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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality indicators for colonoscopy. Gastrointest Endosc 2024; 100:352-381. [PMID: 39177519 DOI: 10.1016/j.gie.2024.04.2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/25/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Department of Medicine/Division of Gastroenterology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine/Division of Gastroenterology, White River Junction VAMC, White River Junction, Vermont, USA; University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco; Chief Medical Officer, University of California San Francisco Health System
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA; VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality Indicators for Colonoscopy. Am J Gastroenterol 2024:00000434-990000000-01296. [PMID: 39167112 DOI: 10.14309/ajg.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Chief Medical Officer, University of California San Francisco Health System, San Francisco, California, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Nicolás-Pérez D, Gimeno-García AZ, Romero-García RJ, Castilla-Rodríguez I, Hernandez-Guerra M. Cost-effectiveness Analysis of Single-Use Duodenoscope Applied to Endoscopic Retrograde Cholangiopancreatography. Pancreas 2024; 53:e357-e367. [PMID: 38518062 DOI: 10.1097/mpa.0000000000002311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
OBJECTIVES Secondary infections due to transmission via the duodenoscope have been reported in up to 3% of endoscopic retrograde cholangiopancreatographies. The use of single-use duodenoscopes has been suggested. We investigate the cost-effectiveness of these duodenoscopes use in cholangiopancreatography. MATERIALS AND METHODS A cost-effectiveness analysis was implemented to compare the performance of cholangiopancreatographies with reusable duodenoscopes versus single-use duodenoscopes. Effectiveness was analyzed by calculating quality-adjusted life years (QALY) from the perspective of the National Health System. Possibility of crossover from single-use to reusable duodenoscopes was considered. A willingness-to-pay of €25,000/QALY was set, the incremental cost-effectiveness ratio (ICER) was calculated, and deterministic and probabilistic sensitivity analyses were performed. RESULTS Considering cholangiopancreatographies with single-use and reusable duodenoscopes at a cost of €2900 and €1333, respectively, and a 10% rate of single-use duodenoscopes, ICER was greater than €3,000,000/QALY. A lower single-use duodenoscope cost of €1211 resulted in an ICER of €23,583/QALY. When the unit cost of the single-use duodenoscope was €1211, a crossover rate of more than 9.5% made the use of the single-use duodenoscope inefficient. CONCLUSIONS Single-use duodenoscopes are cost-effective in a proportion of cholangiopancreatographies if its cost is reduced. Increased crossover rate makes single-use duodenoscope use not cost-effective.
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Affiliation(s)
| | | | | | - Iván Castilla-Rodríguez
- Departamento de Ingeniería Informática y de Sistemas, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
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Ali S, Khetpal N, Fatima M, Hussain S, Ali A, Khan MA, Childs C, Hasan MK. The Safety of Cold Versus Hot Snare Polypectomy in Polyps 10-20 mm: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58462. [PMID: 38765346 PMCID: PMC11100549 DOI: 10.7759/cureus.58462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.
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Affiliation(s)
- Saeed Ali
- Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, USA
| | - Neelam Khetpal
- Department of Hospital Medicine, Hartford Hospital, Hartford, USA
| | - Munazza Fatima
- Department of Anesthesiology, State University of New York (SUNY) Upstate Medical University Hospital, Syracuse, USA
| | - Sana Hussain
- Department of Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | - Asad Ali
- Department of Gastroenterology and Hepatology, State University of New York (SUNY) Upstate Medical University Hospital, Syracuse, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christopher Childs
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, USA
| | - Muhammad K Hasan
- Department of Gastroenterology, Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, USA
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Xiao Q, Eckardt M, Mohamed A, Ernst H, Behrens A, Homann N, Hielscher T, Kähler G, Ebert M, Belle S, Zhan T. Onset Time and Characteristics of Postprocedural Bleeding after Endoscopic Resection of Colorectal Lesions: A Multicenter Retrospective Study. Dig Dis 2023; 42:78-86. [PMID: 37812925 DOI: 10.1159/000534109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Postprocedural bleeding is a major adverse event after endoscopic resection of colorectal lesions, but the optimal surveillance time after endoscopy is unclear. In this study, we determined onset time and characteristics of postprocedural bleeding events. METHODS We retrospectively screened patients who underwent endoscopic resection of colorectal lesions at three German hospitals between 2010 and 2019 for postprocedural bleeding events using billing codes. Only patients who required re-endoscopy were included for analysis. For identified patients, we collected demographic data, clinical courses, characteristics of colorectal lesions, and procedure-related variables. Factors associated with late-onset bleeding were determined by univariate and multivariate logistic regression analysis. RESULTS From a total of 6,820 patients with eligible billing codes, we identified 113 cases with postprocedural bleeding after endoscopic mucosal (61.9%) or snare resection (38.1%) that required re-endoscopy. The median size of the culprit lesion was 20 mm (interquartile range 14-30 mm). The median onset time of postprocedural bleeding was day 3 (interquartile range: 1-6.5 days), with 48.7% of events occurring within 48 h. Multivariate logistic regression analysis demonstrates that a continued intake of antiplatelet drugs (OR: 3.98, 95% CI: 0.89-10.12, p = 0.025) and a flat morphology of the colorectal lesion (OR: 2.98, 95% CI: 1.08-8.01, p = 0.031) were associated with an increased risk for late postprocedural bleeding (>48 h), whereas intraprocedural bleeding was associated with a decreased risk (OR: 0.12, 95% CI: 0.04-0.50, p = 0.001). CONCLUSION Significant postprocedural bleeding can occur up to 18 days after endoscopic resection of colorectal lesions, but was predominantly observed within 48 h. Continued intake of antiplatelet drugs and a flat polyp morphology are associated with risk for late postprocedural bleeding.
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Affiliation(s)
- Qiyun Xiao
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian Eckardt
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Awsan Mohamed
- Department of Medicine IV, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Helmut Ernst
- Department of Medicine IV, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Alexander Behrens
- Department of Internal Medicine II, Academic Teaching Hospital Wolfsburg, Wolfsburg, Germany
| | - Nils Homann
- Department of Internal Medicine II, Academic Teaching Hospital Wolfsburg, Wolfsburg, Germany
| | - Thomas Hielscher
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Ebert
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Cancer Center, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sebastian Belle
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Central Interdisciplinary Endoscopy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tianzuo Zhan
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Cancer Center, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Zachou M, Varytimiadis K, Androutsakos T, Katsaras G, Zoumpouli C, Lalla E, Nifora M, Karantanos P, Nikiteas N, Sougioultzis S, Kalaitzakis E, Kykalos S. Protocol design for randomized clinical trial to compare underwater cold snare polypectomy to conventional cold snare polypectomy for non-pedunculated colon polyps of size 5-10 mm (COLDWATER study). Tech Coloproctol 2023; 27:325-333. [PMID: 36399201 DOI: 10.1007/s10151-022-02731-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Colorectal cancer is internationally the third leading cause of death from a malignant disease. The aim of screening colonoscopy in adults > 45 years of age is early diagnosis and treatment of precancerous polyps. Endoscopic polyp removal (polypectomy) can be achieved with various techniques depending on the size, morphology, and location of the polyp. According to current guidelines, small non-pedunculated polyps should be removed with a cold snare after the colorectal lumen has been insufflated with air (conventional cold snare polypectomy).In recent years, several studies have described the benefits of water aided colonoscopy, as well as the safety and efficacy of underwater cold snare polypectomy for large colon polyps. However, there are insufficient data on conventional and underwater techniques for small polyps, the most commonly diagnosed colorectal polyps. METHODS We have designed a prospective randomized double-blind clinical trial to compare the safety and efficacy of conventional and underwater cold snare polypectomy for non-pedunculated polyps 5-10 mm in size. A total of 398 polyps will be randomized. Randomization will be carried out using the random numbers method of Microsoft Excel 2016. The primary endpoint is the muscularis mucosa resection rate. Secondary endpoints are the depth and percentage of R0 excisions, complications, and the recurrence rate at follow-up endoscopy 6-12 months after polypectomy. DISCUSSION We hypothesize underwater polypectomy will result in a higher muscularis mucosa resection rate. The results of our study will provide useful data for the development of guidelines in polypectomy techniques for non-pedunculated polyps 5-10 mm in size. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov, NCT05273697.
