Metachronous gastric neoplasm beyond 5 years after endoscopic resection for early gastric cancer.

BACKGROUND AND AIMS: The natural course of early gastric cancer (EGC) following endoscopic submucosal dissection (ESD) remains unclear. This study aimed to clarify the long-term clinical outcomes and risk factors of metachronous gastric neoplasm (MGN) 5 years after ESD for EGC. METHODS: We performed a retrospective analysis of patients who underwent ESD for EGC from July 2005 to October 2015 in Seoul National University Hospital. Long-term clinical outcomes and risk factors of MGN after 5 years post-ESD were evaluated. RESULTS: Among the 2059 patients who underwent ESD for EGC, 1102 were followed up for > 5 years. MGN developed in 132 patients 5 years after ESD. During the median follow-up period of 85 months, the cumulative incidences of MGN and metachronous gastric cancer were 11.7, 16.9, and 27.0 and 7.6, 10.8, and 18.7% after 5, 7, and 10 years, respectively. In multivariable analysis, male sex (odds ratio 1.770; P = 0.042), severe intestinal metaplasia (odds ratio 1.255; P = 0.000), tumor-positive lateral margin (odds ratio 2.711; P = 0.008), < 5 mm lateral safety margin (odds ratio 1.568; P = 0.050), and synchronous adenoma (odds ratio 2.612; P = 0.001) were positive predictive factors, and successful eradication of Helicobacter pylori (odds ratio 0.514; P = 0.024) was a negative predictive factor for MGN after 5 years post-ESD. CONCLUSION: The cumulative MGN incidence was high even 5 years post-ESD for EGC. Meticulous long-term endoscopic follow-up is mandatory, especially in male patients with underlying intestinal metaplasia, tumor-positive lateral margins, lateral safety margins of < 5 mm, and synchronous adenomas.

Helicobacter pylori Eradication Can Reverse Rho GTPase Expression in Gastric Carcinogenesis.

Background/Aims: Altered DNA methylation is a key mechanism of epigenetic modification in gastric cancer (GC). This study aimed to evaluate the changes in epigenetic and genetic expression of multiple Rho GTPases in Helicobacter pylori-related gastric carcinogenesis by comparing H. pylori-positive GCs and negative controls. Methods: The messenger RNA expression and methylation of Rho GTPases (RhoA, Rac1, DOCK180, ELMO1, and CDC42) were evaluated in H. pylori-negative (control) human gastric tissues and H. pylori-positive GCs by using real-time reverse transcription-polymerase chain reaction and the quantitative MethyLight assay, respectively. Changes in expression and methylation levels of the genes were also compared between H. pylori-eradicated and -persistent GCs at 1-year follow-up. Results: In GCs, the methylation and expression levels of DOCK180 and ELMO1 were higher than in controls, while RhoA and Rac1 had lower levels than controls. CDC42 had the same expression pattern as DOCK180 and ELMO1 without DNA methylation. Although methylation levels of DOCK180 and ELMO1 had no difference between H. pylori-eradicated and -persistent GCs at the index endoscopic resection, those of H. pylori-persistent GCs increased and H. pylori-eradicated GCs decreased for 1 year. The expression levels of DOCK180, ELMO1, and CDC42 in H. pylori-persistent GCs were higher than those in H. pylori-eradicated GCs over 1 year, unlike those of RhoA and Rac1. The methylation levels at index and the degrees of change over time of RhoA and Rac1 had no difference between H. pylori-persistent and -eradicated GCs. Conclusions: Epigenetic alterations of DOCK180 and ELMO1 are involved in H. pylori-related gastric carcinogenesis. This epigenetic field could be improved by H. pylori eradication.

Identification of gaze pattern and blind spots by upper gastrointestinal endoscopy using an eye-tracking technique.

BACKGROUND: The lesion detection rate of esophagogastroduodenoscopy (EGD) varies depending on the degree of experience of the endoscopist and anatomical blind spots. This study aimed to identify gaze patterns and blind spots by analyzing the endoscopist's gaze during real-time EGD. METHODS: Five endoscopists were enrolled in this study. The endoscopist's eye gaze tracked by an eye tracker was selected from the esophagogastric junction to the second portion of the duodenum without the esophagus during insertion and withdrawal, and then matched with photos. Gaze patterns were visualized as a gaze plot, blind spot detection as a heatmap, observation time (OT), fixation duration (FD), and FD-to-OT ratio. RESULTS: The mean OT and FD were 11.10 ± 11.14 min and 8.37 ± 9.95 min, respectively, and the FD-to-OT ratio was 72.5%. A total of 34.3% of the time was spent observing the antrum. When observing the body of the stomach, it took longer to observe the high body in the retroflexion view and the low-to-mid body in the forward view. CONCLUSIONS: It is necessary to minimize gaze distraction and observe the posterior wall in the retroflexion view. Our results suggest that eye-tracking techniques may be useful for future endoscopic training and education.

