Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon, 7910295, Japan.
Gastroenterology Center, Ehime Prefectural Central Hospital, Kasugamachi 83, Matsuyama, 7900024, Japan.
Gastric Cancer. 2021 Jan;24(1):179-189. doi: 10.1007/s10120-020-01105-0. Epub 2020 Jul 18.
Delayed bleeding after gastric endoscopic submucosal dissection (ESD) in patients receiving anticoagulants remains an unpreventable adverse event. Although direct-acting oral anticoagulants (DOACs) have superior efficacy in preventing thromboembolism, their effects on the occurrence of delayed bleeding remain unclear. This study aimed to elucidate the clinical effect of DOACs on delayed bleeding after gastric ESD.
We retrospectively examined 728 patients who received anticoagulants and were treated for gastric neoplasms with ESD in 25 institutions across Japan. Overall, 261 patients received DOACs, including dabigatran (92), rivaroxaban (103), apixaban (45) and edoxaban (21), whereas 467 patients were treated with warfarin.
Delayed bleeding occurred in 14% of patients taking DOACs, which was not considerably different in patients receiving warfarin (18%). Delayed bleeding rate was significantly lower in patients receiving dabigatran than in those receiving warfarin and lower than that observed for other DOACs. Multivariate analysis showed that age ≥ 65, receiving multiple antithrombotic agents, resection of multiple lesions and lesion size ≥ 30 mm were independent risk factors, and that discontinuation of anticoagulants was associated with a decreased risk of bleeding. In multivariate analysis among patients taking DOACs, dabigatran therapy was associated with a significantly lower risk of delayed bleeding.
The effects of DOACs on delayed bleeding varied between agents, but dabigatran therapy was associated with the lowest risk of delayed bleeding. Switching oral anticoagulants to dabigatran during the perioperative period could be a reasonable option to reduce the risk of delayed bleeding after gastric ESD.
接受抗凝治疗的患者在胃内镜黏膜下剥离（ESD）后发生延迟性出血仍然是一种不可预防的不良事件。虽然直接作用的口服抗凝剂（DOAC）在预防血栓栓塞方面具有更好的疗效，但它们对延迟性出血发生的影响仍不清楚。本研究旨在阐明 DOAC 对胃 ESD 后延迟性出血的临床效果。
我们回顾性检查了 728 名在日本 25 家机构接受抗凝治疗并接受胃肿瘤 ESD 治疗的患者。共有 261 名患者接受了 DOAC 治疗，包括达比加群（92 例）、利伐沙班（103 例）、阿哌沙班（45 例）和依度沙班（21 例），而 467 例患者接受了华法林治疗。
接受 DOAC 治疗的患者中发生延迟性出血的比例为 14%，与接受华法林治疗的患者（18%）没有显著差异。接受达比加群治疗的患者的延迟性出血率明显低于接受华法林治疗的患者，也低于其他 DOAC 治疗的患者。多变量分析显示，年龄≥65 岁、接受多种抗血栓药物、切除多个病灶和病灶大小≥30mm 是独立的危险因素，停止抗凝治疗与出血风险降低有关。在接受 DOAC 治疗的患者中进行的多变量分析显示，达比加群治疗与延迟性出血的风险显著降低相关。
DOAC 对延迟性出血的影响因药物而异，但达比加群治疗与延迟性出血的风险最低相关。在围手术期将口服抗凝药物转换到达比加群可能是降低胃 ESD 后延迟性出血风险的合理选择。