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Affiliation(s)
- M Zachou
- Second Department of Propaedeutic Surgery, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece. .,Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece.
| | - K Varytimiadis
- Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece
| | - T Androutsakos
- Department of Pathophysiology, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Katsaras
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Medical School, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Paediatric Department, General Hospital of Pella-Hospital Unit of Edessa, Edessa, Greece
| | - C Zoumpouli
- Department of Pathology, Sismanogleio General Hospital, Athens, Greece
| | - E Lalla
- Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece
| | - M Nifora
- Department of Pathology, Sismanogleio General Hospital, Athens, Greece
| | - P Karantanos
- Department of Gastroenterology, Sismanogleio General Hospital, Athens, Greece
| | - N Nikiteas
- Second Department of Propaedeutic Surgery, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - S Sougioultzis
- Department of Pathophysiology, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - E Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - S Kykalos
- Second Department of Propaedeutic Surgery, "Laikon" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Auriemma F, Sferrazza S, Bianchetti M, Savarese MF, Lamonaca L, Paduano D, Piazza N, Giuffrida E, Mete LS, Tucci A, Milluzzo SM, Iannelli C, Repici A, Mangiavillano B. From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s. World J Gastrointest Surg 2022; 14:632-655. [PMID: 36158280 PMCID: PMC9353749 DOI: 10.4240/wjgs.v14.i7.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/02/2021] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.
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Affiliation(s)
- Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38014, Italy
| | - Mario Bianchetti
- Digestive Endoscopy Unit, San Giuseppe Hospital - Multimedica, Milan 20123, Italy
| | - Maria Flavia Savarese
- Department of Gastroenterology and Gastrointestinal Endoscopy, General Hospital, Sanremo 18038, Italy
| | - Laura Lamonaca
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Nicole Piazza
- Gastroenterology Unit, IRCCS Policlinico San Donato, San Donato Milanese; Department of Biomedical Sciences for Health, University of Milan, Milan 20122, Italy
| | - Enrica Giuffrida
- Gastroenterology and Hepatology Unit, A.O.U. Policlinico “G. Giaccone", Palermo 90127, Italy
| | - Lupe Sanchez Mete
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Alessandra Tucci
- Department of Gastroenterology, Molinette Hospital, Città della salute e della Scienza di Torino, Turin 10126, Italy
| | | | - Chiara Iannelli
- Department of Health Sciences, Magna Graecia University, Catanzaro 88100, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit and Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano 20089, Italy
| | - Benedetto Mangiavillano
- Biomedical Science, Hunimed, Pieve Emanuele 20090, Italy
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Varese 21053, Italy
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Bhurwal A, Mutneja H, Goel A, Bansal V, Patel A, Brahmbhatt B, Sarkar A. No Significant Difference in Post-ERCP Bleeding Rates Between Dual Antiplatelet Agents and Aspirin Alone: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2022; 56:546-551. [PMID: 34028396 DOI: 10.1097/mcg.0000000000001559] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Several professional society guidelines suggest holding antiplatelet agents before high-risk procedures. However, there is lack of high-grade evidence to support the recommendation as most of the studies have been single center with small sample sizes. We aimed to perform the first systematic review and meta-analysis comparing dual antiplatelet therapy (DAPT) versus aspirin alone in terms of postendoscopic retrograde cholangiopancreatography (ERCP) bleeding. METHODS Three independent reviewers performed a comprehensive review of all original articles published from inception to May 2020, evaluating the post-ERCP bleeding rate in setting of DAPT. Primary outcomes were the overall post-ERCP bleeding rate with the use of dual antiplatelet therapy; comparison of post-ERCP bleeding rate in patients with DAPT versus aspirin alone. Secondary outcomes were comparison of immediate and delayed post-ERCP bleeding outcomes in the 2 cohorts. RESULTS Six studies were included after a thorough search was concluded using the key words. The pooled analysis of studies revealed an overall post-ERCP bleeding rate of 5.7% (95% confidence interval: 3-10.6) on sustained DAPT. Post-ERCP bleeding in DAPT Cohort was not significantly higher as compared with aspirin only Cohort (odds ratio: 1.14, 95% confidence interval: 0.46-2.81). The immediate bleeding and delayed bleeding rates cannot be generalized due to low number of studies. CONCLUSIONS The first systematic review and meta-analysis showed that post-ERCP bleeding rates are not significantly higher in DAPT cohort as compared with aspirin alone. Therefore, the risk of bleeding is less likely related to the antiplatelet agents and more likely related to the procedure itself.
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Affiliation(s)
- Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | - Hemant Mutneja
- Division of Gastroenterology and Hepatology, John H. Stroger Cook County Hospital, Chicago, IL
| | - Akshay Goel
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Vikas Bansal
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN
| | - Anish Patel
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | - Avik Sarkar
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ
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9
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Inagaki Y, Yoshida N, Fukumoto K, Kassai K, Inoue K, Hirose R, Dohi O, Okuda T, Hasegawa D, Okuda K, Ogiso K, Motoyoshi T, Yoriki H, Murakami T, Itoh Y. Risk Factors of Delayed Bleeding After Cold Snare Polypectomy for Colorectal Polyps: A Multicenter Study. Dig Dis Sci 2022; 67:3177-3184. [PMID: 34184204 DOI: 10.1007/s10620-021-07119-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed bleeding (DB) rarely occurs after cold snare polypectomy (CSP) for colorectal polyps, but no large-scale studies have investigated this. The present study evaluated the rate, characteristics, and risk factors of DB of CSP. METHODS We conducted a multicenter retrospective study at 10 Japanese institutions. A total of 18,007 patients underwent CSP for colorectal polyps ≤ 10 mm in size from March 2015 to September 2019, and cases of DB (DB group) were analyzed for the rate, antithrombotic drugs, polyp size, morphology, location, and risk factors. As a control, 269 non-bleeding cases (non-DB group) with 606 polyps who underwent CSP at the same 10 facilities in the 2-week study period were extracted. RESULTS We analyzed 26 DB cases with 28 lesions, and the total DB rate was 0.14% (26/18,007). The DB group had significantly higher rates of using antiplatelets (42.3% vs. 13.0%, p < 0.001) and anticoagulants (19.2% vs. 2.6%, p = 0.002), and significantly higher rates of polyp size ≥ 5 mm (67.9% vs. 45.2%, p = 0.015), rectal lesion (25.0% vs. 6.6%, p = 0.003), and polypoid lesion (89.3% vs. 55.3%, p < 0.001) than the non-DB group. A multivariate analysis (odds ratio; 95% confidence interval) for patient characteristics showed antiplatelet use (4.521; 1.817-11.249, p = 0.001) and anticoagulant use (7.866; 20.63-29.988, p = 0.003) as independent risk factors for DB. Polyp size ≥ 5 mm (3.251; 1.417-7.463, p = 0.005), rectal lesion (3.674; 1.426-9.465, p = 0.007), and polypoid lesion (7.087; 20.81-24.132, p = 0.002) were also risk factors for lesion characteristics. CONCLUSIONS The rate of DB was 0.14% and antithrombotic drug use, polyp size, location, and morphology were related to it.
