• Anticoagulants
• Endoscopy
• Guideline
• Platelet aggregation inhibitors

• Humans
• Anticoagulants/administration & dosage
• Anticoagulants/adverse effects
• Consensus
• Endoscopy, Gastrointestinal/adverse effects
• Endoscopy, Gastrointestinal/methods
• Endoscopy, Gastrointestinal/standards
• Fibrinolytic Agents/administration & dosage
• Fibrinolytic Agents/adverse effects
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/prevention & control
• Platelet Aggregation Inhibitors/administration & dosage
• Platelet Aggregation Inhibitors/adverse effects
• Republic of Korea

• Anticoagulants
• Endoscopy
• Guideline
• Platelet aggregation inhibitors

• Humans
• Endoscopy, Gastrointestinal
• Fibrinolytic Agents/therapeutic use
• Platelet Aggregation Inhibitors/therapeutic use
• Anticoagulants/therapeutic use
• Consensus
• Gastrointestinal Hemorrhage

• Anticoagulants
• Endoscopy
• Guideline
• Platelet aggregation inhibitors

• Antiplatelet agent
• Bleeding
• Endoscopic submucosal dissection

• Endoscopic submucosal resection
• Fibrinolytic agents
• Postoperative hemorrhage
• Purinergic P2Y receptor antagonists

• Humans
• Platelet Aggregation Inhibitors/adverse effects
• Endoscopic Mucosal Resection/adverse effects
• Purinergic P2Y Receptor Antagonists/adverse effects
• Fibrinolytic Agents/adverse effects
• Stomach Neoplasms/pathology
• Gastric Mucosa/pathology
• Retrospective Studies
• Postoperative Hemorrhage/chemically induced
• Postoperative Hemorrhage/epidemiology
• Risk Factors
• Gastrointestinal Hemorrhage/chemically induced
• Gastrointestinal Hemorrhage/epidemiology

• Gastric cancer
• antithrombotic therapy
• endoloop closure
• endoscopic submucosal dissection
• post-ESD bleeding

Postprocedural bleeding is known to be relatively low after argon plasma coagulation (APC) for gastric neoplasms; however, there are few studies proving the effect of antithrombotic agents. This study aimed to analyze the incidence of delayed bleeding (DB) based on antithrombotic agents administered and to identify the risk factors for DB in APC for gastric tumors.

A total of 785 patients with 824 lesions underwent APC for single gastric neoplasm between January 2011 and January 2018. After exclusion, 719 and 102 lesions were classified as belonging to the non-antithrombotics (non-AT) and AT groups, respectively. The clinical outcomes were compared between the two groups, and we determined the risk factors for DB in gastric APC.

Of the total 821 cases, DB occurred in 20 cases (2.4%) 17 cases in the non-AT group and three cases in the AT group (2.4% vs 2.9%, p=0.728). Multivariate analysis of the risk factors for DB confirmed the following significant, independent risk factors male sex (odds ratio, 7.66; 95% confidence interval, 1.02 to 57.69; p=0.048) and chronic kidney disease (odds ratio, 4.51; 95% confidence interval, 1.57 to 13.02; p=0.005). Thromboembolic events and perforation were not observed in all patients regardless of whether they took AT agents.

AT therapy is acceptably safe in gastric APC because it does not significantly increase the incidence of DB. However, patients with chronic kidney disease or male sex need to receive careful follow-up on the incidence of post-APC bleeding.

• Antithrombotic therapy
• Argon plasma coagulation
• Stomach neoplasm

Postoperative delayed bleeding (PDB) after gastric endoscopic submucosal dissection (ESD) is the most common adverse event in patients receiving antithrombotics even with second-look endoscopy. Moreover, with the increasing prevalence of cardiovascular and cerebrovascular diseases in an aging population with associated lifestyle-related diseases, an increasing number of patients receive antithrombotics. Several attempts have been made to prevent PDB in aging population; however, a consensus has yet to be reached.

To examine the efficacy of third-look endoscopy (TLE) for PDB prevention.

One hundred patients with early gastric neoplasms receiving antithrombotics were prospectively enrolled and subjected to ESD with TLE between February 2017 and July 2019. The primary endpoint was PDB rate, which was compared with our preset threshold. Furthermore, we divided the bleeding period into early-and late-onset PDB (E-PDB and L-PDB, respectively) and analyzed its rate. As a secondary analysis, we compared PDB rates with those of a historical control group, using propensity score matching, and calculated the PDB rates per antithrombotic agent use in each group.

