Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms

Abstract

Endoscopic submucosal dissection (ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms, particularly for patients with comorbidities. Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation. With appropriate cessation, antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients. However, high thrombosis-risk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy (HBT) in the perioperative period. Dual antiplatelet therapy (DAPT), a representative combination therapy, is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding. In patients receiving DAPT, gastric ESD may be postponed until DAPT is no longer required. HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk. The continuous use of warfarin or direct oral anticoagulants may be possible alternatives. Here, we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD, whereas most antithrombotic therapies do not. The management of high thrombosis-risk patients is crucial for improved outcomes.

Effect of direct oral anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection

“…We had 16 patients on warfarin in whom we carried out ESD without HBT. All of them, including eight patients with AF with a CHADS 2 score of 0–1 and two patients with deep vein thrombosis, were decided by the prescribing doctors for their low thrombotic risk, although recent Japanese guidelines recommend HBT to all patients on warfarin.…”

“…Still, bleeding risk for antiplatelet agents is manageable in most cases. Aspirin is the most popular antiplatelet agent and is reported not to increase delayed bleeding risk if aspirin is continued during the perioperative period of ESD However, managing delayed bleeding risk in anticoagulants is difficult . When we discontinue warfarin, heparin bridge therapy (HBT) is usually required to prevent thrombotic events .…”

A prospective multicenter observational study evaluating the risk of periendoscopic events in patients using anticoagulants: the Osaka GIANT Study

“…The American Society for Gastrointestinal Endoscopy (ASGE) guidelines and JGES guidelines published in 2012 recommend bridge therapy for patients using VKAs before undergoing high risk endoscopic procedures in those who are at high risk for the development of thromboembolic events 5 9 . However, previous studies by our own group have shown a high risk of gastrointestinal bleeding after HB 12 13 28 . Similar to these retrospective studies, our prospective study confirmed a higher risk of post-procedural gastrointestinal bleeding in patients using VKAs who received HB than in those who did not receive HB.…”

Clinical impact of the perioperative management of oral anticoagulants in bleeding after colonic endoscopic mucosal resection

“…The incidence rates of thrombotic events related to endoscopic surgery were 0–4.2% [18, 19]. In addition, the interruption of warfarin for 4 to 7 days induced thromboembolic events in approximately 1% of patients [20].…”