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Affiliation(s)
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Kohei Fukumoto
- Department of Gastroenterology, Nara City Hospital, Nara, Japan
| | - Kyoichi Kassai
- Department of Gastroenterology, Nishijin Hospital, Kyoto, Japan
| | - Ken Inoue
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Takashi Okuda
- Department of Gastroenterology, Fukuchiyama City Hospital, Kyoto, Japan
| | - Daisuke Hasegawa
- Department of Gastroenterology, Ayabe City Hospital, Kyoto, Japan
| | - Kotaro Okuda
- Department of Gastroenterology, Saiseikai Suita Hospital, Osaka, Japan
| | - Kiyoshi Ogiso
- Department of Gastroenterology, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
| | | | - Hiroyuki Yoriki
- Department of Gastroenterology, Otsu City Hospital, Shiga, Japan
| | - Takaaki Murakami
- Department of Gastroenterology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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Aizawa M, Utano K, Nemoto D, Isohata N, Endo S, Tanaka N, Hewett DG, Togashi K. Risk of Delayed Bleeding after Cold Snare Polypectomy in Patients with Antithrombotic Therapy. Dig Dis Sci 2022; 67:1869-1878. [PMID: 33973083 DOI: 10.1007/s10620-021-06984-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cold snare polypectomy is being increasingly adopted; however, there are few reports of cold snare polypectomy regarding antithrombotic therapy. AIMS This study aimed to investigate the real-world safety of cold snare polypectomy during antithrombotic therapy. METHODS We collected data from consecutive patients undergoing cold snare polypectomy in a single hospital between 2013 and 2017. Indications for cold snare polypectomy were any ≤ 10 mm polyp. The primary outcome was delayed bleeding. We compared rates of delayed bleeding between patients with and without antithrombotic therapy and analyzed risk factors for delayed bleeding using binary logistic regression model with firth procedure. RESULTS In 2152 patients (mean age 67.6 years; male 1411), 4433 colorectal polyps (mean diameter 5.0 mm) underwent cold snare polypectomy. Clipping during the procedure was performed for 5.8%. Delayed bleeding occurred in 0.51% (11/2152) of patients and 0.25% (11/4433) of polyps, but no major delayed bleeding occurred. A total of 244 (11%) patients received antithrombotic therapy. Patients on antithrombotic therapy were older (p < 0.001), more likely male (p < 0.001) and had cold snare polypectomy in the proximal colon (p = 0.011). The rate of delayed bleeding was higher in patients on antithrombotic therapy (1.64% vs. non-antithrombotic therapy 0.37%, p = 0.009). Larger polyp size (> 5 mm), use of clips, and antithrombotic therapy were significant risk factors for delayed bleeding. There was no clear association between specific antithrombotic agents and delayed bleeding. CONCLUSIONS Delayed bleeding after cold snare polypectomy was rare even in patients with antithrombotic therapy, and no major delayed bleeding occurred.
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Affiliation(s)
- Masato Aizawa
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi-machi, Aizuwakamatsu-City, Fukushima, 969-3492, Japan
| | - Kenichi Utano
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi-machi, Aizuwakamatsu-City, Fukushima, 969-3492, Japan
| | - Daiki Nemoto
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi-machi, Aizuwakamatsu-City, Fukushima, 969-3492, Japan
| | - Noriyuki Isohata
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi-machi, Aizuwakamatsu-City, Fukushima, 969-3492, Japan
| | - Shungo Endo
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi-machi, Aizuwakamatsu-City, Fukushima, 969-3492, Japan
| | - Noriko Tanaka
- Department of Health Data Science Research, Healthy Aging Innovation Center (HAIC), Tokyo Metropolitan Geriatric Medical Center, Tokyo, Japan.,Clinical Research Center, Fukushima Medical University, Fukushima, Japan
| | - David G Hewett
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Kazutomo Togashi
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi-machi, Aizuwakamatsu-City, Fukushima, 969-3492, Japan.
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11
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Risk of post-polypectomy bleeding after endoscopic mucosal resection in patients receiving antiplatelet medication: comparison between the continue and hold groups. Surg Endosc 2022; 36:6410-6418. [DOI: 10.1007/s00464-021-08987-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/31/2021] [Indexed: 10/18/2022]
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12
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Kobayashi T, Takeuchi M, Hojo Y, Ishii Y, Koseki Y, Kobayashi Y, Azumi M, Kobayashi Y, Kohisa J, Yoshikawa S, Terai S. Risk of delayed bleeding after hot snare polypectomy and endoscopic mucosal resection in the colorectum with continuation of anticoagulants. J Gastrointest Oncol 2021; 12:1518-1530. [PMID: 34532107 DOI: 10.21037/jgo-21-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background Current guidelines recommend the temporary discontinuation of anticoagulants before colonoscopic polypectomy, but the effect of this practice on reducing the risk of delayed bleeding after hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR) remains unclear. Our aim was to assess the impact of anticoagulants on the risk of colorectal delayed bleeding after HSP and EMR, and evaluate the necessity of drug withdrawal. Methods We reviewed the clinical data of patients with colorectal polyps using antithrombotic drugs who underwent HSP and/or EMR between January 2016 and September 2020 at Nagaoka Red Cross Hospital. After excluding antiplatelet users, patients were classified into those who continued anticoagulants [continuation group: 50 patients (93 lesions)] and those who discontinued anticoagulants [discontinuation group: 87 patients (190 lesions)]. Results Delayed bleeding occurred in 12 lesions, and there was no significant difference in the incidence rates between the continuation and the discontinuation groups (3.2% vs. 4.7%; P=0.756). Logistic regression analysis showed that continued use of anticoagulants was not a significant risk factor for delayed bleeding compared to anticoagulant discontinuation (odds ratio, 0.670; 95% CI, 0.177-2.537; P=0.556). There was no significant difference in the incidence rate and risk of delayed bleeding, regardless of the length of the anticoagulant withdrawal period. Conclusions Continued use of anticoagulants, compared to their discontinuation, did not increase the risk of colorectal delayed bleeding after HSP and EMR. Our results suggest that current guideline recommendations for anticoagulant withdrawal before colonoscopic polypectomy may be reconsidered. Trial Registration UMIN000040449.
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Affiliation(s)
- Takamasa Kobayashi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yuki Hojo
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yui Ishii
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Youhei Koseki
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yoko Kobayashi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Motoi Azumi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yuji Kobayashi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Junji Kohisa
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Seiichi Yoshikawa
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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13
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Yan Z, Gao F, Xie J, Zhang J. Incidence and risk factors of colorectal delayed post-polypectomy bleeding in patients taking antithrombotics. J Dig Dis 2021; 22:481-487. [PMID: 34296519 PMCID: PMC9291470 DOI: 10.1111/1751-2980.13034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In this study we aimed to investigate the incidence and risk factors for delayed post-polypectomy bleeding (DPPB) in Chinese patients taking antithrombotics including antiplatelet agents and anticoagulants. METHODS A retrospective study was conducted in patients who underwent colorectal polypectomy from January 2017 to May 2020. Their demographic characteristics, features of the polyps including number, size, morphology, and location, and use of antiplatelet agents and anticoagulants were collected. The incidence and risk factors for DPPB were compared between the patients with and without antithrombotic use. RESULTS A total of 5152 polyps from 2267 patients were resected under endoscopy. Of these patients, 35 (1.54%) experienced DPPB. Compared with the control group who did not take antithrombotics (1.18%), the incidence of DPPB was significantly higher in patients treated with heparin bridge (HB) therapy (17.39%; P < 0.001) and clopidogrel (4.88%; P = 0.022), but did not differ in patients taking aspirin (1.28%), dual antiplatelet therapy (3.70%), warfarin alone (0%), or direct oral anticoagulants (3.85%). Using the multivariate analysis, HB therapy (odds ratio [OR] 16.735, 95% confidence interval [CI] 4.320-64.834, P < 0.001), male sex (OR 3.825, 95% CI 1.298-11.265, P = 0.015), polyps >1 cm (OR 4.584, 95% CI 1.782-11.794, P = 0.002) and rectal polyps (OR 8.820, 95% CI 3.968-19.602, P < 0.001) were independently associated with a high risk of DPPB. CONCLUSIONS HB and clopidogrel therapies significantly increase the incidence of DPPB. HB therapy, male sex, polyp size and polyps located in the rectum are significant risk factors for DPPB.
