P1.222. Occult Platelet Dysfunction After Esophagectomy: NSAIDs, Supplements, and the Limits of Intraoperative Coagulation Testing

Abstract

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Case Submission We present a diagnostically challenging case of postoperative hemorrhage following hybrid Ivor-Lewis esophagectomy, highlighting the limitations of standard coagulation testing and the clinical impact of overlooked antiplatelet agents and complementary therapies. A 63-year-old man underwent esophagectomy for locally advanced adenocarcinoma after neoadjuvant chemotherapy. Six hours postoperatively, he became hemodynamically unstable, with hemoglobin dropping from 98 to 68 g/L. Re-exploration revealed no surgical source of bleeding. Intraoperative thromboelastography (TEG) was normal. Endoscopy, however, identified an actively bleeding duodenal ulcer requiring operative hemostasis. ADP platelet function testing demonstrated significant platelet inhibition. It was only later that the patient disclosed chronic use of ibuprofen, diclofenac, and Turkey Tail mushroom extract, which he had begun after reading about its use in Japanese cancer care. This case illustrates the underappreciated risk of NSAID-associated platelet dysfunction and gastrointestinal bleeding, particularly in the perioperative setting. Non-selective NSAIDs such as ibuprofen and diclofenac impair thromboxane A₂–mediated aggregation and increase mucosal vulnerability to ulceration. Though routinely prescribed for analgesia, their use immediately prior to major surgery warrants careful consideration — especially when multiple agents are involved. While the hemostatic effects of complementary medicines are less well understood, their growing prevalence in cancer patients introduces an additional layer of risk. Trametes versicolor (Turkey Tail), widely used in Japan as an adjuvant therapy for gastrointestinal cancers, contains polysaccharide-K (PSK), an immunomodulatory compound believed to enhance natural killer cell and T-cell activity. Emerging data suggest PSK may also interfere with platelet aggregation and adhesion, although its perioperative significance remains unclear. In this case, concurrent use of NSAIDs and Turkey Tail extract may have had additive effects on platelet dysfunction. Importantly, this case highlights the limitations of TEG in detecting qualitative platelet defects, especially when clot strength appears preserved. ADP-based assays offer better sensitivity to COX- and P2Y12-mediated dysfunction and should be considered when bleeding occurs despite normal TEG parameters. This case invites discussion on: • When to escalate to platelet function testing in the setting of unexplained bleeding • Best practices for screening use of NSAIDs and oncology-adjunct complementary therapies (e.g., medicinal mushrooms such as Turkey Tail/PSK) that may impair platelet function • How to proactively identify common non-prescribed health supplements—such as fish oil, ginkgo biloba, and garlic—that may also influence bleeding risk • Whether guidelines should address withholding both prescribed and non-prescribed agents with hemostatic effects in the perioperative period The combined effects of common NSAIDs and increasingly used supplements warrant multidisciplinary attention to ensure perioperative safety in oncology surgery.