Use of Anticoagulants Increases Risk of Bleeding After Colorectal Endoscopic Submucosal Dissection

Overview

Journal Endosc Int Open

Specialty Gastroenterology

Date 2018 Jul 7

PMID 29978006

Citations 13

Authors

Ken Yamashita

Shiro Oka

Shinji Tanaka

Kazuki Boda

Daiki Hirano

Kyoku Sumimoto

Takeshi Mizumoto

Yuki Ninomiya

Yuzuru Tamaru

Kenjiro Shigita

Nana Hayashi

Yoji Sanomura

Kazuaki Chayama

Affiliations

Soon will be listed here.

Abstract

Background And Study Aims: Japanese guidelines for gastroenterological endoscopy have recommended temporary withdrawal of anticoagulants (warfarin, direct oral anticoagulants [DOAC], or heparin) to prevent hemorrhagic complications during endoscopic submucosal dissection (ESD) for colorectal neoplasias (CRNs). However, serious thrombosis might occur during temporary withdrawal of anticoagulants. The current study aimed to evaluate outcomes with anticoagulants in patients undergoing ESD for CRNs.

Patients And Methods: This study was a single-institution retrospective cohort study based on clinical records. We assessed 650 consecutive patients with 698 CRNs who underwent ESD at Hiroshima University Hospital between December 2010 and June 2016. The patients were divided into three groups: the warfarin group (19 patients with 19 CRNs), DOAC group (7 patients with 9 CRNs), and no-antithrombotics group (624 patients with 670 CRNs). We replaced warfarin with heparin 3 to 5 days before endoscopy. Although DOAC was suspended on the morning of endoscopy, we did not replace heparin.

Results: Bleeding after the procedure occurred in 26.3 % (5/19), 22.0 % (2/9), and 2.7 % (18/670) of patients in the warfarin, DOAC, and no-antithrombotics groups, respectively. In the warfarin group, four patients who bled after the procedure took not only warfarin but also other antiplatelets. En bloc resection rates were 94.7 % (18/19), 100 % (9/9), and 96.6 % (647/670) in the warfarin, DOAC, and no-antithrombotics groups, respectively. No patients experienced ischemic events in the perioperative period.

Conclusions: Among patients undergoing ESD for CRNs, risk of bleeding was higher among patients who took anticoagulants than among those who did not. In particular, careful attention to patients who took antiplatelets in addition to warfarin before ESD for CRNs is warranted.

Citing Articles

Safety of edoxaban for delayed bleeding in gastrointestinal endoscopic procedures with a high risk of bleeding.

Mizuno K, Yokoyama J, Shibata O, Kojima Y, Kawata Y, Takahashi K DEN Open. 2024; 5(1):e70018.

PMID: 39372286 PMC: 11450183. DOI: 10.1002/deo2.70018.

The Management of Direct Oral Anticoagulants for Colorectal Endoscopic Submucosal Dissection: A Multicenter Observational Study.

Arimoto J, Ohata K, Tachikawa J, Goto S, Hayashi A, Ebisawa Y Dig Dis Sci. 2024; 69(3):933-939.

PMID: 38340260 DOI: 10.1007/s10620-024-08316-w.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants.

Sugimoto M, Murata M, Kawai T World J Gastroenterol. 2023; 29(19):2916-2931.

PMID: 37274799 PMC: 10237096. DOI: 10.3748/wjg.v29.i19.2916.

[Research Progress in Delayed Bleeding after Endoscopic Submucosal Dissection of Early-Stage Gastrointestinal Cancer].

Zhu R, Ma C, Min M Sichuan Da Xue Xue Bao Yi Xue Ban. 2022; 53(3):381-385.

PMID: 35642142 PMC: 10409415. DOI: 10.12182/20220560503.

Factors for conversion risk of colorectal endoscopic submucosal dissection: a multicenter study.

Kamigaichi Y, Oka S, Tanaka S, Nagata S, Kunihiro M, Kuwai T Surg Endosc. 2022; 36(8):5698-5709.

PMID: 35579699 DOI: 10.1007/s00464-022-09250-6.