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Affiliation(s)
- Zhen Yan
- Department of GastroenterologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Feng Gao
- Department of GastroenterologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Jiang Xie
- Department of Respiratory and Critical MedicineBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Jie Zhang
- Department of GastroenterologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
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14
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Risk Factors Associated With Postendoscopic Mucosal Resection Bleeding in Patients With Cirrhosis: A Retrospective Multicenter Cohort Study. J Clin Gastroenterol 2021; 55:355-360. [PMID: 32796193 DOI: 10.1097/mcg.0000000000001407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM There is limited data regarding the safety of endoscopic mucosal resection (EMR) in the cirrhotic population. Our study aimed to evaluate the safety of colonoscopic EMR in cirrhosis. MATERIALS AND METHODS This was a retrospective review of cirrhotics who underwent colonic EMR at 8 Cleveland Clinic Centers between January 1, 2006, and December 31, 2018. Patient data including polyp details and complications occurring within 30 days of the procedure were noted. Univariable and multivariable logistic regression analyses were conducted to find risk factors for post-EMR bleeding. RESULTS A total of 238 patients who underwent EMR were included. There were 145 males (60.9%) and the mean age was 61.9±8.6 years. Immediate and delayed bleeding, and postpolypectomy syndrome rates were 9.2%, 5.8%, and 1.3%, respectively. Significant risk factors for postpolypectomy bleeding were: increased age (P=0.001), procedure duration >37 minutes (P=0.001), antiplatelet use within 5 days (P=0.023), and lesion diameter >15 mm (P=0.004). Multivariable analysis revealed independent predictors of procedure-related bleeding: age above 65 years [odds ratio (OR) 2.14, P=0.044], antiplatelet use within 5 days (OR 2.42, P=0.047), right colon polyp (OR 3.51, P=0.001), and lesion diameter >15 mm (OR 3.22, P=0.003). CONCLUSIONS EMR in cirrhotics has an acceptable bleeding risk. Age above 65 years, right colon polyp, polyp size >15 mm, and use of antiplatelets within 5 days are independent risk factors for bleeding.
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15
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Harada H, Miyaoka Y, Yuki T, Iwaki T, Maeda G, Nakahara R, Murakami D, Ujihara T, Katsuyama Y, Hayasaka K, Kushiyama Y, Fujishiro H, Amano Y. Postpolypectomy bleeding of colorectal polyps in patients with continuous warfarin and short-term interruption of direct oral anticoagulants. Gastrointest Endosc 2021; 93:691-698. [PMID: 33022270 DOI: 10.1016/j.gie.2020.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Postpolypectomy bleeding (PPB) is the most common adverse event after colorectal polypectomy. Use of anticoagulants is an important risk factor for PPB. This study aimed to evaluate PPB in patients receiving treatment with warfarin and direct oral anticoagulants (DOACs). METHODS Between August 2017 and July 2019, 5449 patients with 12,601 polyps who underwent endoscopic snare resection of colorectal polyps were enrolled. Endoscopic snare resection was performed in patients receiving continuous warfarin (C-warfarin) and in patients who experienced 1 day cessation of (O-) of DOACs in accordance with the Japanese Gastroenterological Endoscopy Society guidelines. RESULTS The PPB rate in the group receiving anticoagulants was statistically higher than that in the group without anticoagulants (8.5% [33/387] vs 1.2% [63/5,062], respectively; P < .001). By multivariate logistic regression analysis, male gender (odds ratio [OR], 2.17; P = .007), warfarin (OR, 4.64; P < .001), DOACs (OR, 6.59; P < .001), and multipolyp removal (OR, 1.77; P = .007) were significant risk factors for PPB. PPB was observed in 9 and 21 patients in the C-warfarin and O-DOACs groups, respectively: C-warfarin (8.0% [9/113]), O-dabigatran (6.1% [2/33]), O-rivaroxaban (14.8% [9/61]), O-apixaban (9.8% [9/92]), and O-edoxaban (1.8% [1/56]). The PPB rate with the O-edoxaban group was significantly lower than that with the O-rivaroxaban group (P < .05). CONCLUSIONS Use of anticoagulant therapy was an independent risk factor for PPB. The rates of PPB in patients receiving C-warfarin and O-DOACs were also higher than those in patients not receiving anticoagulants. Edoxaban may be safe through short-term withdrawal in patients undergoing endoscopic snare resection of colorectal polyps.
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Affiliation(s)
- Hideaki Harada
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Youichi Miyaoka
- Department of Endoscopy, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Takafumi Yuki
- Department of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Tomoyuki Iwaki
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Gen Maeda
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Ryotaro Nakahara
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Daisuke Murakami
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Tetsuro Ujihara
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | | | - Kenji Hayasaka
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | | | - Hirofumi Fujishiro
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Yuji Amano
- Department of Endoscopy, New Tokyo Hospital, Chiba, Japan
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16
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Bozkurt H, Sert ÖZ, Ölmez T, Keklikkıran ZZ, Uzun O, Gülmez S, Polat E, Duman M. The risk of post-polypectomy bleeding among patients receiving antithrombotic agents: A prospective observational study. SAO PAULO MED J 2021; 139:218-225. [PMID: 33759909 PMCID: PMC9625013 DOI: 10.1590/1516-3180.2020.0305.r1.10122020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/10/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines for gastroenterological endoscopy in patients receiving antithrombotic therapy. Colonoscopic polypectomy procedures are associated with a high risk of bleeding. OBJECTIVES The present study evaluated the safety of colonoscopic polypectomy procedures in terms of bleeding, among patients receiving antithrombotic therapy. DESIGN AND SETTING Prospective observational study conducted in a tertiary-level public cardiovascular hospital in Istanbul, Turkey. METHODS Colonoscopic polypectomies carried out in a single endoscopy unit between July 2018 and July 2019 were evaluated prospectively. The patients' data, including age, gender, comorbidities, whether antithrombotic drug use was ceased or whether patients were switched to bridging therapy, polyp size, polyp type, polyp location, histopathology, resection methods (hot snare, cold snare or forceps) and complications relating to the procedures were recorded. RESULTS The study was completed with 94 patients who underwent a total of 167 polypectomy procedures. As per the advice of the physicians who prescribed antithrombotic medications, 108 polypectomy procedures were performed on 60 patients without discontinuing medication and 59 polypectomy procedures were performed on 34 patients after discontinuing medication. The age, gender distribution and rate of bleeding did not differ significantly between the patients whose medication was discontinued and those whose medication was continued (P > 0.05). CONCLUSION This study found that the colonoscopic polypectomy procedure without discontinuation of antithrombotic medication did not increase the risk of bleeding. This procedure can be safely performed by experienced endoscopists in patients with an international normalized ratio (INR) below 2.5.
