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Endoscopic submucosal dissection for early gastric cancer without interruption of warfarin and aspirin.

Tounou S, Morita Y, Hosono T, Harada H, Hayasaka K, Katsuyama Y, Suehiro S, Nagano S, Shimizu T - Endosc Int Open (2015)

Bottom Line: He had a past medical history of metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft.Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent.We performed gastric ESD safely on continuous warfarin and low dose aspirin without any complications.

View Article: PubMed Central - PubMed

Affiliation: Teikyo University Chiba Medical Center - Gastroenterology, Ichihara, Chiba, Japan.

ABSTRACT
Many guidelines for the management of antithrombotic therapy in endoscopic procedures state that warfarin should be replaced by heparin in high risk endoscopic procedures. However, heparin bridging therapy is costly, requires a long hospital stay, and is indicated as a risk factor for bleeding after endoscopic submucosal dissection (ESD). It is not yet clear whether it is better to perform gastric ESD on continuous warfarin therapy or heparin bridging therapy. We report the case of a 65-year-old Japanese man who had been diagnosed with early gastric cancer. He had a past medical history of metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft. Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent. We performed gastric ESD safely on continuous warfarin and low dose aspirin without any complications.

No MeSH data available.


Related in: MedlinePlus

Slightly elevated lesion located in the lesser curvature of the upper part of the stomach, and 6 mm in size, in a 65-year-old man. b High power endoscopic view of the lesion with narrow-band imaging. c Marking the area surrounding the lesion before starting endoscopic submucosal dissection (ESD). d Very shallow mucosal cutting was performed with a Dual knife to avoid injury to vessels in the submucosal layer. e Pre-coagulation with a hot biopsy forceps was carried out before dissecting the submucosal layer. f Large vessels were observed in the submucosal layer. g Status of visible vessels in the submucosal layer after coagulation using the hot biopsy forceps. h Status after hemostasis for the post-ESD ulcer.
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FI157-1: Slightly elevated lesion located in the lesser curvature of the upper part of the stomach, and 6 mm in size, in a 65-year-old man. b High power endoscopic view of the lesion with narrow-band imaging. c Marking the area surrounding the lesion before starting endoscopic submucosal dissection (ESD). d Very shallow mucosal cutting was performed with a Dual knife to avoid injury to vessels in the submucosal layer. e Pre-coagulation with a hot biopsy forceps was carried out before dissecting the submucosal layer. f Large vessels were observed in the submucosal layer. g Status of visible vessels in the submucosal layer after coagulation using the hot biopsy forceps. h Status after hemostasis for the post-ESD ulcer.

Mentions: A 65-year-old Japanese man visited our hospital for treatment of early gastric cancer. He had a history of diabetes mellitus, metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft. Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent. The international normalized ratio of prothrombin time (PT-INR) had been controlled at around 2.0 (1.5 – 2.5). A superficial elevated type (0 – IIa) early gastric cancer of 6 mm in size had been found at another medical facility and it was located in the lesser curvature of the upper part of the stomach (Fig. 1 a, b). The histopathology diagnosis of a biopsy specimen was well-differentiated tubular adenocarcinoma (tub1). Coagulation of the lesion might have been a useful treatment option but the patient desired complete resection and a definite pathological diagnosis. Endoscopic mucosal resection (EMR) was another treatment option but the lesion was small, and the risk of bleeding or perforation was thought to be low. However, we felt that ESD was the ideal therapy for this lesion and the patient also desired it. We consulted the cardiologist who prescribed warfarin and aspirin about interruption of antithrombotic agents, and who strongly recommended their continuous use or heparin bridging therapy and aspirin because the patient had a high thromboembolic risk. We explained to the patient that heparin bridging therapy was recommended in many guidelines but it was not clear whether it was better to perform gastric ESD on continuous warfarin therapy or heparin bridging therapy, and that heparin bridging therapy would need a longer hospital stay and have higher medical costs. We also explained that ESD with continuous warfarin use was a challenging therapy and the risk of post-ESD bleeding was unknown. After our explanation, the patient opted to receive ESD with continuous warfarin and aspirin therapy rather than heparin bridging therapy and informed consent for this therapy was obtained. The PT-INR was 1.67 on the morning of performing ESD, and it was performed on warfarin and aspirin therapy. The procedure was performed by a highly experienced endoscopist using a regular video-endoscope (GIF-HQ290; Olympus Medical Systems Co., Tokyo, Japan) with distal attachments (D-201-11804; Olympus Medical Systems). As the ESD device, a Dual knife (KD-650L; Olympus Medical Systems) was used. The electrical generator was a VIO 300 D (Erbe Co., Tübingen, Germany) with a setting of endocut effect 3, 120 W for mucosal incision and forced coagulation effect 3, 50 W for submucosal dissection. Usually, swift coagulation is used in submucosal dissection but we consider that forced coagulation is more effective for preventing hemorrhage during ESD in patients on antithrombotic therapies.


