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Gholami R, Khan R, Ramkissoon A, Alabdulqader A, Gimpaya N, Bansal R, Scaffidi MA, Prasad V, Detsky AS, Baker JP, Grover SC. Recommendation Reversals in Gastroenterology Clinical Practice Guidelines. J Can Assoc Gastroenterol 2022; 5:98-99. [PMID: 35368318 PMCID: PMC8972276 DOI: 10.1093/jcag/gwab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recommendations in clinical practice guidelines (CPGs) may be reversed when evidence emerges to show they are futile or unsafe. In this study, we identified and characterized recommendation reversals in gastroenterology CPGs. Methods We searched CPGs published by 20 gastroenterology societies from January 1990 to December 2019. We included guidelines which had at least two iterations of the same topic. We defined reversals as when (a) the more recent iteration of a CPG recommends against a specific practice that was previously recommend in an earlier iteration of a CPG from the same body, and (b) the recommendation in the previous iteration of the CPG is not replaced by a new diagnostic or therapeutic recommendation in the more recent iteration of the CPG. The primary outcome was the number of recommendation reversals. Secondary outcomes included the strength of recommendations and quality of evidence cited for reversals. Results Twenty societies published 1022 CPGs from 1990 to 2019. Our sample for analysis included 129 unique CPGs. There were 11 recommendation reversals from 10 guidelines. New evidence was presented for 10 recommendation reversals. Meta-analyses were cited for two reversals, and randomized controlled trials (RCTs) for seven reversals. Recommendations were stronger after the reversal for three cases, weaker in two cases, and of similar strength in three cases. We were unable to compare recommendation strengths for three reversals. Conclusion Recommendation reversals in gastroenterology CPGs are uncommon but highlight low value or harmful practices.
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Affiliation(s)
- Reza Gholami
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anushka Ramkissoon
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California,USA
| | - Allan S Detsky
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Jeffrey P Baker
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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Bozkurt H, Sert ÖZ, Ölmez T, Keklikkıran ZZ, Uzun O, Gülmez S, Polat E, Duman M. The risk of post-polypectomy bleeding among patients receiving antithrombotic agents: A prospective observational study. SAO PAULO MED J 2021; 139:218-225. [PMID: 33759909 PMCID: PMC9625013 DOI: 10.1590/1516-3180.2020.0305.r1.10122020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/10/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines for gastroenterological endoscopy in patients receiving antithrombotic therapy. Colonoscopic polypectomy procedures are associated with a high risk of bleeding. OBJECTIVES The present study evaluated the safety of colonoscopic polypectomy procedures in terms of bleeding, among patients receiving antithrombotic therapy. DESIGN AND SETTING Prospective observational study conducted in a tertiary-level public cardiovascular hospital in Istanbul, Turkey. METHODS Colonoscopic polypectomies carried out in a single endoscopy unit between July 2018 and July 2019 were evaluated prospectively. The patients' data, including age, gender, comorbidities, whether antithrombotic drug use was ceased or whether patients were switched to bridging therapy, polyp size, polyp type, polyp location, histopathology, resection methods (hot snare, cold snare or forceps) and complications relating to the procedures were recorded. RESULTS The study was completed with 94 patients who underwent a total of 167 polypectomy procedures. As per the advice of the physicians who prescribed antithrombotic medications, 108 polypectomy procedures were performed on 60 patients without discontinuing medication and 59 polypectomy procedures were performed on 34 patients after discontinuing medication. The age, gender distribution and rate of bleeding did not differ significantly between the patients whose medication was discontinued and those whose medication was continued (P > 0.05). CONCLUSION This study found that the colonoscopic polypectomy procedure without discontinuation of antithrombotic medication did not increase the risk of bleeding. This procedure can be safely performed by experienced endoscopists in patients with an international normalized ratio (INR) below 2.5.
