A preoperative risk-scoring model for predicting intraoperative hemorrhage during endoscopic submucosal dissection...

Intraoperative hemorrhage is the most frequent complication of endoscopic submucosal dissection (ESD). We aim to develop and externally validate a preoperative risk-scoring model for predicting intraoperative hemorrhage during ESD for gastric neoplasms.

Patients who underwent ESD for gastric neoplasms from four endoscopy centers were enrolled in this retrospective study, with 1123 patients in derivation cohort and 345 patients in validation cohort. In derivation cohort, univariable and multivariable logistic regression analysis were used to identify independent preoperative predictors of intraoperative hemorrhage. A risk-scoring model was created by assigning weighted points to selected predictors. External validation was conducted to analyse the discrimination and calibration of the prediction model.

A prediction model for intraoperative hemorrhage included 5 variables: upper-third location (5 points), large lesion size (≥ 25 mm) (4 points), current HP infection (3 points), junior endoscopist (3 points) and middle-third location (2 points). Patients were stratified into low- (0-2 points), intermediate- (3-4 points), high- (5-6 points), and very high-risk (≥ 7 points) groups, with corresponding bleeding rates of 4.8%, 35.9%, 80.2% and 98.5%, respectively. In external validation cohort, the model showed excellent discrimination, with a c-statistic of 0.96 (95% CI 0.95-0.98), and good calibration (calibration-in-the-large, - 0.04; calibration slope, 0.94).

We developed a preoperative risk-scoring model to predict intraoperative hemorrhage of ESD for gastric neoplasms. For lesions of large size or located on the upper-third of the stomach, ESD should be performed by senior endoscopists after successful HP eradication to minimize the occurrence of bleeding.