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World J Gastrointest Endosc. Dec 16, 2016; 8(20): 756-762
Published online Dec 16, 2016. doi: 10.4253/wjge.v8.i20.756
Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms
Toshiyuki Yoshio, Tsutomu Nishida, Yoshito Hayashi, Hideki Iijima, Masahiko Tsujii, Junko Fujisaki, Tetsuo Takehara
Toshiyuki Yoshio, Junko Fujisaki, Department of Gastroenterology, Cancer Institute Hospital, Tokyo 135-8550, Japan
Toshiyuki Yoshio, Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka 560-8565, Japan
Tsutomu Nishida, Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka 560-8565, Japan
Yoshito Hayashi, Hideki Iijima, Masahiko Tsujii, Tetsuo Takehara, Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka 560-8565, Japan
Masahiko Tsujii, Department of Gastroenterology, Higashiosaka City General Hospital, Osaka 560-8565, Japan
Author contributions: Yoshio T contributed to the conception, collected materials and wrote the manuscript; Nishida T contributed to the conception and supervised; Hayashi Y, Iijima H, Tsujii M, Fujisaki J and Takehara T made critical revisions related to important intellectual content of the manuscript.
Conflict-of-interest statement: The authors reported no conflicts of interest.
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: Tsutomu Nishida, MD, PhD, Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan. tnishida.gastro@gmail.com
Telephone: +81-6-68430101 Fax: +81-6-68583531
Received: June 6, 2016
Peer-review started: June 11, 2016
First decision: July 20, 2016
Revised: August 12, 2016
Accepted: September 21, 2016
Article in press: September 22, 2016
Published online: December 16, 2016
Processing time: 190 Days and 13.1 Hours
Abstract

Endoscopic submucosal dissection (ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms, particularly for patients with comorbidities. Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation. With appropriate cessation, antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients. However, high thrombosis-risk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy (HBT) in the perioperative period. Dual antiplatelet therapy (DAPT), a representative combination therapy, is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding. In patients receiving DAPT, gastric ESD may be postponed until DAPT is no longer required. HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk. The continuous use of warfarin or direct oral anticoagulants may be possible alternatives. Here, we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD, whereas most antithrombotic therapies do not. The management of high thrombosis-risk patients is crucial for improved outcomes.

Keywords: Antithrombotic therapy; Endoscopic submucosal dissection; Heparin bridge therapy; Dual antiplatelet therapy; Delayed bleeding

Core tip: It is unclear if antithrombotic therapy increases delayed bleeding after endoscopic submucosal dissection (ESD) of gastric neoplasms. With appropriate cessation, antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients. However, high thrombosis-risk patients are often treated with combination therapy with antithrombotic agents, such as dual antiplatelet therapy (DAPT), and occasionally require the continuation of antithrombotic agents or heparin bridge therapy (HBT) in the perioperative period. Both patients with DAPT and HBT have a high risk of delayed bleeding. The management of these antithrombotic therapies is important in the perioperative period of ESD.