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Affiliation(s)
- Hilmi Bozkurt
- MD, MSc. General Surgeon, Gastrointestinal Surgeon and Molecular Oncology Doctoral Student, University of Health Sciences, Haseki Research and Education Hospital, Istanbul, Turkey.
| | - Özlem Zeliha Sert
- MD, MSc. General Surgeon, Gastrointestinal Surgeon and Molecular Oncology Doctoral Student, University of Health Sciences, Haydarpaşa Research and Education Hospital, Istanbul, Turkey.
| | - Tolga Ölmez
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Zeynep Zehra Keklikkıran
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Orhan Uzun
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Selçuk Gülmez
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Erdal Polat
- MD. Associate Professor, General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Mustafa Duman
- MD. Professor, General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
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Yasuda R, Yoshida N, Murakami T, Hirose R, Inoue K, Dohi O, Naito Y, Inada Y, Okuda T, Hasegawa D, Okuda K, Ogiso K, Inagaki Y, Soga K, Tomie A, Itoh Y. Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants. Gastroenterol Res Pract 2019; 2019:5743561. [PMID: 31929785 DOI: 10.1155/2019/5743561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/07/2019] [Accepted: 11/28/2019] [Indexed: 12/28/2022] Open
Abstract
Backgrounds and Aims Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors. Materials and Methods This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients' clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups. Results The rates of POH were 7.9%∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6%∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively (∗ vs. ∗∗, p < 0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2 ± 8.3 vs. 7.2 ± 4.9, p < 0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment. Conclusions Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics.
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5
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Ono S, Ishikawa M, Matsuda K, Tsuda M, Yamamoto K, Shimizu Y, Sakamoto N. Clinical impact of the perioperative management of oral anticoagulants in bleeding after colonic endoscopic mucosal resection. BMC Gastroenterol 2019; 19:206. [PMID: 31791254 PMCID: PMC6889536 DOI: 10.1186/s12876-019-1124-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/21/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Heparin bridging therapy (HBT) is indeed related to a high frequency of bleeding after endoscopic mucosal resection (EMR). In this study, our aim was to investigate clinical impact of management of oral anticoagulants without HBT in bleeding after colonic EMR. METHODS From data for patients who underwent consecutive colonic EMR, the relationships of patient factors and procedural factors with the risk of bleeding were analysed. Our management of antithrombotic agents was based on the shortest cessation as follows: the administration of warfarin was generally continued within the therapeutic range, and direct oral anticoagulants (DOACs) were not administered on the day of the procedure. We calculated bleeding risks after EMR in patients who used antithrombotic agents and evaluated whether perioperative management of anticoagulants without HBT was beneficial for bleeding. RESULTS A total of 1734 polyps in 825 EMRs were analysed. Bleeding occurred in 4.0% of the patients and 1.9% of the polyps. The odds ratios for bleeding using multivariate logistic regression analysis were 3.67 in patients who used anticoagulants and 4.95 in patients who used both anticoagulants and antiplatelet agents. In patients with one-day skip of DOACs, bleeding occurred in 6.5% of the polyps, and there were no significant differences in bleeding risk between HBT and continuous warfarin or one-day skip DOACs. CONCLUSIONS The use of oral anticoagulants was related to bleeding after colonic EMR, and perioperative management of oral anticoagulants based on the shortest cessation without HBT would be clinically acceptable.
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Affiliation(s)
- Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan.
