The risks and characteristics of the delayed bleeding after endoscopic submucosal dissection for early gastric carcinoma in cases with anticoagulants

Abstract

Background

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric carcinoma. Vitamin K antagonists and direct oral anticoagulants (DOAC) were reported to increase the risk of delayed bleeding after ESD. However, the evaluation of ESD cases taking anticoagulants is scarce. We analyzed the risk and characteristics of delayed bleeding after gastric ESD in patients on anticoagulants.

Methods

We performed a retrospective observational study at a single center. Consecutive patients who underwent ESD for early gastric carcinoma and took anticoagulants, including warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban, between January 2012 and December 2018, were analyzed. We also calculated delayed bleeding rates for those without anticoagulants.

Results

Of 1855 eligible patients who underwent gastric ESDs, 143 took anticoagulants. Delayed bleeding occurred in 30 (21.0%) cases taking anticoagulants, with 15 (19.5%) cases in the DOAC group [rivaroxaban, seven cases (21.2%); dabigatran, four cases (20.0%); apixaban, four cases (23.5%); and edoxaban, zero cases (0%)] and 15 cases (22.7%) in the warfarin group. Furthermore, 43/344 (12.5%) patients taking antiplatelets and 76/1368 (5.6%) patients without antithrombic drugs experienced delayed bleeding. Multivariable logistic analysis revealed post-heart valve replacement (OR, 6.56; 95% CI, 1.75–24.7; p < .05) as a risk for delayed bleeding in warfarin-taking patients, while no statistically significant factor was found in DOAC-taking patients.

Conclusions

Anticoagulants were associated with a high incidence of severe delayed bleeding. Careful attention should be paid to patients on anticoagulants after gastric ESD, especially those on warfarin after heart valve replacement.

Keywords:

• ESD
• endoscopic submucosal dissection
• direct oral anticoagulants
• vitamin K antagonists
• early gastric carcinoma
• bleeding

Acknowledgments

The authors thank Editage (www.editage.jp) for their English language editing. Editage was compensated for their work.

Author contributions

H.S. had full access to all data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: H.S., K.I., and Y.N. Data acquisition: H.S. Analysis and interpretation of data: H.S. Drafting of the manuscript: H.S., K.I., and Y.N. Supervision: D.H., A.C., and T.M.

Disclosure statement

Drs. Hiroaki Saito and Kenjiro Suzuki report an honorarium from TAIHO Pharmaceutical Co., Ltd, outside of the submitted work. Drs. Yukari Tanaka, Dai Hirasawa, and Toru Okuzono report an honorarium from Daiichi Sankyo Company outside of the submitted work. Drs. Yukari Tanaka and Tomoki Matsuda report an honorarium from Pfizer outside of the submitted work. Drs. Akimichi Chonan, Kimihiro Igarashi, Ippei Tanaka, Masaharu Tsubokura, Yoshitaka Nawata, Shuhei Unnno, Yoshitaka Nishikawa, Masato Nakahori, and Yoko Abe declare no conflicts of interest.

Data availability

The data that support the findings of this study are available from the corresponding author, HS, upon reasonable request.