.8%). In the intermediate-risk category, DB occurred in one patient in the MSCC group (1/29; 3.4%; 95% CI: 0.08–17.8%), and no DB was observed in the PMSCC group (0/3; 0.0%; 95% CI: 0.00–70.8%); the confidence intervals overlapped the threshold rate (6.1%). In the high-risk category, DB occurred in 1/4 (25.0%; 95% CI: 0.63–80.6%) and 5/30 (16.7%; 95% CI: 5.6–34.7%) patients in the MSCC and PMSCC groups, respectively; neither the observed rate nor its confidence interval fell below the threshold rate (11.4%).

Conclusions: The MSCC method is an effective prophylactic strategy for preventing DB in the low-risk category as defined by the BEST-J score.

Keywords: gastric ESD, delayed bleeding, BEST-J score, prophylactic method.