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.
Highlights
There is a lack of consensus regarding the risk of postoperative hemorrhage in patients on antithrombotic therapy who undergo endoscopic submucosal dissection (ESD)
Studies concerning post-ESD ulcer healing and postoperative hemorrhage have reported that proton pump inhibitor (PPI) therapy gives good healing rates for post-ESD ulcers, and that it is effective in preventing postoperative hemorrhage [1,2], so PPIs are widely administered post-ESD
We investigated for the first time the risk of hemorrhage following gastric ESD in patients on antithrombotic therapy on the basis of a protocol setting out the timing of their discontinuation and recommencement of antithrombotic therapy, as well as the risk associated with different antithrombotic agents
Summary
There 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. Postoperative complications of ESD, including perforations of the upper gastrointestinal tract and post-ESD ulcer bleeding (postoperative hemorrhage), are increasingly becoming a problem. With the advance of the ageing society, we are increasingly likely to perform ESD in patients with concurrent medical conditions, in particular heart conditions and cerebrovascular disease. Many of these patients are on long-term antithrombotic therapy (antiplatelet agents or anticoagulants). Inhibitors of acid secretion such as PPIs have been reported to be effective in reducing the incidence and prevalence of upper gastrointestinal hemorrhage [4,5,6]
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