| | - Marin Ishikawa
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Kana Matsuda
- Department of Gastroenterology, Graduate School of Medicine and Faculty of Medicine Hokkaido University, Sapporo, Japan
| | - Momoko Tsuda
- Department of Gastroenterology, Graduate School of Medicine and Faculty of Medicine Hokkaido University, Sapporo, Japan
| | - Keiko Yamamoto
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuichi Shimizu
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology, Graduate School of Medicine and Faculty of Medicine Hokkaido University, Sapporo, Japan
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6
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Bozkurt H, Ölmez T, Bulut Cİ, Sert ÖZ, Keklikkıran ZZ, Karaköse E, Senger AS, Akbulut S, Polat E, Duman M. The safety of upper gastrointestinal endoscopic biopsy in patients receiving antithrombic drugs. A single-centre prospective observational study. Prz Gastroenterol 2020; 15:234-40. [PMID: 33005269 DOI: 10.5114/pg.2019.88622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/25/2019] [Indexed: 01/15/2023]
Abstract
Introduction In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines on gastroenterological endoscopy in patients undergoing antithrombotic therapy, although the safety of endoscopic procedures in patients receiving antithrombotic drugs has yet to be sufficiently studied. Aim This study evaluates the safety of upper gastroenterological endoscopic biopsy in patients receiving antithrombotic drugs. We evaluated the prospective observational safety of endoscopic biopsy performed in the endoscopy unit of our patients using antithrombotic drugs. Material and methods Oesophagogastroduodenoscopies (OGD) and biopsies performed at a single endoscopy unit between July 2018 and February 2019 were examined in this prospective observational study. Patients receiving antithrombotic drugs due to cardiovascular and neurological reasons, who underwent an endoscopic mucosal biopsy for diagnostic purposes, were included in the study. Results The study was completed with 166 patients who underwent an endoscopic biopsy, from whom a total of 327 biopsies taken. The patients were examined in two groups: those “receiving antithrombotic drugs” and those who had “stopped taking antithrombotic drugs”. There was no statistically significant difference between the two groups with respect to bleeding. Conclusions This prospective observational study showed that performing an endoscopic biopsy without the cessation of antithrombotic drugs does not increase bleeding risk. Low-risk procedures, such as endoscopic mucosal biopsies, can be performed confidently by experienced endoscopists.
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Hakuta R, Kogure H, Nakai Y, Hamada T, Noguchi K, Saito K, Saito T, Takahara N, Mizuno S, Yagioka H, Ito Y, Tada M, Isayama H, Koike K. Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study. Dig Endosc 2019; 31:316-322. [PMID: 30586206 DOI: 10.1111/den.13326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure-related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear. METHODS In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non-users of antithrombotic agents (antiplatelet agents and anticoagulants). RESULTS We analyzed a total of 144 patients (47 users and 97 non-users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non-users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non-users, respectively). CONCLUSIONS Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure-related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Yamaguchi H, Fukuzawa M, Kawai T, Matsumoto T, Suguro M, Uchida K, Koyama Y, Madarame A, Morise T, Aoki Y, Sugimoto A, Yamauchi Y, Kono S, Tsuji Y, Yagi K, Itoi T. Impact of gastric endoscopic submucosal dissection in elderly patients: The latest single center large cohort study with a review of the literature. Medicine (Baltimore) 2019; 98:e14842. [PMID: 30882676 PMCID: PMC6426470 DOI: 10.1097/md.0000000000014842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
With the increase in the elderly population, we are witnessing an increase in the rate of patients with underlying diseases and those under treatment with antithrombotic drugs.In this study, we compared the treatment outcomes of endoscopic submucosal dissection (ESD) and other parameters in the following 3 groups: super-elderly, elderly, and nonelderly.Compared with the other groups, the super-elderly group showed a significantly higher incidence of underlying diseases and the rate of antithrombotic treatment (P < .05). However, we observed no significant difference in the rate of curative resection or incidence of complications among the 3 groups. ESD is a relatively safe technique when performed on super-elderly patients. However, we have identified some cases in the super-elderly group, for which ESD was selected as a minimally invasive treatment for lesions that did not meet the inclusion criteria for open surgery as well as for which follow-up observations were selected rather than additional surgery for noncurative resections.Further investigations concerning ESD are required, focusing on aspects such as indications, additional surgery, and informed consent of the patient or family, particularly when ESD is performed for super-elderly patients.
