Risk factors for early and delayed post-operative bleeding after endoscopic submucosal dissection of gastric neoplasms, including patients with continued use of antithrombotic agents.

Tomoaki Matsumura,Tomoo Nakagawa,Hideaki Ishigami,Makoto Arai,Kenichiro Okimoto,Shoko Minemura,Keiko Saito,Tatsuro Katsuno,Osamu Yokosuka,Daisuke Maruoka

doi:10.1186/1471-230x-14-172

Tomoaki Matsumura, Tomoo Nakagawa + Show 8 more

Open Access

https://doi.org/10.1186/1471-230x-14-172

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Journal: BMC gastroenterology	Publication Date: Oct 3, 2014
Citations: 63	License type: cc-by

Affiliation: Chiba University

Abstract

BackgroundEndoscopic submucosal dissection (ESD) has become widely accepted as a standard treatment for gastric epithelial neoplasms. Antithrombotic agents are widely used to prevent thromboembolic disease. However, the feasibility of endoscopic procedures for patients using such agents has been rarely investigated. The aim of this study was to identify risk factors for post-operative bleeding after gastric ESD and to evaluate the relationship between the use of antithrombotic agents and post-operative bleeding.MethodsFrom June 2005 to March 2014, 413 patients with 425 gastric neoplasms were treated by ESD. The demographic and clinical parameters associated with post-operative bleeding were investigated. 83 patients receiving antithrombotic agents were separately assessed using various methods of administration during the ESD procedure. Post-operative bleeding that occurred within 5 days of ESD was defined as early post-operative bleeding, whereas subsequent bleeding was defined as delayed bleeding.ResultsThe overall post-operative bleeding rate was 4.7%. In patients with continued low-dose aspirin (LDA), heparin replacement (HR), or continued LDA along with HR, post-operative bleeding rates were 9.5%, 23.8%, and 25.0%, respectively. On multivariate analysis, a specimen size of ≥40 mm was a risk factor for early post-operative bleeding [odds ratio (OR) 6.08, 95% CI: 1.74–21.27], and HR and chronic kidney disease (CKD) requiring hemodialysis were risk factors for delayed bleeding (OR 12.23, 95% CI: 2.63–56.77 and OR 28.35, 95% CI: 4.67–172.11, respectively). Continued LDA was not a risk factor for post-operative bleeding.ConclusionsLarge specimen size is a risk factor for early post-operative bleeding, and HR and CKD requiring hemodialysis are risk factors for delayed bleeding. Patients with risk factors should be carefully watched, allowing for the timing of post-operative bleeding after ESD.

Highlights

Endoscopic submucosal dissection (ESD) has become widely accepted as a standard treatment for gastric epithelial neoplasms
Antithrombotic agents are very effective in the management of thromboembolic diseases [5,6], their use increases the incidence of gastrointestinal (GI) bleeding [7,8,9]
In 3 patients, we confirmed post-operative bleeding on second-look endoscopy, and two of them were patients taking antithrombotic agents

Summary

Introduction

Endoscopic submucosal dissection (ESD) has become widely accepted as a standard treatment for gastric epithelial neoplasms. Endoscopic submucosal dissection (ESD) is widely recognized as the optimal treatment for gastric epithelial neoplasms [1,2,3,4]. Antithrombotic agents are very effective in the management of thromboembolic diseases [5,6], their use increases the incidence of gastrointestinal (GI) bleeding [7,8,9]. Lanas et al reported that Helicobacter pylori infection increased the risk of upper GI bleeding in patients taking LDA [10]. Endoscopic procedures such as ESD cause post-operative bleeding at a constant rate. Because many patients who undergo gastric ESD are infected with Helicobacter pylori, the post-ESD bleeding rate for patients receiving antithrombotic agents is expected to be >5%

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