Gastric ESD under Heparin Replacement at High-Risk Patients of Thromboembolism Is Technically Feasible but Has a High Risk of Delayed Bleeding: Osaka University ESD Study Group

Abstract

Objectives. Heparin replacement (HR) is often performed in patients with a high risk of thrombosis undergoing endoscopic procedures. However, information about the influence of HR is scarce. The aim of this study is to assess the clinical impact of HR for gastric endoscopic submucosal dissection (ESD). Methods. This is a retrospective study comprising approximately 1310 consecutive gastric neoplasms in 1250 patients, who underwent ESD in 5 institutes. We assessed the clinical findings and outcomes of ESD under HR, compared to ESD without HR as control. Results. A total of 24 EGC lesions in 24 patients were treated by ESD under HR. In the HR group, the complete en-bloc resection rate was 100%. The delayed bleeding rate was, however, higher in the HR group than in the controls (38% versus 4.6%). The timing of bleeding in the HR group was significantly later than in controls. In the control group, 209 patients discontinued antithrombotic therapy during perioperative period, and their delayed bleeding rate was not different from those without antithrombotic therapy (5.7% versus. 4.4%). A thromboembolic event was encountered in 1 patient under HR after delayed bleeding. Conclusion. ESD under HR is technically feasible but has a high risk of delayed bleeding.

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.…”

Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis

“…12 Heparin replacement was not identified as a significant risk factor in 1 study, 43 although an opposite result was found in another study. 40 Gastroprotective agents were associated with lower PPB in patients undergoing AT in 1 study. 54 Corticosteroid use was not identified as a risk factor for PPB.…”

“…Age was not identified as a risk factor in most studies, with only 1 study reporting that younger patients may be at higher risk for PPB. 34 Furthermore, 10 studies found no significant differences in elderly patients, 19,25,30,[35][36][37][38][39][40][41] although 1 study identified age > 80 years as an independent risk factor for PPB. 42 PPB rates were similar between genders in most studies, [13][14][15][16][17][18][20][21][22][23][25][26][27][28][29][30][31][32][33][34]36,39,[42][43][44] with only 1 study reporting an association male sex associated with PPB.…”

Continued use of low-dose aspirin may increase risk of bleeding after gastrointestinal endoscopic submucosal dissection: A meta-analysis

“…A recent study showed that the ratio of bleeding after ESD was higher in the anticoagulant agents group than in the nonanticoagulants agent group, 23.3% and 2%, respectively; however, the study did not examine the methods of drug use or which antithrombotic drugs may increase the rate of bleeding (27). In another study, the use of heparin caused a higher risk of delayed bleeding after gastric ESD (33). Takeuchi found that combining LDA with warfarin and longer ESD operations increased the rate of post-ESD bleeding (27).…”