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Affiliation(s)
| | | | - Takashi Kawai
- Endoscopy Center, Tokyo Medical University Hospital, Tokyo, Japan
| | | | - Maya Suguro
- Department of Gastroenterology and Hepatology
| | | | | | | | | | - Yuki Aoki
- Department of Gastroenterology and Hepatology
| | - Akihiko Sugimoto
- Endoscopy Center, Tokyo Medical University Hospital, Tokyo, Japan
| | | | - Shin Kono
- Department of Gastroenterology and Hepatology
| | | | - Kenji Yagi
- Department of Gastroenterology and Hepatology
| | - Takao Itoi
- Department of Gastroenterology and Hepatology
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9
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Sanomura Y, Oka S, Tanaka S, Yorita N, Kuroki K, Kurihara M, Mizumoto T, Yoshifuku Y, Chayama K. Taking Warfarin with Heparin Replacement and Direct Oral Anticoagulant Is a Risk Factor for Bleeding after Endoscopic Submucosal Dissection for Early Gastric Cancer. Digestion 2018; 97:240-249. [PMID: 29421806 DOI: 10.1159/000485026] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/07/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) remains problematic, especially in patients taking anticoagulants, there are differing views on the ideal and optimal management for these patients. This study investigated the risk of bleeding after ESD in patients taking anticoagulants. METHODS We enrolled 61 consecutive patients taking anticoagulants (anticoagulant group) and 968 patients taking no antithrombotic agents (non-antithrombotic group) treated with ESD for EGC between December 2010 and October 2016. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors. RESULTS Incidences of bleeding after ESD were significantly higher (14%; 11/76) in the anticoagulant group compared to the non-antithrombotic group (3%; 40/1,167). Moreover, bleeding after ESD was significantly more common in patients in the warfarin monotherapy group (14%; 5/37) and in the direct oral anticoagulant (DOAC) monotherapy group (22%; 4/18), compared to the non-antithrombotic group. Multivariate analysis revealed that dialysis, the use of anticoagulants, and an operation time ≥75 min were independent risk factors for bleeding after ESD. CONCLUSIONS Our data suggest that patients who take warfarin and receive heparin bridging, and those who take DOAC medication, are prone to bleeding after ESD for EGC.
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Affiliation(s)
- Yoji Sanomura
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Naoki Yorita
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazutaka Kuroki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Mio Kurihara
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Mizumoto
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshikazu Yoshifuku
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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10
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Matsumoto M, Yoshii S, Shigesawa T, Dazai M, Onodera M, Kato M, Sakamoto N. Safety of Cold Polypectomy for Colorectal Polyps in Patients on Antithrombotic Medication. Digestion 2018; 97:76-81. [PMID: 29393134 DOI: 10.1159/000484219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The cold polypectomy (CP) technique has been increasingly used in recent years. However, there have been few studies about post-polypectomy bleeding (PPB) in patients who underwent CP and who were on antithrombotic drugs. The objective of this study was to determine the safety of CP in patients on antithrombotic medication. METHODS The subjects were patients who underwent CP in our hospital between April 2014 and March 2016. PPB rates were examined in relation to the use of antithrombotic medication. RESULTS CP was performed to remove 2,466 polyps in 1,003 patients. There were 549 polyps (22.3%) in186 patients in the antithrombotic group and 1,917 polyps (77.7%) in 817 patients in the non-antithrombotic group. PPB occurred in 0.55% (3/549) of patients in the antithrombotic group and in 0.10% (2/1,917) of patients in the non-antithrombotic group, showing no significant difference (p = 0.07). Patients in the antithrombotic group in whom PPB occurred included 1 aspirin user with 1 polyp and 1 aspirin plus clopidogrel user with 2 polyps. No PPB occurred in patients on other antithrombotic agents or receiving heparin bridging. There was no significant difference between PPB rates in patients with small polyps (6-9 mm) in the antithrombotic and non-antithrombotic groups, but there was a significant difference between PPB rates in the 2 groups for patients with diminutive group (1-5 mm). CONCLUSION CP is a safe procedure even in patients on antithrombotic medication.
