The postoperative bleeding rate and its risk factors in patients on antithrombotic therapy who undergo gastric endoscopic submucosal dissection

Abstract

BackgroundThere is a lack of consensus regarding the risk of postoperative hemorrhage in patients on antithrombotic therapy who undergo endoscopic submucosal dissection (ESD).We examined postoperative bleeding rates and risk factors for postoperative hemorrhage from post-ESD gastric ulcers in patients on antithrombotic therapy.MethodsThe subjects of this study were 833 patients who underwent ESD of gastric tumors. Of these, 743 were not on antithrombotic therapy and 90 were on some form of antithrombotic therapy (46 on low-dose aspirin (LDA) only, 23 on LDA + thienopyridine, and 21 on LDA + warfarin). All patients commenced proton pump inhibitor (PPI) therapy immediately postoperatively. Antiplatelet agents were discontinued for 7 days preoperatively and postoperative Day 1, and anticoagulants for 5 days preoperatively and postoperative Day 1.ResultsThe postoperative bleeding rate in the antithrombotic group was 23.3%, significantly higher than the 2.0% observed in the non-antithrombotic group. Significant differences were seen in patients in the antithrombotic group with and without postoperative bleeding according to ESD duration (p = 0.041), PPI + mucosal protective agent combination therapy (p = 0.039), and LDA + warfarin combination therapy (p < 0.001). Multivariate analysis of these factors yielded odds ratios of 1.04 for ESD duration, 14.83 for LDA + warfarin combination therapy, and 0.27 for PPI + mucosal protective agent combination therapy.ConclusionsThe risk of postoperative hemorrhage following gastric ESD was higher in patients with antithrombotic therapy than in those without that therapy. Among these patients, LDA + warfarin combination therapy and longer ESD duration were significant risk factors for postoperative bleeding. On the contrary, a mucosal protective agent to PPI therapy, lowering the odds ratio for postoperative bleeding, which suggests that the addition of a mucosal protective agent might be effective in preventing post-ESD hemorrhage in patients on antithrombotic therapy.

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

“…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. 16,24,43 Lesion characteristics.…”

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

“…Direct oral anticoagulants (DOACs) target either thrombin or factor Xa, thereby attenuating thrombosis. Currently, 4 DOACs can be used for preventing stroke in atrial fibrillation: dabigatran, rivaroxaban, apixaban, and edoxaban; however, there is insufficient data concerning the management of patients taking anticoagulants who undergo ESD for EGC [19-23]. Therefore, we investigated the outcomes of ESD for EGC in patients taking anticoagulants, including the risk of bleeding during or after ESD.…”

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

“…There were also some unanswered questions regarding the bleeding of post-ESD and aspirin use. 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).…”

“…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). Moreover, Satoshi showed that taking thienopyridine derivatives with aspirin increased the hazard of bleeding after ESD, particularly in gastric ESD (34).…”

“…Some researchers have shown that patients are at higher risk of bleeding during or after ESD with continuous LDA use (9,26,27). Others have shown the opposite result, indicating that using the LDA continuously does not increase the hazard of bleeding (10,24).…”