Postoperative bleeding after gastric endoscopic submucosal dissection in patients receiving antithrombotic therapy

Abstract

Background and aims It is controversial whether antithrombotic therapy increases the risk of bleeding after endoscopic submucosal dissection (ESD). The aim of this study was to evaluate the effects of antithrombotic therapy on gastric ESD. Methods Patients who underwent gastric ESD at Toranomon Hospital between April 2005 and July 2014 were enrolled. The risk of post-ESD bleeding was evaluated by multivariate logistic regression analysis. Results Of 1781 patients enrolled, 253 were taking an antithrombotic; 186 discontinued taking a single antithrombotic (n = 150) or multiple antithrombotics (n = 36) before ESD, whereas 15 continued taking a single antiplatelet agent and another 52 switched to heparin alternative therapy during the peri-ESD period. Post-ESD bleeding occurred in 101 patients (5.7 %): 68 patients (3.8 %) who did not take an antithrombotic, 11 patients (7.3 %) who discontinued taking a single antithrombotic, six patients (16.7 %) who discontinued taking multiple antithrombotics, one patient (6.7 %) who continued taking a single antiplatelet agent, and 15 patients (28.8 %) who switched to heparin therapy. In multivariate analysis, heparin alternative therapy [odds ratio (OR) 10.04, 95 % confidence interval (CI) 4. 35-23.16], discontinuation of the use of multiple antithrombotics before ESD (OR 5.44, 95 % CI 2.00-14.79), tumor location in the lower third of the stomach (OR 2.17, 95 % CI: 1.32-3.58), and a long procedure time (100 min or greater; OR 2.00, 95 % CI 1.25-3.20) were independent risk factors for post-ESD bleeding. Among 52 subjects who switched to heparin therapy, one developed acute renal infarction and one developed cerebral bleeding. Conclusions Because heparin alternative therapy significantly increases the risk of post-ESD bleeding and may not decrease the risk of thromboembolic events, other options should be considered for patients receiving anticoagulation therapy.

Taking Warfarin with Heparin Replacement and Direct Oral Anticoagulant Is a Risk Factor for Bleeding after Endoscopic Submucosal Dissection for Early Gastric Cancer

“…Moreover, bleeding has been associated with high bleeding risk procedures and taking warfarin with heparin bridging [29, 30]. Furuhata et al [31] and Yoshio et al [22] also reported that heparin alternative therapy significantly increases the risk of post-ESD bleeding for EGC [22, 31]. Our data also showed that bleeding after gastric ESD occurred in 14% of patients taking warfarin with heparin bridging.…”

Effect of Antithrombotic Therapy and Long Endoscopic Submucosal Dissection Procedure Time on Early and Delayed Postoperative Bleeding

“…However, they elaborated that postoperative bleeding occurred later in patients who ceased aspirin treatment compared to those who continued taking aspirin [32]. Between the findings of previous studies and our studies, we found that there were some differences in terms of the risk of the cessation of antithrombotic therapy [24,26,27,33]. These discrepancies may be accounted for by the differences in the numbers and types of antithrombotic agents mentioned in these studies.…”

Evaluation of the bleeding risk with various antithrombotic therapies after gastric endoscopic submucosal dissection

“…However, whereas few reports have evaluated the safety of antithrombotic therapy in high-risk procedures such as ESD before the revision of the JGES2012 guideline 19 20 , several reports have evaluated the safety after the revision of the guideline 21 22 23 . For example, Igarashi et al 21 reported that the delayed bleeding rate associated with gastric ESD was significantly higher in patients receiving antithrombotic therapy than in those not receiving such therapy; this included procedures under both cessation and continuation of antiplatelet agents.…”