In total, 96 patients and 114 specimens were finally evaluated. The overall PDB rate was 7.9% (9/114) [90%CI: 4.7-13.1, P = 0.005], while the late-and early-onset PDB rates (L-PDB and E-PDB) were 5.3% [90%CI: 2.7-9.9, P < 0.0001] and 2.6% [90%CI: 1.1-6.4, P = 0.51], respectively. Propensity score matching generated 58 matched pairs for TLE and control groups. No differences were found in overall PDB incidence (10.3% vs 20.7%, P = 0.12), whereas L-PDB occurrence significantly differed (5.2% vs 17.2%, P = 0.04) between groups. Considering antithrombotics’ use, the overall PDB rate was higher for direct oral anticoagulants and multiple antithrombotics in the control group, while L-PDB incidence was lower in the TLE group for these agents (8.7% vs 23.1% and 5.0% vs 29.4%, respectively).

TLE for gastric ESD reduces overall PDB, and especially L-PDB incidence, among patients receiving antithrombotics.

• Endoscopic submucosal dissection
• Postoperative delayed bleeding
• Third look endoscopy
• Antithrombotic agents
• Late phase bleeding
• Phase II

• Aged
• Endoscopic Mucosal Resection/adverse effects
• Endoscopy
• Fibrinolytic Agents/adverse effects
• Gastric Mucosa/surgery
• Gastroscopy
• Humans
• Postoperative Hemorrhage/chemically induced
• Postoperative Hemorrhage/epidemiology
• Postoperative Hemorrhage/prevention & control
• Retrospective Studies
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/surgery

Endoscopic submucosal dissection (ESD) for gastric neoplasms during continuous low-dose aspirin (LDA) administration is generally acceptable according to recent guidelines. This retrospective study aimed to investigate the effect of continuous LDA on the postoperative bleeding after gastric ESD in patients receiving dual antiplatelet therapy (DAPT).

To investigate the feasibility of gastric ESD with continuous LDA in patients with DAPT.

A total of 597 patients with gastric neoplasms treated with ESD between January 2010 and June 2017 were enrolled. The patients were categorized according to type of antiplatelet therapy (APT).

The postoperative bleeding rate was 6.9% (41/597) in all patients. Patients were divided into the following two groups: no APT (n = 443) and APT (n = 154). APT included single-LDA (n = 95) and DAPT (LDA plus clopidogrel, n = 59) subgroups. In the single-LDA and DAPT subgroups, 56 and 39 patients were received continuous LDA, respectively. The bleeding rate with continuous single-LDA (10.7%) was similar to that with discontinuous single-LDA (10.3%) (P > 0.99). Although the bleeding rate with continuous LDA in patients receiving DAPT (23.1%) was higher than that with discontinuous LDA in patients receiving DAPT (5.0%), no significant difference was observed (P = 0.141).

The bleeding rate with continuous LDA in patients receiving DAPT was not statistically different from that with discontinuous LDA in patients receiving DAPT. Therefore, continuous LDA administration may be acceptable for ESD in patients receiving DAPT, although patients should be carefully monitored for possible bleeding.

• Dual antiplatelet therapy
• Endoscopic submucosal dissection
• Low-dose aspirin
• Postoperative bleeding
• Thienopyridine

• Aged
• Aged, 80 and over
• Aspirin/administration & dosage
• Aspirin/adverse effects
• Clopidogrel/administration & dosage
• Clopidogrel/adverse effects
• Endoscopic Mucosal Resection/adverse effects
• Endoscopic Mucosal Resection/methods
• Feasibility Studies
• Female
• Gastric Mucosa/blood supply
• Gastric Mucosa/pathology
• Gastric Mucosa/surgery
• Gastrointestinal Hemorrhage/epidemiology
• Gastrointestinal Hemorrhage/etiology
• Gastroscopy/adverse effects
• Gastroscopy/methods
• Humans
• Male
• Middle Aged
• Platelet Aggregation Inhibitors/administration & dosage
• Platelet Aggregation Inhibitors/adverse effects
• Platelet Aggregation Inhibitors/standards
• Postoperative Hemorrhage/epidemiology
• Postoperative Hemorrhage/etiology
• Practice Guidelines as Topic
• Retrospective Studies
• Risk Factors
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Thrombosis/prevention & control
• Treatment Outcome