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Affiliation(s)
- Mio Matsumoto
- Department of Gastroenterology, Hokkaido Medical Center, Sapporo, Japan
| | - Shinji Yoshii
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | - Taku Shigesawa
- Department of Gastroenterology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Masayoshi Dazai
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | - Manabu Onodera
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | | | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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11
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Kato M, Uedo N, Hokimoto S, Ieko M, Higuchi K, Murakami K, Fujimoto K. Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment: 2017 Appendix on Anticoagulants Including Direct Oral Anticoagulants. Dig Endosc 2018; 30:433-440. [PMID: 29733468 DOI: 10.1111/den.13184] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023]
Abstract
In 2012, the Japan Gastroenterological Endoscopy Society published "Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment" concerning thromboembolism associated with antithrombotic therapy withdrawal. Since then, physicians have started prescribing oral anticoagulants, creating a need for standards reflecting their use in clinical practice. Therefore, new findings regarding anticoagulants are included in this appendix. However, the evidence levels are low for many statements contained herein and these appended guidelines still need to be verified in clinical settings.
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Affiliation(s)
- Mototsugu Kato
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Noriya Uedo
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seiji Hokimoto
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Masahiro Ieko
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuhide Higuchi
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazunari Murakami
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuma Fujimoto
- Guidelines Committee, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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12
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Affiliation(s)
- Shinji Yoshii
- Department of Gastroenterology, Sapporo Medical Center, NTT EC, Sapporo, Japan
| | - Mio Matsumoto
- Department of Gastroenterology, Hokkaido Medical Center, Sapporo, Japan
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13
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Kono Y, Matsubara M, Toyokawa T, Takenaka R, Suzuki S, Nasu J, Yoshioka M, Nakagawa M, Mizuno M, Sakae H, Abe M, Gotoda T, Miura K, Kanzaki H, Iwamuro M, Hori K, Tsuzuki T, Kita M, Kawano S, Kawahara Y, Okada H. Multicenter Prospective Study on the Safety of Upper Gastrointestinal Endoscopic Procedures in Antithrombotic Drug Users. Dig Dis Sci 2017; 62:730-8. [PMID: 28050786 DOI: 10.1007/s10620-016-4437-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The Japan Gastroenterological Endoscopy Society updated its guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment in July 2012. However, the safety of endoscopic procedures in antithrombotic drug users has not been fully investigated. AIMS To evaluate the safety of upper gastrointestinal endoscopic procedures in antithrombotic drug users. METHODS From September 2013 to September 2015, patients who were taking antithrombotic drugs and who underwent upper gastrointestinal endoscopic procedures were prospectively enrolled at five hospitals. Incidences of bleeding and thrombosis during endoscopic procedures were evaluated. RESULTS A total of 270 patients [221 for endoscopic mucosal biopsy and 49 for endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) were enrolled. The bleeding rate was 0.9% for endoscopic mucosal biopsy and 22% for EMR/ESD, respectively. The bleeding rate after endoscopic mucosal biopsy was not significantly high, even if antithrombotic drugs were continued (0 vs. 1%, P > 0.99), while it was significantly higher among multiple antithrombotic drug users than single drug users (5.9 vs. 0%, P < 0.05). The bleeding rate after EMR/ESD was also higher among multiple antithrombotic drug users than single drug users, but was not significantly different (33 vs. 14%, P = 0.17). Moreover, there were no differences in bleeding rates according to the cessation or continuance of antithrombotic drugs (20 vs. 25%, P = 0.74). There were no thromboembolisms in all cases. CONCLUSIONS Upper gastrointestinal endoscopic procedures performed under the new guidelines appear acceptable. However, endoscopic procedures among multiple antithrombotic drug users show a greater potential for bleeding.
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