Endoscopic submucosal dissection for early gastric cancer without interruption of warfarin and aspirin.

Tounou S, Morita Y, Hosono T, Harada H, Hayasaka K, Katsuyama Y, Suehiro S, Nagano S, Shimizu T - Endosc Int Open (2015)

Slightly elevated lesion located in the lesser curvature of the upper part of the stomach, and 6 mm in size, in a 65-year-old man. b High power endoscopic view of the lesion with narrow-band imaging. c Marking the area surrounding the lesion before starting endoscopic submucosal dissection (ESD). d Very shallow mucosal cutting was performed with a Dual knife to avoid injury to vessels in the submucosal layer. e Pre-coagulation with a hot biopsy forceps was carried out before dissecting the submucosal layer. f Large vessels were observed in the submucosal layer. g Status of visible vessels in the submucosal layer after coagulation using the hot biopsy forceps. h Status after hemostasis for the post-ESD ulcer.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4554514&req=5

FI157-1: Slightly elevated lesion located in the lesser curvature of the upper part of the stomach, and 6 mm in size, in a 65-year-old man. b High power endoscopic view of the lesion with narrow-band imaging. c Marking the area surrounding the lesion before starting endoscopic submucosal dissection (ESD). d Very shallow mucosal cutting was performed with a Dual knife to avoid injury to vessels in the submucosal layer. e Pre-coagulation with a hot biopsy forceps was carried out before dissecting the submucosal layer. f Large vessels were observed in the submucosal layer. g Status of visible vessels in the submucosal layer after coagulation using the hot biopsy forceps. h Status after hemostasis for the post-ESD ulcer.
Mentions: A 65-year-old Japanese man visited our hospital for treatment of early gastric cancer. He had a history of diabetes mellitus, metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft. Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent. The international normalized ratio of prothrombin time (PT-INR) had been controlled at around 2.0 (1.5 – 2.5). A superficial elevated type (0 – IIa) early gastric cancer of 6 mm in size had been found at another medical facility and it was located in the lesser curvature of the upper part of the stomach (Fig. 1 a, b). The histopathology diagnosis of a biopsy specimen was well-differentiated tubular adenocarcinoma (tub1). Coagulation of the lesion might have been a useful treatment option but the patient desired complete resection and a definite pathological diagnosis. Endoscopic mucosal resection (EMR) was another treatment option but the lesion was small, and the risk of bleeding or perforation was thought to be low. However, we felt that ESD was the ideal therapy for this lesion and the patient also desired it. We consulted the cardiologist who prescribed warfarin and aspirin about interruption of antithrombotic agents, and who strongly recommended their continuous use or heparin bridging therapy and aspirin because the patient had a high thromboembolic risk. We explained to the patient that heparin bridging therapy was recommended in many guidelines but it was not clear whether it was better to perform gastric ESD on continuous warfarin therapy or heparin bridging therapy, and that heparin bridging therapy would need a longer hospital stay and have higher medical costs. We also explained that ESD with continuous warfarin use was a challenging therapy and the risk of post-ESD bleeding was unknown. After our explanation, the patient opted to receive ESD with continuous warfarin and aspirin therapy rather than heparin bridging therapy and informed consent for this therapy was obtained. The PT-INR was 1.67 on the morning of performing ESD, and it was performed on warfarin and aspirin therapy. The procedure was performed by a highly experienced endoscopist using a regular video-endoscope (GIF-HQ290; Olympus Medical Systems Co., Tokyo, Japan) with distal attachments (D-201-11804; Olympus Medical Systems). As the ESD device, a Dual knife (KD-650L; Olympus Medical Systems) was used. The electrical generator was a VIO 300 D (Erbe Co., Tübingen, Germany) with a setting of endocut effect 3, 120 W for mucosal incision and forced coagulation effect 3, 50 W for submucosal dissection. Usually, swift coagulation is used in submucosal dissection but we consider that forced coagulation is more effective for preventing hemorrhage during ESD in patients on antithrombotic therapies.

Bottom Line: He had a past medical history of metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft.Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent.We performed gastric ESD safely on continuous warfarin and low dose aspirin without any complications.

View Article: PubMed Central - PubMed

Affiliation: Teikyo University Chiba Medical Center - Gastroenterology, Ichihara, Chiba, Japan.

ABSTRACT
Many guidelines for the management of antithrombotic therapy in endoscopic procedures state that warfarin should be replaced by heparin in high risk endoscopic procedures. However, heparin bridging therapy is costly, requires a long hospital stay, and is indicated as a risk factor for bleeding after endoscopic submucosal dissection (ESD). It is not yet clear whether it is better to perform gastric ESD on continuous warfarin therapy or heparin bridging therapy. We report the case of a 65-year-old Japanese man who had been diagnosed with early gastric cancer. He had a past medical history of metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft. Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent. We performed gastric ESD safely on continuous warfarin and low dose aspirin without any complications.

No MeSH data available.


Related in: MedlinePlus