Vessel coagulation in third-space endoscopy: a randomized controlled trial

Background: Third-space endoscopy is standard practice for neoplastic and motility disorders; however, it carries a high risk of intraprocedural bleeding. Such risk may be reduced by prophylactic coagulation of submucosal vessels, but this requires instrument exchange. A new approach involves pre-sealing submucosal vessels under saline immersion using standard electrocautery settings and the same knife. Methods: Patients undergoing third-space procedures (endoscopic submucosal dissection or peroral endoscopic myotomy) were randomized to receive either targeted saline-immersion pre-sealing (intervention group) or conventional coagulation (carbon dioxide insufflation, control group) for prophylactic management of vessels ≥1.2 mm. Dissection settings were identical. Rate of per-patient intraprocedural bleeding requiring re-treatment for vessels ≥1.2 mm was the main outcome. Per-vessel analyses were also performed. The use of an adjunctive device and coagulation time were also assessed. Results: 70 patients (37 immersion, 33 control) with 864 ≥1.2-mm vessels were included. Saline-immersion pre-sealing significantly reduced bleeding rates: per patient (32.4% vs. 75.8%; relative risk [RR] 0.43, 95%CI 0.26-0.71; number needed to treat [NNT] 2.3; P < 0.01); per vessel (6.3% vs. 29.9%; RR 0.21, 95%CI 0.14-0.31; NNT 4.2; P < 0.01). Use of coagulation forceps for bleeding treatment also decreased (0% vs. 24.2% and 0% vs. 8.3%; P < 0.01). A significant reduction in mean (SD) coagulation time was reported in the saline-immersion group (22.7 [26.4] vs. 29.6 [49.8] seconds; P < 0.01). Conclusions: A substantial reduction in the risk of intraprocedural bleeding was achieved by saline-immersion pre-sealing in per-patient and per-vessel analyses, prompting its implementation in clinical practice.