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Affiliation(s)
- Hilmi Bozkurt
- MD, MSc. General Surgeon, Gastrointestinal Surgeon and Molecular Oncology Doctoral Student, University of Health Sciences, Haseki Research and Education Hospital, Istanbul, Turkey.
| | - Özlem Zeliha Sert
- MD, MSc. General Surgeon, Gastrointestinal Surgeon and Molecular Oncology Doctoral Student, University of Health Sciences, Haydarpaşa Research and Education Hospital, Istanbul, Turkey.
| | - Tolga Ölmez
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Zeynep Zehra Keklikkıran
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Orhan Uzun
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Selçuk Gülmez
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Erdal Polat
- MD. Associate Professor, General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Mustafa Duman
- MD. Professor, General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
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17
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Kishino T, Oyama T, Hotta K, Ishii E, Momoi T, Shimizu T, Kunieda K, Takeda S, Komatsu H. Risk of colonoscopic post-polypectomy bleeding in patients after the discontinuation of antithrombotic therapy. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:752-759. [PMID: 33361037 DOI: 10.5152/tjg.2020.19428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Few studies have examined the incidence of post-polypectomy bleeding (PPB) after discontinuation of antithrombotic therapies. Therefore, this study aimed to evaluate the incidence of PPB and thromboembolic events in patients whose antithrombotic agents were discontinued before colonoscopy. MATERIALS AND METHODS We retrospectively selected all patients who underwent colon polypectomy at a community hospital. A total of 282 patients (540 polypectomies) discontinued antithrombotic agents (group 1), and 1,648 patients (2,827 polypectomies) did not take antithrombotic agents (group 2). The cessation periods before and after polypectomies were 4 and 3 days for warfarin, 5 and 3 days for anti-platelet agents, and 7 and 5 days of combination therapy, respectively. Main outcome measurements were the incidence of PPB and thromboembolic events. RESULTS Immediate PPB rates were 3.9% (11/282) in group 1 and 4.6% (76/1648) in group 2 (adjusted odds ratio [OR], 0.85; 95% confidence interval [CI], 0.42-1.72; p=0.65). Delayed PPB rates were 1.4% (4/282) in group 1 and 1.1% (18/1648) in group 2 (adjusted OR, 1.24; 95% CI, 0.36-4.24; p=0.732). No thromboembolic events were observed in either group. CONCLUSION Our cessation periods were appropriate, and further shortening of these periods is possible.
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Affiliation(s)
- Takaaki Kishino
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan; Department of Gastroenterology, Nara City Hospital, Nara, Japan
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Kinichi Hotta
- Division of Endoscopy and Gastrointestinal Oncology, Shizuoka Cancer Center, Nagaizumi, Japan
| | | | - Tamaki Momoi
- Department of Gastroenterology, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Takehiro Shimizu
- Department of Gastroenterology, Isesaki Municipal Hospital, Isesaki, Japan
| | - Kenji Kunieda
- Department of Medical Oncology, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Shinichiro Takeda
- Department of Gastroenterology, Matsudo City Hospital, Matsudo, Japan
| | - Hirokazu Komatsu
- Department of Community Care, Saku Central Hospital, Saku, Japan
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18
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. [Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 76:282-296. [PMID: 33361705 DOI: 10.4166/kjg.2020.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/03/2022]
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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19
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Clin Endosc 2020; 53:663-677. [PMID: 33242928 PMCID: PMC7719428 DOI: 10.5946/ce.2020.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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Chan A, Philpott H, Lim AH, Au M, Tee D, Harding D, Chinnaratha MA, George B, Singh R. Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence. World J Gastrointest Endosc 2020; 12:408-450. [PMID: 33269053 PMCID: PMC7677885 DOI: 10.4253/wjge.v12.i11.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/01/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).
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Affiliation(s)
- Andrew Chan
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Hamish Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Amanda H Lim
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Minnie Au
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Derrick Tee
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Damian Harding
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Mohamed Asif Chinnaratha
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Biju George
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
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21
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Xiang BJ, Huang YH, Jiang M, Dai C. Effects of antithrombotic agents on post-operative bleeding after endoscopic resection of gastrointestinal neoplasms and polyps: A systematic review and meta-analysis. World J Meta-Anal 2020. [DOI: 10.13105/wjma.v8.i5.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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22
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Xiang BJ, Huang YH, Jiang M, Dai C. Effects of antithrombotic agents on post-operative bleeding after endoscopic resection of gastrointestinal neoplasms and polyps: A systematic review and meta-analysis. World J Meta-Anal 2020; 8:411-434. [DOI: 10.13105/wjma.v8.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/07/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are some studies investigating the relationship between antithrombotic medication and postoperative bleeding after endoscopic resection (ER) with controversial results.
AIM To perform a meta-analysis evaluating the effects of antithrombotic therapy on postoperative bleeding after ER.
METHODS A systematic search was conducted on PubMed, Web of Science, Cochrane Library. The Newcastle-Ottawa scale was used to evaluate the quality of studies. Stata 12.0 was used for statistical analysis. The odds ratio (OR) and 95%CI were calculated and heterogeneity was quantified using Cochran’s Q test and I2.
RESULTS Total 66 studies were included in the meta-analysis. Pooled data suggested that antithrombotic therapy was significantly associated with postoperative bleeding (OR = 2.302, 95%CI: 2.057-2.577, P = 0.000) after ER. The risk of postoperative bleeding after endoscopic submucosal dissection, endoscopic mucosal resection and polypectomy in the antithrombotic group was higher than the non-antithrombotic group (OR = 2.439, 95%CI: 1.916-3.105; OR = 2.688, 95%CI: 1.098-6.582; OR = 2.112, 95%CI: 1.434-3.112).
CONCLUSION The risk of postoperative bleeding after ER correlated with the types and management of antithrombotic agents by our meta-analysis.
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Affiliation(s)
- Bing-Jie Xiang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Yu-Hong Huang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Min Jiang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Cong Dai
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
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23
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Yang SC, Wu CK, Tai WC, Liang CM, Li YC, Yeh WS, Lee CH, Yang YH, Tsai TH, Hsu CN, Chuah SK. Incidence and risk factors of colonoscopic post-polypectomy bleeding and perforation in patients with end-stage renal disease. J Gastroenterol Hepatol 2020; 35:1704-1711. [PMID: 31900958 DOI: 10.1111/jgh.14969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/16/2019] [Accepted: 01/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Colonoscopic polypectomy in end-stage renal disease (ESRD) patients are at risks of post-polypectomy bleeding and perforation, but evidences are limited. This study aimed to determine the incident polypectomy complications among ESRD patients. METHODS In the nationwide ESRD cohort, a propensity score matched case-control study design was conducted to assess risk associated with post-polypectomy bleeding and perforation using the Taiwanese National Health Insurance Research Database from 1997 to 2013 for adults aged 40 years and older; 7011 ESRD and 19 118 non-ESRD patients met the study criteria. A total of 5302 patients in each group were matched for further analyses. The primary endpoint was post-polypectomy bleeding or bowel perforation in 30 days. The secondary endpoint was mortality and length of hospital stay for the bleeding complications requiring hospitalization. RESULTS Overall incidences of post-polypectomy bleeding or perforation in patients with ESRD was higher than the non-ESRD group (5.83% vs 1.78%, P < 0.0001) in the matched cohort. High risk of adverse outcomes was associated with ESRD (adjusted odds ratio [aOR], 2.38, 95% confidence interval [CI], 1.85-3.05), female patient (aOR, 1.7, 95% CI, 1.37-2.11), history of acute myocardial infarction (aOR, 1.91, 95% CI, 1.1-3.32), liver disease (aOR, 1.79, 95% CI, 1.37-2.34), diabetes (aOR, 1.45, 95% CI, 1.16-1.82), cancer (aOR, 1.4, 95% CI, 1.09-1.81), inpatient setting (aOR, 13.19, 95% CI, 9.73-17.88), and prior use of clopidogrel (aOR, 1.61, 95% CI, 1.03-2.52) and warfarin (aOR, 2.03, 95% CI, 1.21-3.41). CONCLUSIONS End-stage renal disease was associated with approximately twofold higher risk of colonoscopic post-polypectomy bleeding or perforation and should be cautiously performed in this special population cohort.
