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

Abstract

Background: Recent updated guidelines of the Japanese Society of Gastroenterology recommend the use of a single dose of antiplatelet agents in patients undergoing endoscopic submucosal dissection (ESD). However, the postoperative bleeding risk after gastric ESD associated with the continuation or interruption of antithrombotic therapy remains controversial. We aimed to evaluate whether certain factors including interrupted antithrombotic therapy could affect early and delayed post-ESD bleeding risk. Methods: Three hundred sixty-four patients with gastric neoplasms were treated with ESD at our hospital between October 2005 and December 2012. Seventy-four patients with interrupted antithrombotic therapy were undertaken with ESD. Early and delayed postoperative bleeding patterns were estimated. Various clinical characteristics such as gender, age, tumor location, tumor size, ESD procedure time, platelet count, and comorbidity were evaluated. Results: There was a significant difference (p = 0.042) in the ESD procedure time between the patients with postoperative bleeding and those without it. There was no significant difference in postoperative bleeding between the patients on antithrombotic therapy and not on it. Moreover, interrupted antithrombotic therapy and platelet count were significantly (p = 0.0461 and p = 0.0059, respectively) associated with early postoperative bleeding in multivariate analysis. In addition, in univariate analysis, ESD procedure time was significantly (p = 0.041) associated with delayed postoperative bleeding. Conclusions: Antithrombotic therapy and prolonged ESD procedure time were significantly associated with early and delayed postoperative bleeding, respectively.

Bleeding after endoscopic submucosal dissection of gastric lesions

“…Although gastric ESD is recommended as the choice for the treatment of gastric mucosal and submucosal lesions, we still need to pay attention to the precaution and treatment of complications after gastric ESD, particularly in patients with a high risk of post‐ESD bleeding . Endoscopists must keep in mind the risks of post‐ESD hemorrhage, including patient factors, tumor‐related factors and operation‐related factors so as to adopt effective preventive measures before, during and after surgery in order to prevent or even completely avoid the occurrence of postoperative bleeding …”

Utility of autologous fibrin glue and polyglycolic acid sheet for preventing delayed bleeding associated with antithrombotic therapy after gastric ESD

“…Incidence of delayed bleeding after gastric ESD varies among studies, ranging from 4 % to 10 %. Risk factors for delayed bleeding include lesions in the L region of the stomach, large resection specimen, cirrhosis, dialysis, and antithrombotic therapy 8 9 10 . Antithrombotic therapy is a major problem because of its widespread use in recent years.…”

Feasibility of Autologous Fibrin Glue and Polyglycolic Acid Sheets to Prevent Delayed Bleeding after Endoscopic Submucosal Dissection of Gastric Neoplasms in Patients Receiving Antithrombotic Therapy

“…Following this revision, more gastric ESD procedures have been performed routinely in Japanese patients receiving antithrombotic therapy, and concern has been growing about the corresponding increase in cases of postoperative bleeding. The risk factors for postoperative bleeding in patients undergoing gastric ESD include tumor size and location and, more importantly, antithrombotic therapy [ 18 , 19 ]. Although the new guidelines allow ESD to be performed in patients undergoing antithrombotic therapy, we believe that further measures are needed to improve the safety of gastric ESD in these patients.…”