Gastric ESD under Heparin Replacement at High-Risk Patients of Thromboembolism Is Technically Feasible but Has a High Risk of Delayed Bleeding: Osaka University ESD Study Group
Objectives. Heparin replacement (HR) is often performed in patients with a high risk of thrombosis undergoing endoscopic procedures. However, information about the influence of HR is scarce. The aim of this study is to assess the clinical impact of HR for gastric endoscopic submucosal dissection (ESD). Methods. This is a retrospective study comprising approximately 1310 consecutive gastric neoplasms in 1250 patients, who underwent ESD in 5 institutes. We assessed the clinical findings and outcomes of ESD under HR, compared to ESD without HR as control. Results. A total of 24 EGC lesions in 24 patients were treated by ESD under HR. In the HR group, the complete en-bloc resection rate was 100%. The delayed bleeding rate was, however, higher in the HR group than in the controls (38% versus 4.6%). The timing of bleeding in the HR group was significantly later than in controls. In the control group, 209 patients discontinued antithrombotic therapy during perioperative period, and their delayed bleeding rate was not different from those without antithrombotic therapy (5.7% versus. 4.4%). A thromboembolic event was encountered in 1 patient under HR after delayed bleeding. Conclusion. ESD under HR is technically feasible but has a high risk of delayed bleeding. 1. Introduction Endoscopic resection of early gastric cancer (EGC) started as endoscopic mucosal resection (EMR) [1] and has dramatically developed and been applied in many patients, owing to the establishment of criteria for node-negative tumors [2] and the advancements of endoscopic submucosal dissection (ESD) [3–6]. We recently reported, in a multicenter study, that ESD is a feasible method for treating EGC [7] and that long-term outcome of gastric ESD is satisfactory [8]. We also showed that almost all recurrent lesions, synchronous or metachronous, were treatable by endoscopic resection by scheduled endoscopic surveillance [8]. ESD has become a more acceptable option for EGC than gastrectomy in elderly patients, who often have several comorbidities [9] and accompanying medication such as antithrombogenic agents for the primary and secondary prevention of cerebrovascular and cardiovascular diseases. Some patients with comorbidities such as valvular heart disease, atrial fibrillation with history of cerebrovascular accident have a high risk of developing thrombotic disease. Discontinuation of antithrombotic agents in these patients may cause life-threatening cerebrovascular and cardiovascular events. Such patients are often treated under heparin replacement (HR) of antithrombotic drugs, as a bridge
References
[1]
B. J. Rembacken, T. Gotoda, T. Fujii, and A. T. R. Axon, “Endoscopic mucosal resection,” Endoscopy, vol. 33, no. 8, pp. 709–718, 2001.
[2]
T. Gotoda, A. Yanagisawa, M. Sasako et al., “Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers,” Gastric Cancer, vol. 3, no. 4, pp. 219–225, 2000.
[3]
H. Yamamoto, H. Kawata, K. Sunada et al., “Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate,” Gastrointestinal Endoscopy, vol. 56, no. 4, pp. 507–512, 2002.
[4]
N. Yahagi, M. Fujishiro, N. Kakushima et al., “Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type),” Digestive Endoscopy, vol. 16, no. 1, pp. 34–38, 2004.
[5]
T. Oyama, A. Tomori, K. Hotta et al., “Endoscopic submucosal dissection of early esophageal cancer,” Clinical Gastroenterology and Hepatology, vol. 3, no. 7, pp. S67–S70, 2005.
[6]
I. Oda, T. Gotoda, H. Hamanaka et al., “Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series,” Digestive Endoscopy, vol. 17, no. 1, pp. 54–58, 2005.
[7]
T. Akasaka, T. Nishida, S. Tsutsui et al., “Short-term outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasm: multicenter survey by osaka university ESD study group,” Digestive Endoscopy, vol. 23, no. 1, pp. 73–77, 2011.
[8]
M. Kato, T. Nishida, K. Yamamoto, et al., “Scheduled endoscopic surveillance controls secondary cancer after curative endoscopic resection for early gastric cancer: a multicentre retrospective cohort study by Osaka University ESD study group,” Gut. In press.
[9]
N. Kakushima, M. Fujishiro, S. Kodashima et al., “Technical feasibility of endoscopic submucosal dissection for gastric neoplasms in the elderly Japanese population,” Journal of Gastroenterology and Hepatology, vol. 22, no. 3, pp. 311–314, 2007.
[10]
G. M. Eisen, T. H. Baron, J. A. Dominitz et al., “Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures,” Gastrointestinal Endoscopy, vol. 55, no. 7, pp. 775–779, 2002.
[11]
M. J. Zuckerman, W. K. Hirota, D. G. Adler et al., “ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures,” Gastrointestinal Endoscopy, vol. 61, no. 2, pp. 189–194, 2005.
[12]
C. Boustière, A. Veitch, G. Vanbiervliet et al., “Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline,” Endoscopy, vol. 43, no. 5, pp. 445–461, 2011.
[13]
S.-Y. Lee, S.-J. Tang, D. C. Rockey et al., “Managing anticoagulation and antiplatelet medications in GI endoscopy: a survey comparing the East and the West,” Gastrointestinal Endoscopy, vol. 67, no. 7, pp. 1076–1081, 2008.
[14]
S. Ono, M. Fujishiro, K. Niimi et al., “Technical feasibility of endoscopic submucosal dissection for early gastric cancer in patients taking anti-coagulants or anti-platelet agents,” Digestive and Liver Disease, vol. 41, no. 10, pp. 725–728, 2009.
[15]
K. Takizawa, I. Oda, T. Gotoda et al., “Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection—an analysis of risk factors,” Endoscopy, vol. 40, no. 3, pp. 179–183, 2008.
[16]
O. Goto, M. Fujishiro, S. Kodashima et al., “A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding,” Gastrointestinal Endoscopy, vol. 71, no. 2, pp. 241–248, 2010.
[17]
K. D. Choi, H.-Y. Jung, G. H. Lee et al., “Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding,” Surgical Endoscopy and Other Interventional Techniques, vol. 22, no. 8, pp. 1882–1886, 2008.
[18]
J. H. Lim, S. G. Kim, J. W. Kim et al., “Do antiplatelets increase the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms?” Gastrointestinal Endoscopy, vol. 75, no. 4, pp. 719–727, 2012.
