Guideline for General and Gastroenterological Surgery in Patients Undergoing Antithrombotic Treatment: “Kokura Protocol 2019” with Appendix on Direct Oral Anticoagulants (DOACs)

Takahisa Fujikawa


In patients taking antithrombotic therapy (ATT), we have to manage two conflicting risks of bleeding and thromboembolism perioperatively. We have established our own perioperative antithrombotic management protocol for ATT-burdened patients (“Kokura Protocol”), and based on this protocol, the hospital guideline for gastroenterological and general surgery in patients receiving ATT was made and have been used. Thereafter, in consideration of newly launched anticoagulants called direct oral anticoagulants (DOACs), the guideline has been updated with appendix on DOACs. In this paper, our current updated guideline concerning perioperative ATT management during GE and general surgery will be outlined.


guideline, gastroenterological surgery, antithrombotic therapy, antiplatelet therapy, anticoagulation therapy


Fujikawa T, Tanaka A, Abe T, et al. Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital. J Am Coll Surg. 2013;217(6):1044-1053. doi:S1072-7515(13)01019-3 [pii] 10.1016/j.jamcollsurg.2013.08.005

Fujikawa T, Tanaka A, Abe T, Yoshimoto Y, Tada S, Maekawa H. Effect of antiplatelet therapy on patients undergoing gastroenterological surgery: thromboembolic risks versus bleeding risks during its perioperative withdrawal. World J Surg. 2015;39(1):139-149. doi:10.1007/s00268-014-2760-3

Acosta RD, Abraham NS, Chandrasekhara V, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16. doi:10.1016/j.gie.2015.09.035

Kato M, Uedo N, Hokimoto S, et al. Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment: 2017 Appendix on Anticoagulants Including Direct Oral Anticoagulants. Dig Endosc. 2018;30(4):433-440. doi:10.1111/den.13184

Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373(9):823-833. doi:10.1056/NEJMoa1501035

Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962. doi:10.1016/S0140-6736(13)62343-0

Fujimoto K, Fujishiro M, Kato M, et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2014;26(1):1-14. doi:10.1111/den.12183

JCS Joint Working Group. Guidelines for Pharmacotherapy of Atrial Fibrillation (JCS 2013). Circ J. 2014;78(8):1997-2021. doi:10.1253/circj.cj-66-0092

Dubois V, Dincq A-S, Douxfils J, et al. Perioperative management of patients on direct oral anticoagulants. Thromb J. 2017;15(1):14. doi:10.1186/s12959-017-0137-1

Raval AN, Cigarroa JE, Chung MK, et al. Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation. 2017;135(10). doi:10.1161/CIR.0000000000000477

Steffel J, Verhamme P, Potpara TS, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39(16):1330-1393. doi:10.1093/eurheartj/ehy136

Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-close aspirin for secondary cardiovascular prevention - Cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - Review and meta-analysis. J Intern Med. 2005;257(5):399-414. doi:10.1111/j.1365-2796.2005.01477.x

Bowry ADK, Brookhart MA, Choudhry NK. Meta-analysis of the efficacy and safety of clopidogrel plus aspirin as compared to antiplatelet monotherapy for the prevention of vascular events. Am J Cardiol. 2008;101(7):960-966. doi:10.1016/j.amjcard.2007.11.057

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