Background:
Endoscopic Submucosal Dissection (ESD) in the rectum, while offering many advantages, has delayed complications such as bleeding and perforation. Some consider routine post-ESD overnight hospital observation to monitor for these complications. Prophylactic ESD defect closure has been suggested to reduce these complications. However, the benefit of prophylactic ESD defect closure in the rectum is still unclear. We aimed to determine if prophylactic rectal ESD defect closure will impact post-ESD outcomes.

Methods:
An international multicenter retrospective study (12 centers; 9 US, 1 Canada, 1 UK and 1 Italy) was performed on patients who underwent rectal ESD between 2016 and 2023. All procedures with intraprocedural perforations were excluded. Multiple risk factors associated with complications within 2 weeks of ESD and their relationship with defect closure were assessed. Chi-square, t-test, and Fisher’s exact were used, as appropriate. The p-value was set at <0.05. SPSS v29.0.1.0 was used.

Results:
A total of 385 patients were included in the study. Complete closure of ESD defect was performed in 166 (43%) patients. There were significantly higher pre-ESD polyp interventions (44% v 25%, p<0.01), higher traction use (20% v 12%, p=0.03), lower use of prophylactic hemostasis (20% v 49%, p<0.01), and smaller lesion size (4.2 cm v 5.1 cm, p<0.01) in the closure group compared to the open group (Table 1). Overall, post-ESD complications were observed in 21 (5.5%) patients. On logistic regression analysis, anticoagulant use (16% v 4%, p<0.01), NICE3 lesions (16% v 5%, p=0.04) and incomplete/hybrid resections (17% v 4%, p<0.01) were associated with a significantly higher number of post-ESD complications (Table 2). In these high-risk groups, ESD defect closure was associated with lower rate of complications. But those differences did not reach statistical significance (Table 3). While defect closure did not significantly reduce the rate of overall post-ESD complications (p=0.16), there were no delayed perforations in the closure group compared to 3 (1.3%) in the open group (Table 4). A significantly lower number of patients were kept for overnight observation in the hospital post-ESD in the closure group compared to the open group (17% v 37%, p<0.01).

Conclusions:
Prophylactic closure of rectal ESD defects leads to significantly less need for overnight observation post-ESD. Anticoagulant use, NICE 3 lesions and incomplete resections were associated with significantly higher risk of post-ESD complications within 2 weeks. While the overall post-ESD complications were not significantly reduced with defect closure, selective prophylactic closure of rectal ESD defects in high-risk groups will need to be further studied in larger samples.

Table 1

Tables 2-4

Michele Francesco Chiappetta

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