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

Abstract

Background: 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. Methods: 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. Results: 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; I² = 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. Conclusions: 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. Trial Registration: PROSPERO registration: CRD420251172925.