Impact of the Interval between Previous Endoscopic Exam and Diagnosis on the Mortality and Treatment Modality of Undifferentiated-Type Gastric Cancer.

PURPOSE: The impact of the interval between previous endoscopy and diagnosis on the treatment modality or mortality of undifferentiated (UD)-type gastric cancer is unclear. This study aimed to investigate the effect of endoscopic screening interval on the stage, cancer-related mortality, and treatment methods of UD-type gastric cancer. MATERIALS AND METHODS: We reviewed the medical records of newly diagnosed patients with UD gastric cancer in 2013, in whom the interval between previous endoscopy and diagnosis could be determined. The patients were classified into different groups according to the period from the previous endoscopy to diagnosis (<12 months, 12-23 months, 24-35 months, ≥36 months, and no history of endoscopy), and the outcomes were compared between the groups. In addition, patients who underwent endoscopic and surgical treatment were reclassified based on the final treatment results. RESULTS: The number of enrolled patients was 440, with males representing 64.1% of the study population; 11.8% of the participants reported that they had undergone endoscopy for the first time in their cancer diagnosis. The percentage of stage I cancer at diagnosis significantly decreased as the interval from the previous endoscopy to diagnosis increased (65.4%, 63.2%, 64.2%, 45.9%, and 35.2% for intervals of <12 months, 12-23 months, 24-35 months, ≥36 months, and no previous endoscopy, respectively, P<0.01). Cancer-related mortality was significantly lower for a 3-year interval of endoscopy (P<0.001). CONCLUSIONS: A 3-year interval of endoscopic screening reduces gastric-cancer-related mortality, particularly in cases of UD histology.

Use of direct oral anticoagulants does not significantly increase delayed bleeding after endoscopic submucosal dissection for early gastric neoplasms.

Direct oral anticoagulants (DOACs) are widely prescribed for the prevention of stroke in elderly patients with atrial fibrillation and approved indication for DOAC has been expanded. We aimed to evaluate the risk of delayed bleeding in patients who had taken DOAC and underwent endoscopic submucosal dissection (ESD) for gastric neoplasms. We included consecutive patients who underwent ESD between January 2016 and July 2019 in Seoul National University Hospital. Patients were divided into four groups (no med; no medication, DOAC, WFR; warfarin, anti-PLT; anti-platelet agent) according to the medications they had been taken before the procedure. We defined delayed bleeding as obvious post-procedural gastrointestinal bleeding sign including hematemesis or melena combined with hemoglobin drop ≥ 2 g/dL. Among 1634 patients enrolled in this study, 23 (1.4%) patients had taken DOAC and they usually stopped the medication for 2 days before the ESD and resumed within 1 or 2 days. We compared rates of delayed bleeding between groups. Delayed bleeding rates of the groups of no med, DOAC, WFR, and anti-PLT were 2.1% (32/1499) 8.7% (2/23), 14.3% (2/14), 11.2% (11/98), respectively (P < 0.001). However, there was no difference of delayed bleeding rate between no med and DOAC group after propensity score matching (no med vs DOAC, 1.7% vs 10.0%, P = 0.160). Taking DOAC was not associated statistically with post-ESD bleeding when adjusted by age, sex, comorbidities and characteristics of target lesion (Adjusted Odds Ratio: 2.4, 95% Confidence intervals: 0.41-13.73, P = 0.335). Crude rate of bleeding in DOAC users seemed to be higher than no medication group after performing ESD with 2 days of medication cessation. When adjusted by age, sex, and comorbidity, however, this difference seems to be small, which suggests that gastric post-ESD bleeding may be influenced by patients' underlying condition in addition to medication use.

Hierarchical Analysis of Factors Associated with T Staging of Gastric Cancer by Endoscopic Ultrasound.