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Affiliation(s)
- Shih-Cheng Yang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Cheng-Kun Wu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Chih-Ming Liang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Yu-Chi Li
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Wen-Shuo Yeh
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Seng-Kee Chuah
- Division of Hepato-Gastroenterology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan
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Cold Snare Polypectomy in Patients Taking Dual Antiplatelet Therapy: A Randomized Trial of Discontinuation of Thienopyridines. Clin Transl Gastroenterol 2020; 10:e00091. [PMID: 31599746 PMCID: PMC6884347 DOI: 10.14309/ctg.0000000000000091] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION: Cold snare polypectomy (CSP) is a safe and effective method for removing polyps ≤10 mm. The aim of this study was to compare the risk of clinically significant bleeding and thromboembolic events after CSP between stopping and continuing thienopyridines in patients taking dual antiplatelet therapy (DAPT). METHODS: The study was a single-center, noninferiority, and randomized controlled study involving patients who received colonoscopy from October 2015 to October 2016. Patients receiving DAPT with polyps ≤10 mm were randomly assigned to either the DAPT group (patients continued DAPT) or the aspirin group (patients discontinued thienopyridines for 1 week). Primary outcome was clinically significant bleeding. Secondary outcomes included intraprocedural bleeding, nonsignificant hematochezia, and occurrence of thromboembolic events. RESULTS: Forty-two patients with 104 eligible polyps were allocated to the DAPT group, and 45 patients with 101 eligible polyps were allocated to the aspirin group. Patient demographic characteristics including size, location, shape, and pathology of the removed polyps were similar in the 2 groups. Intraprocedural bleeding and nonsignificant hematochezia rates were also similar between the 2 groups (4.8% vs 2.2%, P = 0.608; 19.0% vs 8.9%, P = 0.170). No thromboembolic event occurred in either group. Only 1 patient (2.4%) in the DAPT group showed clinically significant bleeding. No significant bleeding was found in the aspirin group. DISCUSSION: Clinically significant bleeding rate after CSP for polyps ≤10 mm in patients continuing to take DAPT was 2.4%. Therefore, CSP is a safe method for removing small polyps even in patients taking DAPT (ClincialTrials.gov number, NCT02865824).
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25
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Li DF, Chang X, Fang X, Wang JY, Yu ZC, Wei C, Xiong F, Xu ZL, Zhang DG, Liu TT, Luo MH, Wang LS, Yao J. Colonoscopic post-polypectomy bleeding in patients on uninterruptedclopidogrel therapy: A systematic review and meta-analysis. Exp Ther Med 2020; 19:3211-3218. [PMID: 32266017 PMCID: PMC7132234 DOI: 10.3892/etm.2020.8597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Current guidelines recommend temporary cessation of clopidogrel for 7-10 days for patients on clopidogrel undergoing colonoscopy with polypectomy. However, recent prospective randomized controlled trials have advocated for uninterrupted clopidogrel, due to similar post-polypectomy bleeding (PPB) rates with and without continued clopidogrel therapy. Thus, a meta-analysis was conducted to assess the risk of PPB rate in patients on continued clopidogrel therapy. Systemically identified publications were used to compare the rate of PPB in patients on continued clopidogrel therapy with those who had interrupted clopidogrel therapy. The primary outcome was the incidence of PPB. The secondary outcomes were immediate PPB, delayed PPB and serious cardio-thrombotic events. This study has been registered in PROSPERO (no. CRD42018118325). A total of five studies were identified, which included 655 patients in the continued clopidogrel group and 6620 patients in the control group. There was an increased risk of PPB with continued clopidogrel [P=0.0003; risk ratio (RR), 1.96; 95% confidence interval (CI), 1.36-2.83). The rate of immediate PPB was slightly higher in the continued clopidogrel group (5.77% vs. 1.77%, respectively), but was not statistically significant (P=0.06; RR, 1.57; 95%CI, 0.98-2.51). The rate of delayed PPB was increased in the continued clopidogrel group (P=0.0008; RR, 3.10; 95%CI, 1.60-5.98). However, no significant difference in serious cardio-thrombotic events was observed within 30 days (P=0.74; RR, 0.78; 95%CI, 0.18-3.40). Although continued clopidogrel therapy decreased the incidence of serious cardio-thrombotic events, the risk of delayed PPB was increased. Therefore, endoscopists should make all preparations to prevent bleeding in the perioperative period for patients at high thrombotic risk and on continued clopidogrel therapy, if polypectomy cannot be reasonably postponed.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Xin Chang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Xue Fang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Jian-Yao Wang
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Zhi-Chao Yu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Cheng Wei
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Feng Xiong
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Zheng-Lei Xu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ding-Guo Zhang
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ting-Ting Liu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ming-Han Luo
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Li-Sheng Wang
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Jun Yao
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
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26
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Chang K, Lee BS, Tekeste T, Nguyen A, Adeyemo M, Girgis A, Kwok KK, Crowson HM, Burris AO, Attam R, Chaya CT, Durbin TE, Giap AQ, Hunt GC, Iskander J, Kao KT, Lim BS. The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study. BMC Gastroenterol 2020; 20:60. [PMID: 32143633 PMCID: PMC7060595 DOI: 10.1186/s12876-020-01199-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/20/2020] [Indexed: 12/31/2022] Open
Abstract
Background Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions. Method This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage. Results A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893. Conclusion Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.
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Affiliation(s)
- Karen Chang
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Brian S Lee
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Timnit Tekeste
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Andrew Nguyen
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Mopelola Adeyemo
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Agathon Girgis
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Karl K Kwok
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA, 90027, USA
| | - H Michael Crowson
- Department of Educational Psychology, The University of Oklahoma, 820 Van Vleet Oval, Collings Hall, Room 321, Norman, OK, 73019-2041, USA
| | - Alicia O Burris
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Rajeev Attam
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, 9353 Imperial Highway, Downey, CA, 90242, USA
| | - Charles T Chaya
- Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, 10800 Magnolia Avenue, Riverside, CA, 92505, USA
| | - Theodore E Durbin
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, 3440 E La Palma Avenue, Anaheim, CA, 92806, USA
| | - Andrew Q Giap
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, 3440 E La Palma Avenue, Anaheim, CA, 92806, USA
| | - Gordon C Hunt
- Department of Gastroenterology, Kaiser Permanente San Diego Medical Center, 9445 Clairemont Mesa Blvd, San Diego, CA, 92123, USA
| | - John Iskander
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Kevin T Kao
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, 9353 Imperial Highway, Downey, CA, 90242, USA
| | - Brian S Lim
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA. .,Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, 10800 Magnolia Avenue, Riverside, CA, 92505, USA.
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27
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Effect of antiplatelet agent number, types, and pre-endoscopic management on post-polypectomy bleeding: validation of endoscopy guidelines. Surg Endosc 2020; 35:317-325. [DOI: 10.1007/s00464-020-07402-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/30/2020] [Indexed: 12/17/2022]
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Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants. Gastroenterol Res Pract 2019; 2019:5743561. [PMID: 31929785 PMCID: PMC6935785 DOI: 10.1155/2019/5743561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/07/2019] [Accepted: 11/28/2019] [Indexed: 12/28/2022] Open
Abstract
Backgrounds and Aims Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors. Materials and Methods This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients' clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups. Results The rates of POH were 7.9%∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6%∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively (∗ vs. ∗∗, p < 0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2 ± 8.3 vs. 7.2 ± 4.9, p < 0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment. Conclusions Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics.
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Kothari ST, Huang RJ, Shaukat A, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Khashab MA, Jamil LH, Jue TL, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Thosani N, Yang J, DeWitt JM, Wani S. ASGE review of adverse events in colonoscopy. Gastrointest Endosc 2019; 90:863-876.e33. [PMID: 31563271 DOI: 10.1016/j.gie.2019.07.033] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/29/2019] [Indexed: 02/07/2023]
Abstract
Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.