• Clip
• Delayed bleeding
• Gastric endoscopic submucosal dissection

• antithrombotic agents
• bleeding
• endoscopic submucosal dissection
• stomach

• Aged
• Aged, 80 and over
• Anti-Ulcer Agents/therapeutic use
• Endoscopic Mucosal Resection/adverse effects
• Female
• Fibrinolytic Agents/adverse effects
• Humans
• Male
• Postoperative Hemorrhage/etiology
• Proton Pump Inhibitors/therapeutic use
• Pyrroles
• Retrospective Studies
• Stomach Neoplasms/surgery
• Stomach Ulcer/drug therapy
• Sulfonamides
• Time Factors

Current guidelines recommend withholding antiplatelets for 5–7 days before high-risk endoscopic procedures. We investigated whether this reduces post-endoscopic submucosal dissection (ESD) bleeding.

Gastric ESD cases with antiplatelets were retorospectively reviewed. Withholding antiplatelets for 5–7 days before ESD was defined as cessation and 0–4 days as continuation. The rate and risk of post-ESD bleeding according to the types and cessation of antiplatelets were assessed.

Among the 215 patients (117 adenoma and 98 early gastric cancer), 161 patients were on single (94 aspirin, 56 thienopyridine, and 11 other agents), 51 on dual, and 3 on triple antiplatelets. Post-ESD bleeding rates were 12.8% in aspirin users, 3.6% in thienopyridine, 27.5% in dual, 33.3% in triple therapy, and 9.7% in the cessation and 15.0% in the continuation group. Multiple antiplatelets (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.01 to 5.76) and specimen size ≥ 5.5 cm (OR, 2.84; 95% CI, 1.04 to 7.73) were the risk of bleeding, while continuation of thienopyridine (OR, 0.23; 95% CI, 0.05 to 1.09) and antiplatelets (OR, 1.83; 95% CI, 0.68 to 4.94) did not increase the risk of bleeding.

Continuing thienopyridine and aspirin did not increase the risk of post-ESD. Multiple antiplatelet therapy and a large specimen size were independent risk factors of post-ESD bleeding.

• Antiplatelet
• Aspirin
• Endoscopic submucosal dissection
• Post-endoscopic submucosal dissection bleeding
• Thienopyridine

• Anticoagulants
• Antiplatelet agents
• Asia
• Gastrointestinal bleeding
• Thromboembolism

• Antithrombotic therapy
• Early gastric cancer
• Endoscopic submucosal dissection
• Fibrin glue
• Polyglycolic acid sheet

• Antiplatelet
• aspirin
• bleeding
• endoscopic submucosal dissection
• gastric neoplasms

• Aspirin
• Coagulation
• Diagnostic And Therapeutic Endoscopy
• Gastrointestinal Bleeding
• Platelets

• Antithrombotic therapy
• Delayed bleeding
• Dual antiplatelet therapy
• Endoscopic submucosal dissection
• Heparin bridge therapy

• Anticoagulant
• Antiplatelet
• Antithrombotic agent
• Endoscopy
• Stomach neoplasms

• Antithrombotic agents
• Bleeding
• Endoscopic submucosal dissection
• Prevention
• Risk factor

• Anticoagulants/therapeutic use
• Aspirin/therapeutic use
• Comorbidity
• Endoscopic Mucosal Resection
• Endoscopy, Gastrointestinal
• Gastrointestinal Neoplasms/pathology
• Gastrointestinal Neoplasms/surgery
• Hemostasis, Surgical
• Histamine H2 Antagonists/therapeutic use
• Humans
• Kidney Failure, Chronic/epidemiology
• Kidney Failure, Chronic/therapy
• Platelet Aggregation Inhibitors/therapeutic use
• Postoperative Hemorrhage/epidemiology
• Postoperative Hemorrhage/prevention & control
• Proton Pump Inhibitors/therapeutic use
• Renal Dialysis/statistics & numerical data
• Risk Factors
• Tumor Burden

• ENDOSCOPY

Endoscopic submucosal dissection (ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy (SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.

• Endoscopic submucosal dissection
• Second-look endoscopy
• Early gastric cancer