High incidence of postoperative hemorrhage in colorectal endoscopic submucosal dissection during anticoagulant therapy.

Abstract

Dear Editor: Endoscopic submucosal dissection (ESD) is useful for resecting large early colorectal cancers. Postoperative hemorrhage is one of the complications for colorectal ESD. Patients with antithrombotic drug such as antiplatelet and anticoagulant are not uncommonly encountered during colorectal ESD because the number of silver generation grows; patients with multiple co-morbidities and polypharmacy also become more prevalent. Due to the importance of antithrombotic drug, many countries had developed their own clinical guidelines advising whether to continue or withhold antithrombotic drug during a certain procedure. To our knowledge, there are no detail reports about postoperative hemorrhage after colorectal ESD in patients with anticoagulant. In this report, we aimed to compare the status of postoperative hemorrhage for colorectal ESD cases with antithrombotic (anticoagulant or antiplatelet) and those without. Consecutive patients who underwent colorectal ESD at the Kyoto Prefectural University of Medicine from November 2008 to April 2015 were retrospectively reviewed. Indication for ESD included (1) tumors that cannot be resected with EMR, as well as those that are diagnosed as (2) intramucosal cancer (Tis) and part of T1 cancer without risk of lymph node metastasis by magnifying endoscopic examination. We analyzed various clinicopathological outcomes in all ESD cases and all included cases were divided into three groups: group A, cases with antiplatelet; group B, cases with anticoagulant (±antiplatelet); and group C, cases without antithrombotic drug. Characteristics of patients and tumors (age, sex, tumor size, location) as well as procedural record and complications (en bloc resection, procedure time, postoperative hemorrhage, perforation, blood transfusion, thrombosis and etc.) were also examined. We followed the Japanese Gastroenterological Endoscopy Society (JGES) on the management of patients on antithrombotic drugs during endoscopy published in 2005 and 2010. Regularly, antiplatelet drugs including aspirin were withdrawn for 1 to 7 days and restarted 1–3 days after ESD. In patients with high embolic risk, aspirin was continued before and after ESD. With respect to anticoagulants, warfarin was regularly replaced with subcutaneous heparin (20,000 units/day) 3 days before ESD. Heparin was stopped 6 h before ESD. Both heparin and warfarin were re-prescribed 1 day after ESD and were continued 4–14 days until the prothrombin times-international normalized ratio (PT-INR) was recovered. However, in some patients, warfarin was withdrawn 3 days before ESD without heparin replacement and was restarted 2 days after ESD until 2010. Dabigatran was withdrawn 1 day before ESD and restarted 1 day after ESD. This study was approved by the ethics committees of Kyoto Prefectural University of Medicine. This study was carried out in accordance with the World Medical Association Helsinki Declaration and was a part of sub-analysis of the study registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as number UMIN000013772. With respect to overall 678 ESD cases, mean age of patients was 68.2 ± 10.3 years. Three hundred fifty-three * Naohisa Yoshida naohisa@koto.kpu-m.ac.jp