1. Ryonho Koh, MD,1 Kingo Hirasawa, MD,1 Sei Yahara, MD,1 Hiroyuki Oka, MD,1 Kazuya Sugimori, MD,1 Manabu Morimoto, MD,1 Kazushi Numata, MD,1 Atsushi Kokawa, MD,1 Takeshi Sasaki, MD,2 Akinori Nozawa, MD,2 Masataka Taguri, PhD,3,4 Satoshi Morita, PhD,3,4 Shin Maeda, MD,5 Katsuaki Tanaka, MD1,3 Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms R1. 오 신주 / Pf. 장 재영 GASTROINTESTINAL ENDOSCOPY Volume 78, No.3 : 2013

2. Background Endoscopic submucosal dissection(ESD) Standard treatment modality for gastric adenoma and EGC Higher risk of procedure-related adverse events, such as postoperative bleeding and perforation remains a serious problem. Postoperative bleeding is the most common adverse event (reportedly occurs at a rate of 0.9% to 15.6%)

3. Background most common site of significant bleeding in patients receiving oral antithrombotic agents is the GI tract.  The discontinuation of antithrombotic drugs is recommended during endoscopic submucosal dissection (ESD) for gastric neoplasms. Whether interruption of antithrombotic agents decrease th risk of bleeding during and after ESD Whether reinitiation of antithrombotic agents after ESD increases th risk of delayed postoperative bleeding. ?

4. Methods June 2000 ~ December 2010. 1192 early gastric neoplasm in 1032 consecutive patients were treated with ESD Yokohama City University Medical Center Indication Based on endoscopic findings Including those from chromoendoscopy with indigo carmine and biopsy. Gastric adenoma that was difficult to distinguish from adenocarcinoma Patients strongly desired to have resected Pateints

5. Methods All patients taking antithrombotic drugs : stop for 7 days before ESD. ( high-risk patients were switched to intravenous heparin) The ESD procedures were performed by using the standard techniques. Second-look endoscopy was performed on the day after ESD : check for recent hemorrhage / potential site of bleeding on the artificial ulcer. : if bleeding, therapeutic endoscopic hemostasis was executed. Oral antithrombotic treatment was restarted when hemostasis was confirmed by second-look endoscopy. For postoperative treatment, : Omeprazole iv 20mg bid  Omeprazole po 20mg qd Management and procedure

6. Methods Clinical evidence of bleeding in ESD-induced ulcer lesions  hematemesis or melena  presence of blood or coagulants observed by endoscopy. Exclusion criteria Preventive hemostasis for visible vessels without evidence of bleeding at second-look endoscopy. Early postoperative bleeding Occurred during the first 5 postoperative days Delayed postoperative bleeding Subsequent bleeding Definitions of postoperative bleeding

7. Results Most of the bleeding occurred within 14 days (95.2%)

8. Results

9. = 1166

13. Results Overall post-op bleeding Specimen size >40mm Early post-op bleeding Hx of cardiovascular disease Delayed post-op bleeding Oral antithrombotic drug Specimen size >40mm

14. Results Delayed postoperative bleeding rate was highest in lesions with a specimen size of >40mm and with patient use of antithrombotic drugs.

15. Conclusion Interruption of antithrombotic drug therapy may be adequate for preventing early post-ESD bleeding Reinitiating antithrombotic drug therapy is a significant indepen dent risk factor for delayed post-ESD bleeding.

16. Thank you !