Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,
Digestion. 2021;102(2):256-264. doi: 10.1159/000504597. Epub 2019 Nov 26.
Management of antithrombotic agents during endoscopic treatment changed after the publishing of -Japan Gastroenterological Endoscopy Society guidelines for gastroenterological endoscopy in antithrombotic drug users (GL-2012).
We aimed to evaluate the effect of implementing antithrombotic agent management guidelines (GL-2012) on postoperative bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and on the prevention of thromboembolic events.
A total of 1,264 patients who underwent ESD for EGC at Kyoto Prefectural University Hospital between June 2002 and March 2017 were enrolled and divided into 2 groups: 621 patients before the publication of GL-2012 (Pre-GL group) and 643 patients after (Post-GL group). Relationships between postoperative bleeding and various clinicopathological factors in each group were investigated through propensity score-matching analysis.
In the Pre-GL group, antihypertensive agent use (p < 0.01) and upper third of the stomach (p < 0.01) were significantly related to postoperative bleeding in univariate analysis. Antihypertensive agent use (OR 4.6, 95% CI 1.6-12.8) and upper third of the stomach (OR 4.9, 95% CI 1.8-13.4) were significantly related to postoperative bleeding in multivariate analysis. In the Post-GL group, antihypertensive agent use (p < 0.01), dual antiplatelet agents use (p < 0.01), anticoagulant agents use (p < 0.01), and heparin replacement therapy (p < 0.01) were significantly related to postoperative bleeding in univariate analysis. Antihypertensive agent use (OR 3.4, 95% CI 1.1-9.6), dual antiplatelet agents (OR 12.3, 95% CI 2.4-63.0), and heparin replacement therapy (OR 10.2, 95% CI 2.5-41.5) were significantly related to postoperative bleeding in multivariate analysis.
The adherence to GL-2012 might reduce risk of thromboembolic events. On the other hand, dual antiplatelet agents therapy and heparin replacement therapy were the new independent risk factors for ESD postoperative bleeding in EGC after GL-2012. Especially as for heparin replacement therapy, uninterrupted warfarin or a temporary short interruption of direct oral anticoagulants without heparin replacement therapy might be recommended rather than heparin replacement therapy.
抗血栓药物使用者胃肠内镜治疗日本胃肠内镜学会指南（GL-2012）发布后，内镜治疗中抗血栓药物的管理发生了变化。
我们旨在评估实施抗血栓药物管理指南（GL-2012）对早期胃癌（EGC）内镜黏膜下剥离术（ESD）后术后出血的影响，以及对预防血栓栓塞事件的影响。
京都府立大学医院 2002 年 6 月至 2017 年 3 月期间，共纳入 1264 例接受 ESD 治疗的 EGC 患者，分为 2 组：GL-2012 发布前的 621 例（Pre-GL 组）和发布后的 643 例（Post-GL 组）。通过倾向评分匹配分析，研究每组中术后出血与各种临床病理因素之间的关系。
在 Pre-GL 组中，抗高血压药物的使用（p < 0.01）和胃上部（p < 0.01）在单因素分析中与术后出血显著相关。抗高血压药物的使用（OR 4.6，95%CI 1.6-12.8）和胃上部（OR 4.9，95%CI 1.8-13.4）在多因素分析中与术后出血显著相关。在 Post-GL 组中，抗高血压药物的使用（p < 0.01）、双联抗血小板药物的使用（p < 0.01）、抗凝药物的使用（p < 0.01）和肝素替代治疗（p < 0.01）在单因素分析中与术后出血显著相关。抗高血压药物的使用（OR 3.4，95%CI 1.1-9.6）、双联抗血小板药物（OR 12.3，95%CI 2.4-63.0）和肝素替代治疗（OR 10.2，95%CI 2.5-41.5）在多因素分析中与术后出血显著相关。
遵守 GL-2012 可能会降低血栓栓塞事件的风险。另一方面，双联抗血小板药物治疗和肝素替代治疗是 GL-2012 后 EGC ESD 术后出血的新的独立危险因素。特别是对于肝素替代治疗，建议不间断使用华法林或暂时短暂中断直接口服抗凝剂而不进行肝素替代治疗，而不是进行肝素替代治疗。