BACKGROUND: Size, ulcer, differentiation, and location are known to be factors affecting the T stage accuracy of EUS in gastric cancer. However, whether an interaction exists among recognized variables is poorly understood. The aim of this study was to identify the combinatorial characteristics of group with high overestimation rate to determine which group should be considered carefully for EUS-based treatment plans. METHODS: We retrospectively analyzed early gastric cancer patients who underwent EUS from 2005 to 2016. The accuracy of EUS T stage and factors affecting over-/underestimation were examined by using decision tree analysis, the CHAID method. RESULTS: The most significant factor affecting the accuracy of the EUS T stage was the size. The rate of overestimation was higher in lesions > 3 cm (37.2% vs. 28.8% vs. 17.1%, p < 0.001). In lesions > 3 cm, the rate of overestimation was higher in lesions with an ulcer (62.1% vs. 35.0%, p < 0.001). Moreover, for lesions ≤ 3 cm, the accuracy of the EUS T stage was more affected by differentiation and location. The rate of overestimation was higher in undifferentiated-type lesions ≤ 2 cm (24.5% vs. 13.9%, p < 0.001) and 2-3 cm (33.3% vs. 25.7%, p = 0.011). In the differentiated type, the location affected the accuracy of the EUS T stage. CONCLUSION: In this hierarchical analysis, the rate of overestimation was higher in lesions > 3 cm with ulcer, lesions > 3 cm irrespective of ulcer, and undifferentiated-type lesions measuring 2-3 cm.

Long-term natural history after endoscopic resection for gastric dysplasia.

BACKGROUND AND STUDY AIMS: Natural history after endoscopic resection (ER) for gastric dysplasia is still unclear. The aim of this study was to evaluate the long-term clinical outcomes and risk factors after ER for gastric dysplasia between control and cases with synchronous or metachronous gastric neoplasm. METHODS: A total of 1090 patients who had undergone ER for gastric dysplasia and been followed up for at least one year from December 2002 to December 2013 were finally analyzed. Risk factors affecting the development of synchronous or metachronous neoplasm (SMN) and long-term clinical outcomes after ER for gastric dysplasia were evaluated. RESULTS: Synchronous and metachronous neoplasms had developed in 126 (11.6%) and 133 patients (12.2%) during the mean follow-up duration of 63.6 months, respectively. Five-year and 10-year risk of metachronous neoplasm were 9.8% and 27.2%, respectively. Median duration to the development of metachronous neoplasm was 103.1 months. While age (P < 0.001) and mucosal atrophy (P = 0.09) of index cases were associated with the development of synchronous neoplasm, age (P = 0.017), incomplete resection (P = 0.025), and intestinal metaplasia (P = 0.017) of background mucosa of index cases were significantly related to the development of metachronous neoplasm in multivariate analysis. Cumulative incidence of SMN was not significantly different among H. pylori negative, eradicated, and persistent group. CONCLUSIONS: Age, incomplete ER, and background intestinal metaplasia of index gastric dysplasia were significantly associated with metachronous recurrence. Endoscopic surveillance for metachronous recurrence after ER for gastric dysplasia is mandatory for longer than 10 years.

Role of Endoscopic Ultrasound in Selecting Superficial Esophageal Cancers for Endoscopic Resection.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a curative treatment option for superficial esophageal cancer with a minimal risk for lymph node metastasis. Before ESD, accurate clinical staging is important to select the appropriate candidate. We aimed to estimate the practicality of endoscopic ultrasound (EUS) to select pTis and pT1a. METHODS: We included patients with squamous esophageal cancers who underwent surgical resection or ESD between 2005 and 2018. Pathologic reports were reviewed retrospectively, and pathologic T staging was compared with clinical stage evaluated by EUS. RESULTS: Among 532 patients, 321 had superficial esophageal cancer (pTis: 42; pT1a: 115; and pT1b: 164). Accuracy rates, sensitivity, specificity, positive predicted value, and negative predicted value for selecting cT1a by EUS were 82.3%, 60.5%, 91.5%, 74.8%, and 84.7%, respectively. The rate of overstaged pTis-T1a was 39.5%. Upon multivariable analysis, tumor size (>2 cm), poor differentiation, protruding gross type, and use of conventional EUS (versus miniprobe) were associated factors for overstaging of pTis-T1a. CONCLUSIONS: The accuracy of prediction of EUS for selecting mucosal esophageal cancer that can be treated with ESD was favorable. Target lesions with a large size (>2 cm), poor differentiation, and protruding morphology were related to T overstaging; precaution should be taken when evaluating the clinical stage for cancers with those conditions. Furthermore, miniprobe EUS provides higher accuracy for squamous esophageal cancers confined to mucosa.

