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The effect of anticoagulants on delayed bleeding after colorectal endoscopic submucosal dissection

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Abstract

Background and aims

The withdrawal of antithrombotic therapy from patients at high risk of thromboembolism is controversial. Previously, treatment with anticoagulants, such as warfarin and dabigatran, was recommended for heparin bridge therapy (HBT) during endoscopic submucosal dissection (ESD). However, HBT is associated with a high risk of bleeding during and after ESD. This study aimed to investigate the clinical outcomes of colorectal ESD in patients treated with warfarin and direct oral anticoagulants (DOAC).

Methods

This study included 412 patients with superficial colorectal neoplasms that were resected by ESD between June 2010 and June 2018. The patients were classified into two groups: without antithrombotics (n = 286) and with anticoagulants (n = 51). The anticoagulants group was further divided into two groups: warfarin (n = 26) and DOAC (n = 25).

Results

Among all patients, delayed bleeding occurred in 35 (8.5% [35/412]) patients. The bleeding rate in the anticoagulants group (11.8% [6/51]) was higher than that in the group without antithrombotics (6.6% [19/286]), but the difference was not statistically significant (P = 0.240). The bleeding rate in the DOAC group (16.0% [4/25]) was higher than that in the warfarin group (7.7% [2/26]), but the difference was not statistically significant (P = 0.419). All delayed bleeding was successfully managed with endoscopic hemostasis. Thromboembolic events were not observed in any patients.

Conclusions

The bleeding rate with anticoagulants was relatively high. However, all bleeding events with anticoagulants were minor and clinically controllable. Colorectal ESD with DOAC and warfarin may be feasible and acceptable.

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Abbreviations

BMI:

Body mass index

CI:

Confidence interval

CKD:

Chronic kidney disease

DOAC:

Direct oral anticoagulants

ESD:

Endoscopic submucosal dissection

HBT:

Heparin bridge therapy

INR:

International normalized ratio

LST-G:

Laterally spreading tumor: granular type

LST-NG:

Laterally spreading tumor: non-granular type

OR:

Odds ratio

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Author notes

  1. Hideaki Harada, Ryotaro Nakahara, Daisuke Murakami, Satoshi Suehiro, Takuya Nagasaka, Tetsuro Ujihara, Ryota Sagami, Yasushi Katsuyama & Kenji Hayasaka

    Present address: Department of Gastroenterology, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan

Authors and Affiliations

  1. Department of Gastroenterology, Secomedic Hospital, Chiba, Japan

    Shigetaka Tounou

  2. Department of Endoscopy, New Tokyo Hospital, Chiba, Japan

    Yuji Amano

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  1. Hideaki Harada
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Contributions

HH wrote the manuscript and analyzed the data. AY gave final approval of the manuscript. All other authors collected data, reviewed the manuscript, and made revisions.

Corresponding author

Correspondence to Hideaki Harada.

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Disclosures

Hideaki Harada, Ryotaro Nakahara, Daisuke Murakami, Satoshi Suehiro, Takuya Nagasaka, Tetsuro Ujihara, Ryota Sagami, Yasushi Katsuyama, Kenji Hayasaka, Shigetaka Tounou, and Yuji Amano declare that they have no conflicts of interest or financial ties to disclose.

Ethical approval

This study was reviewed and approved by the New Tokyo Hospital Institutional Review Committee.

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The patient provided informed written consent.

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Harada, H., Nakahara, R., Murakami, D. et al. The effect of anticoagulants on delayed bleeding after colorectal endoscopic submucosal dissection. Surg Endosc 34, 3330–3337 (2020). https://doi.org/10.1007/s00464-019-07101-5

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  • DOI: https://doi.org/10.1007/s00464-019-07101-5

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