ИСТИНА

The presenter is Fedorov ED. INTRODUCTION: The benefit of postoperative EGD in order to control/prevent bleeding after endoscopic resection (ER) of gastric and duodenal tumors is still debatable. AIMS & METHODS: The aim of this ongoing study is to evaluate whether second-look endoscopy (SLE) and haemostatic endoclipping is essential to prevent delayed gastrointestinal bleeding (GIB) after ER. A total of 35 patients (m-9, f-26, mean age M±s 68,3 ± 8,2 years) who underwent ER for gastric (31) and duodenal (4) tumors: endoscopic mucosal resection (EMR) – 20(57,2%), endoscopic submucosal dissection (ESD) – 9(25,7%), removal of submucosal tumor (RST) – 6(17,1%) from November 2012 to April 2014 were included in this study. All patients were randomly divided into 2 comparable groups. After ER the patients of both groups received antisecretory therapy with proton pump inhibitors (PPI): the first 3 days - pantoprazole 80 mg intravenously, the next 4 weeks - pantoprazole 80 mg per day orally. Each SLE was performed next day after the ER; endoscopic hemoclipping (EHC) was used to prevent GIB. In the group 1 (IPP+EHC) (19 pts.) endoscopic hemostasis (EH) was performed in all cases of visible vessels on the bottom and margins of the mucosal defect. In the group 2 (IPP alone) (16 pts.) EH was performed only in exceptional situations - at active bleeding or extremely high risk of bleeding (major vessels exposed on the mucosal defect). ER was performed under general anesthesia in 26 cases and local - in 9 cases. Coagulating forceps FD-410LR and argon plasma coagulation probe with electrocoagulator VIO 300 were used for hemostasis. Moreover, at the final stage clip fixing device HX-110LR with clips HX-610- 135 was applied for the prevention of GIB. RESULTS: EH at the final step of ER was performed in 52.6% (10/19) patients of Group 1 and 56.3% (9/16) patients of Group 2. The mean size of mucosal defects after ER was 21.2±14.9 mm and 25.3±18.1 mm respectively. All patients underwent SLE at the second day after the ER. In Group 1 EH was performed in 7 patients with stigmata, including 2 patients with vessel’s size more than 1.5 mm. In Group 2 only one patient had exposed major vessels on the bottom of the postoperative defect after removal of a large villous duodenal tumor that required prophylactic placement of hemoclips. Only one 60-year-old female patient (5,3% from Group 1) had mild GIB on the second day after ESD for ulcerated tubulovillous adenoma of the stomach. It is remarkable that this complication occured a few hours after preventive endoclipping of all thrombosed vessels during SLE. The patient had a malignant course of hypertonic disease. In our opinion, an uncontrolled sharp increase in blood pressure was the main cause of postoperative bleeding. After succesfully perfomed EH the patient recovered on the background of intensified therapy for hypertention and doubled antisecretory therapy. CONCLUSION: According to our preliminary data SLE with prophylactic clipping after ER for gastric and duodenal tumors has no significant impact on the frequency of postoperative GIB. SLE is feasible in selected patients with large postoperative mucosal defects after the wide excision of the tumor.