title: Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD.
  
  
  METHODS
  Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I(2).
  
  
  RESULTS
  Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12).
  
  
  CONCLUSIONS
  Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.
authors.affiliation: Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.
authors.forename: Diogo
authors.initials: D
authors.lastname: Libânio
authors.affiliation: Gastroenterology Department, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
authors.forename: Mariana Nuno
authors.initials: MN
authors.lastname: Costa
authors.affiliation: Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal.
authors.forename: Pedro
authors.initials: P
authors.lastname: Pimentel-Nunes
authors.affiliation: Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal.
authors.forename: Mário
authors.initials: M
authors.lastname: Dinis-Ribeiro
mesh_terms: D000367:Age Factors; D002277:Carcinoma / Q000473:pathology / Q000601:surgery*; D000069916:Endoscopic Mucosal Resection; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005355:Fibrosis; D005753:Gastric Mucosa / Q000601:surgery; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology*; D005773:Gastroscopy; D006331:Heart Diseases / Q000453:epidemiology; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D008103:Liver Cirrhosis / Q000453:epidemiology; D009361:Neoplasm Invasiveness; D016017:Odds Ratio; D019106:Postoperative Hemorrhage / Q000453:epidemiology*; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology; D012307:Risk Factors; D024162:Second-Look Surgery; D012737:Sex Factors; D013272:Stomach Diseases / Q000453:epidemiology; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D013276:Stomach Ulcer / Q000453:epidemiology; D047368:Tumor Burden
chemical_list: D005343:Fibrinolytic Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors