Risk of Postoperative Bleeding in Esophageal Endoscopic Submucosal Dissection for Squamous Cell Carcinoma in Patients on Antiplatelet Therapy: A Multicenter Retrospective Study in Japan

OBJECTIVES: Postendoscopic submucosal dissection (ESD) bleeding remains a critical concern in patients receiving antithrombotic therapy, yet the risk after esophageal ESD is poorly characterized. This multicenter retrospective study evaluated the incidence of post-ESD bleeding and thromboembolism in patients undergoing esophageal ESD while receiving antiplatelet therapy. METHODS: We analyzed 570 patients with esophageal squamous cell carcinoma treated with ESD while on antiplatelet therapy between 2017 and 2022 at 21 institutions in Japan. Patients were categorized into guideline-based discontinuation or continuation, excluding guideline-deviating discontinuation. The primary endpoint was the rate of post-ESD bleeding among thienopyridine users (monotherapy or dual antiplatelet therapy; DAPT) managed with guideline-based discontinuation. Secondary endpoints included bleeding rates according to antiplatelet regimen and thromboembolism incidence. RESULTS: A total of 154, 41, and 375 patients received thienopyridine monotherapy, DAPT, and aspirin monotherapy, respectively. Antiplatelet therapy was continued perioperatively in 32.5%, 31.7%, and 73.1% of these groups. Post-ESD bleeding rates were 2.3% (3/132) and 3.2% (2/63) for guideline-based discontinuation and continuation of thienopyridine users, respectively. Bleeding rates for discontinuation vs. continuation were 0% (0/101) vs. 0.7% (2/274) for aspirin monotherapy, 1.9% (2/104) vs. 4.0% (2/50) for thienopyridine monotherapy, and 3.6% (1/28) vs. 0% (0/13) for DAPT. Thromboembolism occurred in two patients, both receiving aspirin monotherapy. CONCLUSIONS: A substantial number of patients underwent esophageal ESD while continuing antiplatelet therapy. These descriptive findings suggest a need for further evaluation of continued therapy in larger studies.