Empiric Versus Clarithromycin Resistance-Guided Therapy for Helicobacter pylori Based on Polymerase Chain Reaction Results in Patients With Gastric Neoplasms or Gastric Mucosa-Associated Lymphoid Tissue Lymphoma: A Randomized Controlled Trial.

INTRODUCTION: We investigated to compare the effect of empirical therapy vs clarithromycin resistance-guided tailored therapy (tailored therapy) for eradication of Helicobacter pylori. METHODS: In this prospective, single center, open-label randomized controlled trial, we enrolled 72 patients with H. pylori infection from January 2019 through June 2019 in Korea. The patients were randomly assigned to both groups received empirical (n = 36) or tailored therapy (n = 36). Empirical therapy was defined as triple therapy with esomeprazole, amoxicillin, and clarithromycin for 10 days irrespective of clarithromycin resistance. Tailored therapy was triple or quadruple therapy with esomeprazole, metronidazole, tetracycline, and bismuth for 10 days based on genotype markers of resistance determined by gastric biopsy. Resistance-associated mutations in 23S rRNA were confirmed by multiplex polymerase chain reaction. Eradication status was assessed by C-urea breath test, and the primary outcome was eradication rates. RESULTS: H. pylori was eradicated in 27 patients (75.0%), given empirical therapy and 32 patients (88.9%) treated with tailored therapy (P = 0.136) in intention-to-treat analysis. In per protocol analysis, the eradication rate was 97.0% and 81.8% in tailoredvs empirical groups (P = 0.046). Although clarithromycin-resistant H. pylori was eradicated in 3/9 (33.3%) with empirical therapy, it was treated in 11/12 (91.7%) with tailored therapy (P = 0.009). There was no difference in compliance between 2 groups. The rate of adverse events of the tailored group was higher than that of the empirical group (P = 0.036) because quadruple therapy had more side effects than those of triple therapy (P = 0.001). DISCUSSION: Tailored therapy based on polymerase chain reaction is a good alternative to increase eradication rates in a region of high prevalence of clarithromycin resistance (see Visual Abstract, Supplementary Digital Content 1, http://links.lww.com/CTG/A342).

Endoscopic Submucosal Dissection Versus Surgery for Superficial Esophageal Squamous Cell Carcinoma: A Propensity Score-Matched Survival Analysis.

INTRODUCTION: Endoscopic submucosal dissection (ESD) is a preferred treatment option for superficial esophageal squamous cell carcinoma (SESCC). However, only few studies compared long-term survival outcomes of ESD with surgery. This study compared the overall survival (OS), recurrence-free survival, and complication rates of ESD with those of surgery. METHODS: We reviewed patients who underwent ESD (n = 70) or surgery (n = 114) for SESCC at Seoul National University Hospital from 2011 to 2017. A propensity score-matched analysis was used to reduce selection bias. To increase the precision of our results interpretation, subgroups were analyzed according to the depth of tumor invasion. RESULTS: In the matching study, the ESD group (n = 34) showed comparable survival outcomes with the surgery group (n = 34). The 5-year OS rates were 89.4% vs 87.8% for the ESD and the surgery groups, respectively; similarly, the 5-year recurrence-free survival rates were 90.9% and 91.6%, respectively. The ESD group showed a lower early major complication rate (2.9% [1 of 34] vs 23.5% [8 of 34], P < 0.001) and shorter hospital stay (median, 3.0 days vs 16.5 days, P < 0.001) than the surgery group. In the tumor in situ (Tis)-subgroup, ESD showed better OS than esophagectomy (P = 0.030). Between-group comparisons of survival outcomes in the T1a and T1b subgroups revealed no significant differences. DISCUSSION: Long-term outcomes of ESD are comparable with surgery for patients with SESCC. For early major complications and duration of hospital stay, ESD was associated with better outcomes than radical surgery. These results support ESD as the preferred treatment option for SESCC.

Synergistic Effect of Lymphatic Invasion and Venous Invasion on the Risk of Lymph Node Metastasis in Patients with Non-Curative Endoscopic Resection of Early Gastric Cancer.

