# Prophylactic Mechanical Closure for Preventing Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta‐Analysis

## TL;DR

This study reviews whether closing the stomach wound after a specific endoscopic procedure reduces delayed bleeding, finding some benefit but with uncertain evidence.

## Contribution

The study provides a systematic review and meta-analysis on the effectiveness of prophylactic mechanical closure in reducing delayed bleeding after gastric ESD.

## Key findings

- Prophylactic closure reduced delayed bleeding (RR 0.36, 95% CI 0.16–0.82) but with low-certainty evidence.
- Advanced closure techniques showed greater benefit (RR 0.14) compared to standard approaches (RR 0.62).
- Immediate complete closure rate was 93.6% (95% CI 45.0%–99.6%).

## Abstract

Delayed bleeding remains the most common adverse event after gastric endoscopic submucosal dissection (ESD). We assessed whether prophylactic mechanical closure is associated with reduced clinically significant delayed bleeding.

PubMed, Embase, Cochrane CENTRAL, Scopus, and ClinicalTrials.gov were searched through October 2025. Comparative studies reporting delayed bleeding within 30 days were included. Random‐effects meta‐analysis with Hartung‐Knapp‐Sidik‐Jonkman adjustment was applied. Evidence certainty was assessed using GRADE.

Nine studies (2646 patients; eight non‐randomized) met inclusion criteria. Prophylactic closure was associated with reduced delayed bleeding (risk ratio [RR] 0.36, 95% confidence interval [CI] 0.16–0.82; p = 0.02; I
2 = 65%; prediction interval 0.05–2.65). However, sensitivity analysis restricted to high‐quality designs (one RCT, two propensity‐matched studies) showed wide confidence intervals without statistical significance (RR 0.30, 95% CI 0.01–10.44; p = 0.28). Subgroup analyses revealed no significant effect modification by antithrombotic status (p = 0.96) or defect size (p = 0.27). In exploratory subgroup analysis, advanced techniques were associated with RR 0.14 (95% CI 0.03–0.55) versus standard approaches RR 0.62 (95% CI 0.21–1.77; interaction p = 0.005), though this difference was confounded by operator expertise. Immediate complete closure rate was 93.6% (95% CI 45.0%–99.6%). GRADE certainty was low due to the predominance of observational studies and substantial heterogeneity.

Prophylactic closure was associated with reduced delayed bleeding after gastric ESD; however, low‐certainty evidence limits definitive conclusions. Well‐designed randomized trials in high‐risk populations are warranted to inform clinical practice.

PROSPERO registration: CRD420251172925

Nine comparative studies (n = 2646) were included. Prophylactic mechanical closure was associated with lower clinically significant delayed bleeding after gastric endoscopic submucosal dissection (risk ratio 0.36, 95% confidence interval 0.16–0.82; I
2 = 65%). Evidence certainty was low; exploratory analyses suggested larger effects with advanced techniques than with standard approaches.