Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; Department of Gastroenterology, People's Hospital of Deyang, Deyang, Sichuan, P.R. China.
Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
Gastrointest Endosc. 2017 Nov;86(5):807-816. doi: 10.1016/j.gie.2017.07.017. Epub 2017 Jul 19.
Bleeding is the most common adverse event after endoscopic submucosal dissection (ESD). Although several studies have reported on the use of antithrombotic agents and post-ESD bleeding, many issues remain controversial. We conducted a meta-analysis and systematic review to evaluate the effects of antithrombotic therapy on post-ESD bleeding.
The published literature was searched on online databases, and all studies were included up to January 2017. Standard forms were used to extract data by 2 independent reviewers. The Newcastle-Ottawa Scale score was used to assess the quality of studies. The pooled odds ratio (OR) was computed for the effect of antithrombotic agents. Publication bias was assessed by funnel plots. Heterogeneity was assessed by the Cochran Q test and I statistic.
Sixteen retrospective articles were included. Regardless of discontinuation (OR, 1.66; 95% confidence interval [CI], 1.15-2.39; P = .007) or continuation (OR, 8.39; 95% CI, 4.64-15.17; P < .00001), antithrombotic therapy was significantly associated with post-ESD bleeding, particularly for delayed bleeding (OR, 2.66; 95% CI, 1.42-4.98; P = .002). The bleeding rate was higher in the discontinued multiple antithrombotics group (OR, 5.17; 95% CI, 3.13-8.54; P < .00001) than in the discontinued a single antithrombotic group (OR, 2.23; 95% CI, 1.29-3.85; P = .004) and single antiplatelet group (OR, 2.08; 95% CI, 0.93-4.63; P = .07). In the subgroup analysis, resuming antithrombotics within 1 week (OR, 2.46; 95% CI, 1.54-3.93; P = .0002) and using heparin replacement (OR, 4.20; 95% CI, 1.94-9.09; P= .0003) significantly increased post-ESD bleeding risk. Continued use of low-dose aspirin (OR, 1.22; 95% CI, 0.17-8.61; P = .84) did not significantly increase the bleeding risk.
Antithrombotic therapy is a risk factor for post-ESD bleeding, especially for delayed bleeding. Using multiple antithrombotic drugs, resuming antithrombotics within 1 week, and heparin replacement were significantly associated with post-ESD bleeding; but continuous low-dose aspirin was not. However, much larger prospective studies are required.
出血是内镜黏膜下剥离术（ESD）后最常见的不良事件。虽然有几项研究报告了抗血栓药物和 ESD 后出血的情况，但仍有许多问题存在争议。我们进行了一项荟萃分析和系统评价，以评估抗血栓治疗对 ESD 后出血的影响。
在在线数据库中搜索已发表的文献，并将所有研究纳入截止到 2017 年 1 月。由 2 位独立的评审员使用标准表格提取数据。使用纽卡斯尔-渥太华量表评分评估研究质量。计算抗血栓药物对效应的合并优势比（OR）。通过漏斗图评估发表偏倚。使用 Cochran Q 检验和 I 统计量评估异质性。
纳入了 16 篇回顾性文章。无论抗血栓药物是否停药（OR，1.66；95%置信区间[CI]，1.15-2.39；P=.007）或持续用药（OR，8.39；95% CI，4.64-15.17；P<.00001），抗血栓治疗与 ESD 后出血显著相关，尤其是延迟性出血（OR，2.66；95% CI，1.42-4.98；P=.002）。在停药的多种抗血栓药物组中，出血发生率更高（OR，5.17；95% CI，3.13-8.54；P<.00001），而在停药的单一抗血栓药物组（OR，2.23；95% CI，1.29-3.85；P=.004）和单一抗血小板药物组（OR，2.08；95% CI，0.93-4.63；P=.07）中则较低。在亚组分析中，在 1 周内重新开始抗血栓治疗（OR，2.46；95% CI，1.54-3.93；P=.0002）和使用肝素替代物（OR，4.20；95% CI，1.94-9.09；P=.0003）显著增加了 ESD 后出血的风险。持续使用低剂量阿司匹林（OR，1.22；95% CI，0.17-8.61；P=.84）并不显著增加出血风险。
抗血栓治疗是 ESD 后出血的一个危险因素，尤其是延迟性出血。使用多种抗血栓药物、在 1 周内重新开始抗血栓治疗以及肝素替代物与 ESD 后出血显著相关；而持续使用低剂量阿司匹林则没有显著增加出血风险。但是，还需要更大规模的前瞻性研究。
