Abstract
Objective. Guidelines on antiplatelet medication use during endoscopy are based on limited evidence. We investigate the risk of bleeding and ischemic events in patients undergoing endoscopic mucosal resection (EMR) of esophageal lesions in the setting of scheduled cessation and prompt resumption of clopidogrel. Design. Single centre retrospective review. Patients. Patients undergoing EMR of esophageal lesions. Interventions. Use of clopidogrel before EMR and resumption after EMR. Patients cease antiplatelets and anticoagulants 7 days before EMR and resume clopidogrel 2 days after EMR in average risk patients. Main Outcomes. Gastrointestinal bleeding (GIB) and ischemic events (IE) within 30 days of EMR. Results. 798 patients underwent 1716 EMR. 776 EMR were performed on patients on at least 1 antiplatelet/anticoagulant (APAC). 17 EMR were performed following clopidogrel cessation. There were 14 GIB and 2 IE. GIB risk in the setting of recent clopidogrel alone (0%) was comparable to those not on APAC (1.1%) (P = 1.0). IE risk on clopidogrel (6.3%) was higher than those not on APAC (0.1%) (P = 0.03). Limitations. Retrospective study. Conclusions. Temporary cessation of clopidogrel before EMR and prompt resumption is not associated with an increased risk of gastrointestinal bleeding but may be associated with increased ischemic events.
Highlights
Background and AimsEndoscopic mucosal resection (EMR) has emerged as an alternative to esophagectomy in the treatment of high grade dysplasia (HGD) and intramucosal esophageal carcinoma (EC) [1]
We investigate the risk of bleeding and ischemic events in patients undergoing endoscopic mucosal resection (EMR) of esophageal lesions in the setting of scheduled cessation and prompt resumption of clopidogrel
Of those performed on patients with recent APAC use, 595 (76.7%) had APAC discontinued before the EMR, 26 EMR (3.4%) were performed on APAC, 3 (0.4%) patients were bridged on low molecular weight heparin, and data was missing on 152 EMR (19.6%)
Summary
Endoscopic mucosal resection (EMR) has emerged as an alternative to esophagectomy in the treatment of high grade dysplasia (HGD) and intramucosal esophageal carcinoma (EC) [1] It involves the resection of a localized segment of diseased mucosa which results in an ulcer. Observational studies suggest that concomitant use of clopidogrel and proton pump inhibitors (PPI) may attenuate clopidogrel’s efficacy resulting in increased cardiovascular events [9, 10]. This may be relevant in patients with Barrett’s esophagus undergoing EMR who may be on PPI therapy for reflux. There is a paucity of evidence to guide decision making regarding the management of antiplatelet use in the setting of EMR [11]
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