The postoperative bleeding rate and its risk factors in patients on antithrombotic therapy who undergo gastric endoscopic submucosal dissection

BMC Gastroenterol. 2013 Sep 6;13:136. doi: 10.1186/1471-230X-13-136.

Abstract

Background: 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.

Methods: The 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.

Results: The 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.

Conclusions: The 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.

MeSH terms

  • Adenoma / surgery
  • Aged
  • Anti-Ulcer Agents / therapeutic use
  • Anticoagulants / adverse effects*
  • Anticoagulants / therapeutic use
  • Aspirin / adverse effects
  • Aspirin / therapeutic use
  • Carcinoma / surgery
  • Case-Control Studies
  • Clopidogrel
  • Dissection
  • Female
  • Gastric Mucosa / surgery*
  • Gastrointestinal Hemorrhage / chemically induced
  • Gastrointestinal Hemorrhage / epidemiology*
  • Gastroscopy
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Odds Ratio
  • Platelet Aggregation Inhibitors / adverse effects*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Postoperative Hemorrhage / chemically induced
  • Postoperative Hemorrhage / epidemiology*
  • Proton Pump Inhibitors / therapeutic use
  • Retrospective Studies
  • Risk Factors
  • Stomach Diseases / epidemiology*
  • Stomach Neoplasms / surgery*
  • Stomach Ulcer / prevention & control
  • Thienopyridines / therapeutic use
  • Ticlopidine / analogs & derivatives
  • Ticlopidine / therapeutic use
  • Warfarin / adverse effects
  • Warfarin / therapeutic use

Substances

  • Anti-Ulcer Agents
  • Anticoagulants
  • Platelet Aggregation Inhibitors
  • Proton Pump Inhibitors
  • Thienopyridines
  • Warfarin
  • Clopidogrel
  • Ticlopidine
  • Aspirin