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Affiliation(s)
| | - Robert J Huang
- Stanford University Medical Center, Stanford, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Deepak Agrawal
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Douglas S Fishman
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | | | | | - Laith H Jamil
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, Coralville, Iowa, USA
| | | | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- University of Texas at Houston, Bellaire, Texas, USA
| | - Julie Yang
- Einstein Hospital, New York, New York, USA
| | - John M DeWitt
- Division of Gastroenterology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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Study design of endoscopic polypectomy on clopidogrel (EPOC): A randomised controlled trial. Contemp Clin Trials Commun 2019; 16:100479. [PMID: 31737799 PMCID: PMC6849125 DOI: 10.1016/j.conctc.2019.100479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/20/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023] Open
Abstract
Concurrent cardiovascular disease and antiplatelet use (clopidogrel, prasugrel and ticagrelor) use poses a significant peri-endoscopic management challenge with a paucity of high-quality evidence available. Antiplatelet temporary interruption places patients at risk of serious cardiovascular thrombotic events. Continuing these agents potentially increases the risk of procedure related bleeding however this risk could be sufficiently mitigated by cold snare polypectomy and endoscopic clipping to manage intraprocedural bleeding, making routine colonoscopy on continued antiplatelet agents safe. The EPOC trial will examine whether continuation of antiplatelet therapy (clopidogrel, prasugrel or ticagrelor) as single or dual therapy with aspirin, is inferior or superior to temporary interruption of antiplatelet therapy, current standard of care, with regard to the use of endoscopic rescue clips or clinically significant post-polypectomy bleeding after cold snare polypectomy of polyps ≤10 mm. EPOC is a parallel group, proceduralist-blinded randomized controlled trial comparing recruiting patients on antiplatelet therapy undergoing elective colonoscopy. This trial is underway throughout Australia and New Zealand with a view to expanding to additional sites. 496 subjects in each arm are required for this study. EPOC is the first randomised controlled trial comparing temporary interruption with continuation of antiplatelet therapy in patients undergoing elective colonoscopy.
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Yao C, Chiu Y, Wu K, Tai W, Hu M, Chou Y, Liang C, Lu L, Chuah S. The effect of discontinuation of aspirin on colonoscopic postpolypectomy bleeding. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Chih‐Chien Yao
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Yi‐Chun Chiu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Keng‐Liang Wu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
- Graduate Institute of Clinical Medical SciencesChang Gung University Taoyuan Taiwan
| | - Wei‐Chen Tai
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Ming‐Luen Hu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Yeh‐Pin Chou
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Chih‐Ming Liang
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Lung‐Sheng Lu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
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Ket SN, Mangira D, Ng A, Tjandra D, Koo JH, La Nauze R, Metz A, Moss A, Brown G. Complications of cold versus hot snare polypectomy of 10-20 mm polyps: A retrospective cohort study. JGH OPEN 2019; 4:172-177. [PMID: 32280761 PMCID: PMC7144768 DOI: 10.1002/jgh3.12243] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/25/2019] [Accepted: 06/25/2019] [Indexed: 02/06/2023]
Abstract
Background and Aim Cold snare polypectomy is safe and efficacious for removing polyps <10 mm with reduced rates of delayed postpolypectomy bleeding and postpolypectomy syndrome. This technique can also be used for sessile polyps ≥10 mm; however, further evidence is required to establish its safety. The aim of this study was to compare intraprocedure and postprocedure adverse events in patients who underwent cold (CSP) versus hot snare polypectomy (HSP) of 10-20 mm sessile colonic polyps. Methods Electronic medical records and endoscopy reports of all patients who underwent polypectomy for Paris 0-IIa, Is, or 0-IIa + Is 10-20 mm colonic polyps between January 2015 and June 2017 at three tertiary academic hospitals and one private hospital were retrospectively reviewed. Data on patient demographics, polyp characteristics, method of polypectomy, and intraprocedural and postpolypectomy adverse events were collected. Results A total of 408 patients (median age 67, 50% male) had 604 polyps, 10-20 mm in size, removed. Of these, 258 polyps were removed by HSP, with a median size of 15 mm (interquartile range [IQR] 12-20), compared to 346 polyps that were removed by CSP, with median size of 12 mm (IQR 10-15), P < 0.001. In the HSP group, 15 patients presented with postprocedure complications, including 11 with clinically significant bleeding, 2 with postpolypectomy syndrome, and 2 with abdominal pain. This compares with no postpolypectomy complications in the CSP group, P < 0.001. Conclusion In this study, CSP was not associated with any postpolypectomy adverse events. CSP appears to be safer than HSP for removing 10-20 mm-sized sessile polyps. A prospective multicenter study has been commenced to verify these findings and to assess the efficacy of CSP for the complete resection of polyps of this size.
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Affiliation(s)
- Shara N Ket
- Department of Gastroenterology Alfred Health Melbourne Victoria Australia.,Central Clinical School Monash University Melbourne Victoria Australia
| | - Dileep Mangira
- Department of Endoscopic Services Western Health Melbourne Victoria Australia.,Department of Medicine - Western Health, Melbourne Medical School University of Melbourne Melbourne Victoria Australia
| | - Allysia Ng
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Douglas Tjandra
- Department of Gastroenterology Melbourne Health Melbourne Victoria Australia
| | - Ja H Koo
- Department of Endoscopic Services Western Health Melbourne Victoria Australia
| | - Richard La Nauze
- Department of Gastroenterology Alfred Health Melbourne Victoria Australia
| | - Andrew Metz
- Department of Gastroenterology Melbourne Health Melbourne Victoria Australia
| | - Alan Moss
- Department of Endoscopic Services Western Health Melbourne Victoria Australia.,Department of Medicine - Western Health, Melbourne Medical School University of Melbourne Melbourne Victoria Australia.,Epworth Hospital Melbourne Victoria Australia
| | - Gregor Brown
- Department of Gastroenterology Alfred Health Melbourne Victoria Australia.,Central Clinical School Monash University Melbourne Victoria Australia.,Epworth Hospital Melbourne Victoria Australia
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Lichtenstein D, Vemula A. In CVD, continuing vs interrupting clopidogrel before colonoscopy did not differ for delayed postpolypectomy bleeding. Ann Intern Med 2019; 171:JC6. [PMID: 31307067 DOI: 10.7326/acpj201907160-006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Chan FKL, Kyaw MH, Hsiang JC, Suen BY, Kee KM, Tse YK, Ching JYL, Cheong PK, Ng D, Lam K, Lo A, Lee V, Ng SC. Risk of Postpolypectomy Bleeding With Uninterrupted Clopidogrel Therapy in an Industry-Independent, Double-Blind, Randomized Trial. Gastroenterology 2019; 156:918-925.e1. [PMID: 30518511 DOI: 10.1053/j.gastro.2018.10.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 10/14/2018] [Accepted: 10/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Guidelines recommend withholding clopidogrel 7 days before polypectomy to decrease bleeding risk, but these were written based on limited evidence. We investigated whether uninterrupted clopidogrel therapy increases the risk of delayed postpolypectomy bleeding in patients undergoing colonoscopy. METHODS We identified patients receiving clopidogrel for cardiovascular disease undergoing elective colonoscopies in Hong Kong from February 28, 2012 through April 11, 2018. Eligible patients were instructed to stop taking clopidogrel 7 days before colonoscopy. Then, they were randomly assigned to groups given clopidogrel (75 mg) or placebo daily until the morning of colonoscopy. All patients resumed their usual prescriptions of clopidogrel after colonoscopy. The primary end point was delayed postpolypectomy bleeding that required hospitalization or intervention up to 30 days after colonoscopy. Secondary end points were immediate postpolypectomy bleeding and serious cardio-thrombotic events for as long as 6 months after colonoscopy, according to Antithrombotic Trialists' criteria. All events were adjudicated by an independent masked committee. RESULTS In total, 387 patients underwent colonoscopy and 216 required polypectomies (106 patients in the clopidogrel group and 110 patients in the placebo group). The cumulative incidence of delayed postpolypectomy bleeding was 3.8% (95% confidence interval 1.4-9.7) in the clopidogrel group and 3.6% (95% confidence interval 1.4-9.4) in the placebo group (P = .945 by log-rank test). There were no significant differences in immediate postpolypectomy bleeding (8.5% vs 5.5%; P = .380) and cardio-thrombotic events (1.5% vs 2%; P = .713). CONCLUSIONS In a randomized controlled trial of clopidogrel users undergoing colonoscopy, a slightly larger proportion of patients continuing clopidogrel developed delayed and immediate postpolypectomy bleeding, although this difference was not statistically significant. ClinicalTrials.gov, number NCT01806090.
