Retrospective Cohort Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 14, 2017; 23(30): 5557-5566
Published online Aug 14, 2017. doi: 10.3748/wjg.v23.i30.5557
Postoperative bleeding in patients on antithrombotic therapy after gastric endoscopic submucosal dissection
Chiko Sato, Kingo Hirasawa, Ryonho Koh, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Hiroaki Kaneko, Makomo Makazu, Shin Maeda
Chiko Sato, Kingo Hirasawa, Ryonho Koh, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Hiroaki Kaneko, Makomo Makazu, Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
Shin Maeda, Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
Author contributions: Sato C and Hirasawa K contributed to conception and design; Sato C, Hirasawa K, Koh R, Ikeda R, Fukuchi T, Kobayashi R, Kaneko H and Makazu M contributed to acquisition of data; Sato C and Hirasawa K contributed to analysis and interpretation of data; Hirasawa K contributed to drafting of the article; Hirasawa K and Maeda S contributed to critical revision of the article; Sato C and Hirasawa K contributed to statistical analysis; Hirasawa K and Maeda S final approved the article; all authors listed have contributed substantially to the design, data collection and analysis, and editing of the manuscript.
Institutional review board statement: This research was approved by the research ethics committee in our hospital (Approval number: D1602024).
Informed consent statement: Patients were not required to provide informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Kingo Hirasawa, MD, PhD, Endoscopy Division, Yokohama Medical University Center Hospital, 4-57, Urafune-cho, Minami-ku, Yokohama 232-0024, Japan. kingo-h@urahp.yokohama-cu.ac.jp
Telephone: +81-45-2615656 Fax: +81-45-2535382
Received: May 17, 2017
Peer-review started: May 19, 2017
First decision: June 8, 2017
Revised: June 26, 2017
Accepted: July 12, 2017
Article in press: July 12, 2017
Published online: August 14, 2017
Processing time: 89 Days and 1.9 Hours
Abstract
AIM

To investigated the relationship between postoperative bleeding following gastric endoscopic submucosal dissection (ESD) and individual antithrombotic agents.

METHODS

A total of 2488 gastric neoplasms in 2148 consecutive patients treated between May 2001 and June 2016 were studied. The antithrombotic agents were categorized into antiplatelet agents, anticoagulants, and other antithrombotic agents, and we included combination therapies [e.g., dual antiplatelet therapy (DAPT)]. The risk factors associated with post-ESD bleeding, namely, antithrombotic agents overall, individual antithrombotic agents, withdrawal or continuation of antithrombotic agents, and bleeding onset period (during the first six days or thereafter), were analyzed using univariate and multivariate analyses.

RESULTS

The en bloc resection and complete curative resection rates were 99.2% and 91.9%, respectively. Postoperative bleeding occurred in 5.1% cases. Bleeding occurred in 10.3% of the patients administered antithrombotic agents. Being male (P = 0.007), specimen size (P < 0.001), and antithrombotic agent used (P < 0.001) were independent risk factors for postoperative bleeding. Heparin bridging therapy (HBT) (P = 0.002) and DAPT/multidrug combinations (P < 0.001) were independent risk factors associated with postoperative bleeding. The bleeding rate of the antithrombotic agent continuation group was significantly higher than that of the withdrawal group (P < 0.01). Bleeding within postoperative day (POD) 6 was significantly higher in warfarin (P = 0.015), and bleeding after POD 7 was significantly higher in DAPT/multidrug combinations (P = 0.007). No thromboembolic events were reported.

CONCLUSION

We must closely monitor patients administered HBT and DAPT/multidrug combinations after gastric ESD, particularly those administered multidrug combinations after discharge.

Keywords: Gastric cancer; Endoscopic submucosal dissection; Postoperative hemorrhages; Antithrombotic agent; Heparin

Core tip: The major complication of gastric endoscopic submucosal dissection (ESD) is postoperative bleeding. Previous studies reported the relationship between postoperative bleeding and antithrombotic agents. We aimed to investigate postoperative bleeding following gastric ESD in relation to specific antithrombotic agents. We showed that antithrombotic agents, in particular heparin bridging therapy and dual antiplatelet therapy/multidrug combination, were independent risk factors for delayed bleeding. Furthermore, bleeding in the early period was significantly higher for warfarin, and bleeding in the late period was significantly higher for multidrug combination. We must strictly observe multidrug combination users especially after discharge.