Rates and risk factors of bleeding after gastric endoscopic submucosal dissection with continuous warfarin or 1-day withdrawal of direct oral anticoagulants

Shoichiro Hirata; Kenta Hamada; Masaya Iwamuro; Hirokazu Mouri; Koji Miyahara; Takao Tsuzuki; Kenji Yamauchi; Sayo Kobayashi; Sakuma Takahashi; Ryuta Takenaka; Shinichiro Hori; Masafumi Inoue; Tatsuya Toyokawa; Mamoru Nishimura; Shuhei Ishiyama; Jiro Miyaike; Ryo Kato; Minoru Matsubara; Naoko Yunoki; Hiromitsu Kanzaki; Yoshiro Kawahara; Hiroyuki Okada; Hideki Ishikawa; Motoyuki Otsuka; Okayama Gut Study Group

doi:10.1111/jgh.16757

Rates and risk factors of bleeding after gastric endoscopic submucosal dissection with continuous warfarin or 1-day withdrawal of direct oral anticoagulants

J Gastroenterol Hepatol. 2024 Oct 3. doi: 10.1111/jgh.16757. Online ahead of print.

Authors

Shoichiro Hirata¹, Kenta Hamada², Masaya Iwamuro¹, Hirokazu Mouri³, Koji Miyahara⁴, Takao Tsuzuki⁵, Kenji Yamauchi^{6

7}, Sayo Kobayashi⁸, Sakuma Takahashi⁷, Ryuta Takenaka⁹, Shinichiro Hori^{5

10}, Masafumi Inoue¹¹, Tatsuya Toyokawa¹², Mamoru Nishimura¹³, Shuhei Ishiyama¹⁴, Jiro Miyaike¹⁵, Ryo Kato^{16

17}, Minoru Matsubara¹⁸, Naoko Yunoki¹⁹, Hiromitsu Kanzaki^{1

9}, Yoshiro Kawahara², Hiroyuki Okada^{1

5}, Hideki Ishikawa²⁰, Motoyuki Otsuka¹; Okayama Gut Study Group

Affiliations

¹ Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
² Department of Practical Gastrointestinal Endoscopy, Okayama University, Okayama, Japan.
³ Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Japan.
⁴ Department of Internal Medicine, Hiroshima City Hospital, Hiroshima, Japan.
⁵ Department of Gastroenterology, Japanese Red Cross Society Himeji Hospital, Himeji, Japan.
⁶ Department of Gastroenterology, Mitoyo General Hospital, Kanonji, Japan.
⁷ Department of Gastroenterology, Kagawa Prefectural Central Hospital, Takamatsu, Japan.
⁸ Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan.
⁹ Department of Internal Medicine, Tsuyama Chuo Hospital, Tsuyama, Japan.
¹⁰ Department of Endoscopy, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan.
¹¹ Department of Gastroenterology, Japanese Red Cross Okayama Hospital, Okayama, Japan.
¹² Department of Gastroenterology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan.
¹³ Department of Internal Medicine, Okayama City Hospital, Okayama, Japan.
¹⁴ Department of Internal Medicine, Okayama Saiseikai General Hospital, Okayama, Japan.
¹⁵ Department of Internal Medicine, Saiseikai Imabari Hospital, Imabari, Japan.
¹⁶ Department of Gastroenterology, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan.
¹⁷ Department of Gastroenterology, Okayama Rosai Hospital, Okayama, Japan.
¹⁸ Department of Internal Medicine, Sumitomo Besshi Hospital, Niihama, Japan.
¹⁹ Department of Internal Medicine, Akaiwa Medical Association Hospital, Akaiwa, Japan.
²⁰ Department of Molecular-Targeting Prevention, Kyoto Prefectural University of Medicine, Osaka, Japan.

PMID: 39363400
DOI: 10.1111/jgh.16757

Abstract

Background and aim: The 2017 Japanese guidelines recommend continuing warfarin therapy during the perioperative period or discontinuing direct oral anticoagulants (DOACs) only on the day of endoscopic submucosal dissection for early gastric cancer. However, their safety has not been sufficiently explored. This study aimed to validate this management method.

Methods: This retrospective, multicenter study analyzed the characteristics and outcomes of patients who underwent gastric endoscopic submucosal dissection between July 2017 and June 2019. The patients were categorized according to the use of warfarin or DOACs.

Results: Among the 62 eligible patients, 53 (85%) were male (median age, 76 years). Warfarin was used in 10 patients (16%) and DOACs in 52 patients (84%). Fourteen patients taking DOACs (27%) used concomitant antiplatelet agents, with seven patients (13%) continuing treatment at the time of the endoscopic procedure. No postprocedural bleeding occurred in patients receiving warfarin (0%), whereas 10 cases (19%) of bleeding occurred in patients receiving DOACs: rivaroxaban, 0% (0/22); dabigatran, 0% (0/2); edoxaban, 43% (6/14); and apixaban, 29% (4/14). The type of anticoagulant (P < 0.01) and continuation of antiplatelet therapy (P = 0.02) were risk factors for postprocedural bleeding in patients receiving DOACs. Intraprocedural bleeding requiring transfusion or symptomatic thromboembolic events were not reported.

Conclusions: Continuous warfarin therapy is preferred. DOAC withdrawal 1 day before a procedure is associated with a high bleeding rate, which may differ for different types of anticoagulants. The continuation of antiplatelet medications in patients receiving DOACs carries a high risk of bleeding and is a future challenge.

Keywords: direct oral anticoagulants; endoscopic submucosal dissection; gastric cancer; postprocedural bleeding; warfarin.