Yamashita Ken, Oka Shiro, Tanaka Shinji, Boda Kazuki, Hirano Daiki, Sumimoto Kyoku, Mizumoto Takeshi, Ninomiya Yuki, Tamaru Yuzuru, Shigita Kenjiro, Hayashi Nana, Sanomura Yoji, Chayama Kazuaki
Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan.
Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan.
Endosc Int Open. 2018 Jul;6(7):E857-E864. doi: 10.1055/a-0593-5788. Epub 2018 Jul 4.
Japanese guidelines for gastroenterological endoscopy have recommended temporary withdrawal of anticoagulants (warfarin, direct oral anticoagulants [DOAC], or heparin) to prevent hemorrhagic complications during endoscopic submucosal dissection (ESD) for colorectal neoplasias (CRNs). However, serious thrombosis might occur during temporary withdrawal of anticoagulants. The current study aimed to evaluate outcomes with anticoagulants in patients undergoing ESD for CRNs.
This study was a single-institution retrospective cohort study based on clinical records. We assessed 650 consecutive patients with 698 CRNs who underwent ESD at Hiroshima University Hospital between December 2010 and June 2016. The patients were divided into three groups: the warfarin group (19 patients with 19 CRNs), DOAC group (7 patients with 9 CRNs), and no-antithrombotics group (624 patients with 670 CRNs). We replaced warfarin with heparin 3 to 5 days before endoscopy. Although DOAC was suspended on the morning of endoscopy, we did not replace heparin.
Bleeding after the procedure occurred in 26.3 % (5/19), 22.0 % (2/9), and 2.7 % (18/670) of patients in the warfarin, DOAC, and no-antithrombotics groups, respectively. In the warfarin group, four patients who bled after the procedure took not only warfarin but also other antiplatelets. En bloc resection rates were 94.7 % (18/19), 100 % (9/9), and 96.6 % (647/670) in the warfarin, DOAC, and no-antithrombotics groups, respectively. No patients experienced ischemic events in the perioperative period.
Among patients undergoing ESD for CRNs, risk of bleeding was higher among patients who took anticoagulants than among those who did not. In particular, careful attention to patients who took antiplatelets in addition to warfarin before ESD for CRNs is warranted.
日本胃肠内镜指南建议在内镜下黏膜剥离术（ESD）治疗结直肠肿瘤（CRN）期间临时停用抗凝剂（华法林、直接口服抗凝剂[DOAC]或肝素），以预防出血并发症。然而，在临时停用抗凝剂期间可能会发生严重血栓形成。本研究旨在评估接受CRN的ESD患者使用抗凝剂的结局。
本研究是一项基于临床记录的单机构回顾性队列研究。我们评估了2010年12月至2016年6月在广岛大学医院接受ESD的650例连续患者的698个CRN。患者分为三组：华法林组（19例患者的19个CRN）、DOAC组（7例患者的9个CRN）和无抗栓药物组（624例患者的670个CRN）。在内镜检查前3至5天，我们用肝素替代华法林。虽然DOAC在内镜检查当天上午停用，但我们未用肝素替代。
华法林组、DOAC组和无抗栓药物组术后出血发生率分别为26.3%（5/19）、22.0%（2/9）和2.7%（18/670）。在华法林组中，术后出血的4例患者不仅服用了华法林，还服用了其他抗血小板药物。华法林组、DOAC组和无抗栓药物组的整块切除率分别为94.7%（18/19）、100%（9/9）和96.6%（647/670）。围手术期无患者发生缺血事件。
在接受CRN的ESD患者中，服用抗凝剂的患者出血风险高于未服用抗凝剂的患者。特别是，对于在CRN的ESD术前除华法林外还服用抗血小板药物的患者，需要格外关注。