BACKGROUND: Although additive radical surgery is recommended for patients with non-curative endoscopic resection for early gastric cancer (EGC), lymph node (LN) metastasis or remnant tumor is detected in only about 10% of patients. Therefore, we aimed to identify patients who required surgery by identifying significant risk factors for LN metastasis and evaluate long-term outcomes in patients with non-curative endoscopic resection. METHODS: We retrospectively analyzed the database of Seoul National University Hospital to identify patients who underwent endoscopic resection for EGC from June 2005 to December 2016. RESULTS: Three hundred and twenty-nine patients did not meet the criteria for curative resection after endoscopic resection. Among them, 140 patients underwent additional surgery and 171 patients refused surgery and regularly received follow-up. In the surgery group, LN metastasis was found in 12.1% of patients. Logistic regression analysis revealed that the rate of LN metastasis was significantly higher in patients with lymphatic invasion (LI) (odds ratio [OR] 5.84, p = 0.014) and venous invasion (VI) (OR 5.66, p = 0.006). We analyzed LN metastasis based on LI and VI in the surgical group. LN metastasis was significantly increased in the positive LI and VI groups compared with the negative LI and VI groups (OR 68.32; 95% confidence interval, 4.74-984.82; p = 0.002). CONCLUSIONS: Both LI and VI were significant predictors of LN metastasis. The risk of LN metastasis was augmented when both LI and VI were positive. Therefore, LI and VI should be evaluated separately in patients with non-curative endoscopic resection. Additive surgery should be recommended for patients with LI and/or VI.

Clinical Outcomes of Metachronous Gastric Cancer after Endoscopic Resection for Early Gastric Cancer.

Background/Aims: Patients treated with endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) are at risk of developing metachronous gastric cancer (MGC). The aim of this study was to evaluate the clinical outcomes of MGC after ESD for EGC between the re-ESD and surgery groups. Methods: In total, data from 1,510 patients who underwent ESD for EGC from January 2005 to May 2014 were retrospectively reviewed, and data from 112 patients with MGC were analyzed according to the type of treatment, namely, re-ESD and surgery. The clinicopathological factors affecting the subsequent treatment and outcomes of MGC were evaluated. Results: The median duration to the development of MGC was 47 months. In multivariate analysis, lower body mass index (BMI) (p=0.037) and multiplicity (p=0.014) of index cases were significantly associated with subsequent surgery for MGC. In cases of MGC, a diffuse or mixed-type Lauren classification (p=0.009), the depth of tumor mucosal invasion (p=0.001), and an upper stomach location (p=0.049) were associated with surgery. Overall survival was significantly shorter in the surgery group than in the re-ESD group after treatment for MGC (log-rank test, p=0.01). Conclusions: Lower BMI and multiplicity of index cancers were significantly associated with the surgical resection of MGC. Close follow-up is needed to minimize additional treatment for cases at high risk of advanced MGC after ESD for EGC.

Determining the current indications for endoscopic submucosal dissection in patients with Lauren mixed-type early gastric cancer.

BACKGROUND AND AIM: Recent study showed that early gastric cancer (EGC) with Lauren mixed-type (MT) histology is associated with worse prognosis. We aimed to evaluate the clinicopathologic features and prognostic significance of Lauren MT-EGCs that meets the criteria for endoscopic submucosal dissection (ESD). METHODS: We reviewed 2665 patients with EGC who underwent surgery between 2010 and 2015. The clinicopathologic features and invasiveness including lymph node metastasis (LNM) and lymphovascular invasion (LVI) of MT-EGC were compared with those of intestinal type and diffuse type by Lauren histology. RESULTS: Among 2665 patients, EGCs in 241 (9%) patients were classified as MT. Tumor size was larger and depth of invasion was greater than other histology. Among patients with MT-EGC, 16.6% (40/241) showed LNM and 22.8% (55/241) showed lymphatic invasion, which were significantly higher than that of patients with other Lauren types (8.2% and 15.3% in intestinal type and 9.1% and 8.7% in diffuse type, P < 0.001). This finding remained significant even after adjusting for depth of invasion. However, when we analyzed the patient groups who met the absolute or expanded criteria of ESD, no significant difference was observed in the rates of LNM or LVI or cancer mortality by Lauren classification. CONCLUSION: Mixed-type early gastric cancer (MT-EGC) exhibited larger tumor size, greater depth of invasion, and higher risk of LNM and LVI. However, among the patients who met the absolute or expanded criteria of ESD, no significant difference was observed in LNM, LVI, and gastric cancer mortality risk.

Exploring the possibility of endoscopic submucosal dissection for clinical submucosal invasive early gastric cancers.