References

Takeuchi Y, Iishi H, Tanaka S, Saito Y, Ikematsu H, Kudo S . Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort. Int J Colorectal Dis. 2014; 29(10):1275-84. DOI: 10.1007/s00384-014-1947-2. View

Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T . Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc. 2006; 64(6):877-83. DOI: 10.1016/j.gie.2006.03.932. View

Fujita M, Shiotani A, Murao T, Ishii M, Yamanaka Y, Nakato R . Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics. Dig Endosc. 2014; 27(1):25-9. DOI: 10.1111/den.12303. View

Terasaki M, Tanaka S, Shigita K, Asayama N, Nishiyama S, Hayashi N . Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms. Int J Colorectal Dis. 2014; 29(7):877-82. DOI: 10.1007/s00384-014-1901-3. View

Otake Y, Saito Y, Sakamoto T, Aoki T, Nakajima T, Toyoshima N . New closure technique for large mucosal defects after endoscopic submucosal dissection of colorectal tumors (with video). Gastrointest Endosc. 2012; 75(3):663-7. DOI: 10.1016/j.gie.2011.10.037. View

Matsuda T, Fujii T, Emura F, Kozu T, Saito Y, Ikematsu H . Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest Endosc. 2004; 60(5):836-8. DOI: 10.1016/s0016-5107(04)02033-4. View

Anderson M, Ben-Menachem T, Gan S, Appalaneni V, Banerjee S, Cash B . Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009; 70(6):1060-70. DOI: 10.1016/j.gie.2009.09.040. View

Fujimoto K, Fujishiro M, Kato M, Higuchi K, Iwakiri R, Sakamoto C . Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2013; 26(1):1-14. DOI: 10.1111/den.12183. View

Pollack Jr C, Reilly P, Eikelboom J, Glund S, Verhamme P, Bernstein R . Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015; 373(6):511-20. DOI: 10.1056/NEJMoa1502000. View

10.

Wahl M . Dental surgery in anticoagulated patients. Arch Intern Med. 1998; 158(15):1610-6. DOI: 10.1001/archinte.158.15.1610. View

11.

Ono S, Fujishiro M, Niimi K, Goto O, Kodashima S, Yamamichi N . Technical feasibility of endoscopic submucosal dissection for early gastric cancer in patients taking anti-coagulants or anti-platelet agents. Dig Liver Dis. 2009; 41(10):725-8. DOI: 10.1016/j.dld.2009.01.007. View

12.

Inoue T, Nishida T, Maekawa A, Tsujii Y, Akasaka T, Kato M . Clinical features of post-polypectomy bleeding associated with heparin bridge therapy. Dig Endosc. 2013; 26(2):243-9. DOI: 10.1111/den.12123. View

13.

Sanomura Y, Oka S, Tanaka S, Numata N, Higashiyama M, Kanao H . Continued use of low-dose aspirin does not increase the risk of bleeding during or after endoscopic submucosal dissection for early gastric cancer. Gastric Cancer. 2013; 17(3):489-96. PMC: 4072060. DOI: 10.1007/s10120-013-0305-3. View

14.

Oka S, Tanaka S, Kanao H, Ishikawa H, Watanabe T, Igarashi M . Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan. Dig Endosc. 2010; 22(4):376-80. DOI: 10.1111/j.1443-1661.2010.01016.x. View

15.

Shindo Y, Matsumoto S, Miyatani H, Yoshida Y, Mashima H . Risk factors for postoperative bleeding after gastric endoscopic submucosal dissection in patients under antithrombotics. World J Gastrointest Endosc. 2016; 8(7):349-56. PMC: 4823674. DOI: 10.4253/wjge.v8.i7.349. View

16.

Boustiere C, Veitch A, Vanbiervliet G, Bulois P, Deprez P, Laquiere A . Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2011; 43(5):445-61. DOI: 10.1055/s-0030-1256317. View

17.

Veitch A, Baglin T, Gershlick A, Harnden S, Tighe R, Cairns S . Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut. 2008; 57(9):1322-9. DOI: 10.1136/gut.2007.142497. View

18.

Matsumura T, Arai M, Maruoka D, Okimoto K, Minemura S, Ishigami H . Risk factors for early and delayed post-operative bleeding after endoscopic submucosal dissection of gastric neoplasms, including patients with continued use of antithrombotic agents. BMC Gastroenterol. 2014; 14:172. PMC: 4287424. DOI: 10.1186/1471-230X-14-172. View

19.

Garcia D, Regan S, Henault L, Upadhyay A, Baker J, Othman M . Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med. 2008; 168(1):63-9. DOI: 10.1001/archinternmed.2007.23. View

20.

Shigita K, Oka S, Tanaka S, Sumimoto K, Hirano D, Tamaru Y . Long-term outcomes after endoscopic submucosal dissection for superficial colorectal tumors. Gastrointest Endosc. 2016; 85(3):546-553. DOI: 10.1016/j.gie.2016.07.044. View