title: Risk factors for early and delayed post-operative bleeding after endoscopic submucosal dissection of gastric neoplasms, including patients with continued use of antithrombotic agents.
abstract: BACKGROUND
  Endoscopic submucosal dissection (ESD) has become widely accepted as a standard treatment for gastric epithelial neoplasms. Antithrombotic agents are widely used to prevent thromboembolic disease. However, the feasibility of endoscopic procedures for patients using such agents has been rarely investigated. The aim of this study was to identify risk factors for post-operative bleeding after gastric ESD and to evaluate the relationship between the use of antithrombotic agents and post-operative bleeding.
  
  
  METHODS
  From June 2005 to March 2014, 413 patients with 425 gastric neoplasms were treated by ESD. The demographic and clinical parameters associated with post-operative bleeding were investigated. 83 patients receiving antithrombotic agents were separately assessed using various methods of administration during the ESD procedure. Post-operative bleeding that occurred within 5 days of ESD was defined as early post-operative bleeding, whereas subsequent bleeding was defined as delayed bleeding.
  
  
  RESULTS
  The overall post-operative bleeding rate was 4.7%. In patients with continued low-dose aspirin (LDA), heparin replacement (HR), or continued LDA along with HR, post-operative bleeding rates were 9.5%, 23.8%, and 25.0%, respectively. On multivariate analysis, a specimen size of ≥40 mm was a risk factor for early post-operative bleeding [odds ratio (OR) 6.08, 95% CI: 1.74-21.27], and HR and chronic kidney disease (CKD) requiring hemodialysis were risk factors for delayed bleeding (OR 12.23, 95% CI: 2.63-56.77 and OR 28.35, 95% CI: 4.67-172.11, respectively). Continued LDA was not a risk factor for post-operative bleeding.
  
  
  CONCLUSIONS
  Large specimen size is a risk factor for early post-operative bleeding, and HR and CKD requiring hemodialysis are risk factors for delayed bleeding. Patients with risk factors should be carefully watched, allowing for the timing of post-operative bleeding after ESD.
authors.forename: Tomoaki
authors.initials: T
authors.lastname: Matsumura
authors.affiliation: Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City 260-8670, Japan. araim-cib@umin.ac.jp.
authors.forename: Makoto
authors.initials: M
authors.lastname: Arai
authors.forename: Daisuke
authors.initials: D
authors.lastname: Maruoka
authors.forename: Kenichiro
authors.initials: K
authors.lastname: Okimoto
authors.forename: Shoko
authors.initials: S
authors.lastname: Minemura
authors.forename: Hideaki
authors.initials: H
authors.lastname: Ishigami
authors.forename: Keiko
authors.initials: K
authors.lastname: Saito
authors.forename: Tomoo
authors.initials: T
authors.lastname: Nakagawa
authors.forename: Tatsuro
authors.initials: T
authors.lastname: Katsuno
authors.forename: Osamu
authors.initials: O
authors.lastname: Yokosuka
mesh_terms: D000230:Adenocarcinoma / Q000150:complications / Q000473:pathology / Q000601:surgery*; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D004210:Dissection; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005753:Gastric Mucosa / Q000601:surgery*; D005773:Gastroscopy; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D019106:Postoperative Hemorrhage / Q000209:etiology*; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*
chemical_list: D005343:Fibrinolytic Agents; D006493:Heparin; D001241:Aspirin