BACKGROUND: The current standard treatment modality for clinical submucosal invasive (cT1b) early gastric cancer (EGC) is surgery. However, there are discrepancies in T staging between pre- and post-operative findings, and in cases of overestimation, patients may lose the opportunity to preserve the stomach. The aim of this study was to analyze surgical outcomes of cT1b EGC and determine the pre-treatment factors favoring ESD. METHODS: Patients who underwent gastrectomy for cT1b EGC with a tumor size of 30 mm or less in diameter and differentiated-type histology were retrospectively reviewed from January 2010 to December 2014. According to the final surgical pathologic results, two groups were classified: patients whose pathologic results qualified for current ESD indication (ESD-qualified group, n = 203) and patients whose pathologic results made them ineligible for ESD (ESD-disqualified group, n = 261). The preoperative clinical characteristics were compared. RESULTS: Forty-three percent of the patients (203/464) who underwent gastrectomy for cT1b EGC qualified for ESD; their endoscopic lesion tended to be smaller than 20 mm in size and located in the distal part of stomach. In addition, the ESD-qualified group showed a significantly higher proportion of well-differentiated tubular adenocarcinoma on endoscopic biopsy and of the flat/depressed type in the endoscopic evaluation. CONCLUSION: Forty-three percent of the patients with cT1b EGC who underwent gastrectomy had a chance to preserve their stomach by ESD. Therefore, pre-treatment factors such as endoscopic lesion size, location, histology, and gross type should be considered for treatment modality selection for cT1b EGC.

Clinical efficacy of endoscopic ultrasonography for decision of treatment strategy of gastric cancer.

BACKGROUND: Accurate preoperative tumor staging of gastric cancer is indispensable with expansion of indications for laparoscopic surgery and endoscopic resection. It is important to distinguish mucosal cancer (T1a) in smaller lesion and differentiate early gastric cancer (EGC) in larger lesion considering endoscopic resection indication and laparoscopic surgery indication. We evaluated the clinical outcomes of endoscopic ultrasonography (EUS) for the decision of treatment strategy of gastric cancer compared with pathological staging. METHODS: The patients who underwent EUS and surgical or endoscopic resection for gastric cancer were retrospectively reviewed between September 2005 and February 2016. The depth of tumor invasion (T staging) by EUS was compared with the pathological staging after endoscopic or surgical resection. RESULTS: A total of 6084 patients were finally analyzed. The accuracy rates for T1a and EGC were 75.0 and 89.4%, respectively. The overall accuracy of T staging by EUS was 66.3% when divided by T1a, T1b, and over T2. The accuracy of EUS prior to endoscopic resection was 75.1% in absolute indication and 73.1% in expanded criteria, respectively. The accuracy rates for T1a with lesion ≤ 2 cm in miniprobe EUS and EGC with lesion > 2 cm in conventional EUS were 84.6 and 83.2%, respectively. In multivariate analysis, presence of ulcer, large tumor size, and radial EUS were associated with overestimation, and small tumor size and miniprobe were associated with underestimation in T staging. CONCLUSIONS: EUS showed the high accuracy of 84.6% for T1a in lesion ≤ 2 cm in miniprobe EUS and 83.2% for EGC in lesion > 2 cm in conventional EUS, respectively. EUS can be a complementary diagnostic method to determine endoscopic or surgical treatment modality.

Continuous Use of Thienopyridine May Be as Safe as Low-Dose Aspirin in Endoscopic Resection of Gastric Tumors.

Background/Aims: Current guidelines recommend withholding antiplatelets for 5-7 days before high-risk endoscopic procedures. We investigated whether this reduces post-endoscopic submucosal dissection (ESD) bleeding. Methods: Gastric ESD cases with antiplatelets were retorospectively reviewed. Withholding antiplatelets for 5-7 days before ESD was defined as cessation and 0-4 days as continuation. The rate and risk of post-ESD bleeding according to the types and cessation of antiplatelets were assessed. Results: Among the 215 patients (117 adenoma and 98 early gastric cancer), 161 patients were on single (94 aspirin, 56 thienopyridine, and 11 other agents), 51 on dual, and 3 on triple antiplatelets. Post-ESD bleeding rates were 12.8% in aspirin users, 3.6% in thienopyridine, 27.5% in dual, 33.3% in triple therapy, and 9.7% in the cessation and 15.0% in the continuation group. Multiple antiplatelets (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.01 to 5.76) and specimen size ≥ 5.5 cm (OR, 2.84; 95% CI, 1.04 to 7.73) were the risk of bleeding, while continuation of thienopyridine (OR, 0.23; 95% CI, 0.05 to 1.09) and antiplatelets (OR, 1.83; 95% CI, 0.68 to 4.94) did not increase the risk of bleeding. Conclusions: Continuing thienopyridine and aspirin did not increase the risk of post-ESD. Multiple antiplatelet therapy and a large specimen size were independent risk factors of post-ESD bleeding.