Safety and effectiveness of peroral endoscopic myotomy in patients on antiplatelet or anticoagulant therapy: an international multicenter case-control study

      Background and Aims

      The risk of bleeding and thromboembolic events in patients undergoing peroral endoscopic myotomy (POEM) who are receiving antithrombotic therapy is unknown. Our primary aim was to assess the safety of POEM in this patient subset. Secondary outcomes were rates of clinical success, GERD, and procedure-related outcomes.


      This was an international, 1:1, case-control study performed at 10 centers using prospectively maintained databases. All consecutive patients who underwent POEM before November 2019 were considered for inclusion. Cases were patients on antiplatelet and/or anticoagulant therapy. Controls not receiving antithrombotics were matched for age and esophageal motility disorder. Primary outcomes were major bleeding and thromboembolic events on postprocedural day 30.


      Of 2895 patients who underwent POEM, 126 cases (103 on antiplatelets, 35 anticoagulants, 12 both) and 126 controls were enrolled. The rate of major bleeding was higher for the antithrombotics users (5.6% vs 0.8%, P = .03). Anticoagulants and clopidogrel were temporarily interrupted in all cases. Aspirin was continued in 40.5% of users without increasing the bleeding risk. One thromboembolic event occurred in each group (0.79%; P = 1.00). No POEM-related deaths were noted. Rates of clinical success (91.7% vs 96% in controls, P = .20), postprocedural GERD, and technical-related outcomes were similar in both groups. Antithrombotic management was heterogeneous, and guidelines were not adhered to in 23.8% of cases.


      POEM is safe and effective in patients receiving antithrombotic therapy although it is associated with a greater risk of major bleeding.


      AE (adverse event), CI (confidence interval), DOAC (direct oral anticoagulant), LMWH (low-molecular-weight heparin), POEM (peroral endoscopic myotomy), STROBE (Strengthening the Reporting of Observational studies in Epidemiology)
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      Linked Article

      • Contemporary management of antithrombotic agents for patients undergoing peroral endoscopic myotomy
        Gastrointestinal EndoscopyVol. 93Issue 4
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          Achalasia is a rare disorder with an estimated incidence rate of 0.3 to 1.63 per 100,000 person years.1 Since the first peroral endoscopic myotomy (POEM) was performed in 2008, POEM has become increasingly accepted as first-line therapy for achalasia because of its high clinical efficacy and low adverse event rates.2 However, despite the multitude of publications now emerging, an aspect that remains unclear is the perioperative management and risks associated with the use of antithrombotic agents.
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