Prophylactic Rectal ESD Defect Closure and Post-ESD Outcomes

The study explored the impact of prophylactic closure of rectal ESD (endoscopic submucosal dissection) defects on post-ESD outcomes, focusing on delayed adverse events (DAEs) and post-procedure hospitalization. Here are the key findings:

Study Details:

• Objective: To determine whether closing rectal ESD defects prophylactically improves short-term clinical outcomes, particularly reducing delayed bleeding, perforation, and hospitalization.
• Population: 385 patients who underwent rectal ESD between 2016 and 2023 across 12 centers in North America and Europe. Patients with intraprocedural perforation were excluded.
• Intervention: Defect closure was achieved in 166 patients (43%) using techniques like endoscopic suturing, clips, or other closure devices.
• Outcome Measures: Delayed adverse events (DAEs) — defined as bleeding or perforation within two weeks — and post-procedure hospitalization rates were analyzed.

Key Findings:

1. Delayed Adverse Events (DAEs):

• Overall, DAEs occurred in 5.5% of patients.
• Risk factors for DAEs included chronic anticoagulant use, NICE 3 lesions (high-risk features), and incomplete resections.
• Prophylactic defect closure did not significantly reduce the overall rate of DAEs compared to leaving defects open.
• Delayed perforations were observed exclusively in the open-defect group, while no perforations occurred in patients with closed defects.

2. Hospitalization and Recovery:

• Patients with defect closure had significantly lower rates of overnight hospital admission or observation following ESD.
• This suggests that defect closure may improve post-procedure recovery and reduce healthcare resource utilization.

3. High-Risk Subgroups:

• In patients with higher risk factors (e.g., anticoagulant use or challenging lesions), defect closure showed a numerical reduction in DAEs, though the difference was not statistically significant.

Clinical Implications:

• Routine Closure: The study indicates that prophylactic closure may not be necessary for all rectal ESD cases.
• Selective Closure: Closure is recommended for high-risk patients (e.g., those on anticoagulants or with high-risk lesions) to reduce complications like delayed perforation and hospitalization.

Conclusion:

Prophylactic closure of rectal ESD defects has nuanced benefits. While it may not universally reduce delayed adverse events, it prevents delayed perforation and improves post-procedure recovery, particularly in high-risk patients. The findings suggest a tailored approach, focusing on selective closure for patients with elevated risk profiles to optimize outcomes and resource utilization.