The Myth and Truth about the Usefulness of Second-Look Endoscopy Following Endoscopic Submucosal Resection

We read with great interest the article “The need for secondlook endoscopy to prevent delayed bleeding after endoscopic submucosal dissection for gastric neoplasms: a prospective randomized trial” by Kim et al. The study was designed to evaluate whether the second-look endoscopy (SLE) strategy can reduce the delayed bleeding complication in patients who underwent endoscopic submucosal dissection (ESD) for gastric neoplasms. The study was well designed in prospective cohort and powered to answer the main question with a sample size of 441 patients. Study resulted in the delayed bleeding in 4.1%. The frequency of the delayed bleeding were not different between the SLE and non-SLE groups. Authors concluded that the SLE has no role in prevention of the delayed bleeding in ESD ulcers. Endoscopic hemostasis and neutralization of intragastric acidity are the two major tactics to heal the ulcer and prevent bleeding in both peptic and ESD ulcers. However, differences exist between the ESD and peptic ulcers. In the ESD ulcers, inflammatory infiltrates on ulcer base is minimal and fibrotic scarring is scarce. Underlying vascular network and mucosal integrity around the ESD ulcers are healthy and intact. The advance of endoscopic knives, hemostatic devices, electrosurgical units and technical skills further reduce the tissue injury the area of ESD. With these factors, we can reasonably consider ESD ulcer less risky for bleeding and better for healing than peptic ulcer. The question about SLE begins here. The intraprocedural or immediate bleeding are recognized easily and controlled promptly in in-hospital setting, but the delayed bleeding may occur in out-patients setting and need more attention. The incidence of the delayed bleeding is about 2.1% to 7.0% (Table 1). Factors including large mucosal defect,