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Affiliation(s)
- Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Moe H Kyaw
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - John C Hsiang
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China; Department of Gastroenterology, Changi General Hospital, Sing Health, Singapore
| | - Bing Yee Suen
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Man Kee
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yee Kit Tse
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jessica Y L Ching
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Pui Kuan Cheong
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Daphne Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kelvin Lam
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angeline Lo
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vivian Lee
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China; The State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, China
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Kim SY, Kim HS, Park HJ. Adverse events related to colonoscopy: Global trends and future challenges. World J Gastroenterol 2019; 25:190-204. [PMID: 30670909 PMCID: PMC6337013 DOI: 10.3748/wjg.v25.i2.190] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/22/2018] [Accepted: 12/01/2018] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.
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Affiliation(s)
- Su Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, South Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, South Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, South Korea
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Mangira D, Ket SN, Majeed A, Gibson PR, Brown G. Postpolypectomy prophylactic clip closure for the prevention of delayed postpolypectomy bleeding: A systematic review. JGH OPEN 2018; 2:105-110. [PMID: 30483572 PMCID: PMC6206987 DOI: 10.1002/jgh3.12047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/31/2018] [Indexed: 12/21/2022]
Abstract
Delayed postpolypectomy bleeding (DPPB) is the most common complication of colonoscopic polypectomy. Prophylactic clipping after an uncomplicated polypectomy is increasingly used, but it is unclear if this results in the prevention of DPPB. This study aimed to review prophylactic clip use and its effect on the rates of DPPB. MEDLINE, Embase, and the Cochran Library were systematically searched for studies (1995–March 2017) that used prophylactic hemoclips and assessed DPPB as an outcome. Of 1402 articles identified, nine papers were eligible for inclusion, evaluating 4311 patients and 7783 polyps; 118 patients experienced a DPPB, and 49 of these patients received prophylactic clips. There was no significant difference in DPPB rates in patients who received prophylactic clipping compared to those who did not (odd ratio: 0.8; 95% confidence interval: 0.36–1.77; P = 0.56). There was also no significant difference in the DPPB of polyps <20 mm compared with polyps ≥20 mm. Clip application for prophylactic management of an uncomplicated polypectomy has not been demonstrated to reduce the risk of DPPB, casting doubt on the use of this costly practice.
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Affiliation(s)
- Dileep Mangira
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia.,Department of Gastroenterology Western Health and Melbourne University Melbourne Victoria Australia
| | - Shara N Ket
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia
| | - Ammar Majeed
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia
| | - Peter R Gibson
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia
| | - Gregor Brown
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia.,Epworth Hospital Melbourne Victoria Australia
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Mukai S, Itoi T, Baron TH, Takada T, Strasberg SM, Pitt HA, Ukai T, Shikata S, Teoh AYB, Kim MH, Kiriyama S, Mori Y, Miura F, Chen MF, Lau WY, Wada K, Supe AN, Giménez ME, Yoshida M, Mayumi T, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:537-549. [DOI: 10.1002/jhbp.496] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology; Tokyo Medical University Hospital; Tokyo Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology; Tokyo Medical University Hospital; Tokyo Japan
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology; University of North Carolina at Chapel Hill; NC USA
| | - Tadahiro Takada
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Steven M. Strasberg
- Section of HPB Surgery; Washington University in St. Louis; St. Louis MO USA
| | - Henry A. Pitt
- Lewis Katz School of Medicine at Temple University; Philadelphia PA USA
| | - Tomohiko Ukai
- Department of Family Medicine; Mie Prefectural Ichishi Hospital; Mie Japan
| | | | | | - Myung-Hwan Kim
- Department of Gastroenterology; University of Ulsan College of Medicine; Seoul Korea
| | - Seiki Kiriyama
- Department of Gastroenterology; Ogaki Municipal Hospital; Gifu Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Fumihiko Miura
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Miin-Fu Chen
- Division of General Surgery; Linkou Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Wan Yee Lau
- Faculty of Medicine; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Keita Wada
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Avinash Nivritti Supe
- Department of Surgical Gastroenterology; Seth G S Medical College and K E M Hospital; Mumbai India
| | - Mariano Eduardo Giménez
- Chair of General Surgery and Minimal Invasive Surgery “Taquini”; University of Buenos Aires; Argentina DAICIM Foundation; Buenos Aires Argentina
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery; Chemotherapy Research Institute; International University of Health and Welfare; Chiba Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine; School of Medicine; University of Occupational and Environmental Health; Fukuoka Japan
| | - Koichi Hirata
- Department of Surgery; JR Sapporo Hospital; Hokkaido Japan
| | | | - Kazuo Inui
- Department of Gastroenterology; Second Teaching Hospital; Fujita Health University; Aichi Japan
| | - Masakazu Yamamoto
- Department of Surgery; Institute of Gastroenterology; Tokyo Women's Medical University; Tokyo Japan
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Yamashina T, Fukuhara M, Maruo T, Tanke G, Marui S, Sada R, Taki M, Ohara Y, Sakamoto A, Henmi S, Sawai Y, Saito S, Nishijima N, Nasu A, Komekado H, Sekikawa A, Asada M, Tumura T, Kita R, Kimura T, Osaki Y. Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis. Endosc Int Open 2017; 5:E587-E594. [PMID: 28670615 PMCID: PMC5482743 DOI: 10.1055/s-0043-105578] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 02/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Cold snare polypectomy (CSP) for small colorectal polyps has lower incidence of adverse events, especially delayed postpolypectomy bleeding (DPPB). However, few data are available on comparisons of the incidence of DPPB of CSP and hot polypectomy (HP). The aim of this study was to evaluate the incidence of DPPB after CSP and compare it with that of HP. A propensity score model was used as a secondary analysis. PATIENTS AND METHODS This was a retrospective cohort study conducted in a single municipal hospital. We identified 539 patients with colorectal polyps from 2 mm to 11 mm in size who underwent CSP (804 polyps in 330 patients) or HP (530 polyps in 209 patients) between July 2013 and June 2015. RESULTS There were no cases of DPPB in the CSP group. Conversely, DPPB occurred in 4 patients (1.9 %) after HP, resulting in a significant difference between the CSP and HP groups (0.008 % vs 0 %, P = 0.02). Propensity score-matching analysis created 402 matched pairs, yielding a significantly higher DPPB rate in the HP group than CSP group (0.02 % vs 0 %, P = 0.04). However, significantly more patients in the CSP group had unclear horizontal margins that precluded assessment (83 vs 38 cases, P < 0.001). The retrieval failure rate was significantly higher in the CSP group than in the HP group (3 % vs 0.7 %, P = 0.01). CONCLUSIONS DPPB was less frequent with CSP than HP, as selected by the propensity score-matching model. Our findings indicate that CSP is recommended polypectomy in daily clinical setting. However, special care should be taken during polyp retrieval and horizontal margin assessment, and these issues could be taken into account in follow-up after CSP.
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Affiliation(s)
- Takeshi Yamashina
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan,Corresponding author Takeshi Yamashin Department of Gastroenterology and HepatologyOsaka Red Cross HospitalOsaka, Japan30 Fudegasaki, Tenouji, Osaka 543-8555Japan(+81) 6-(6774)-5131
| | - Manabu Fukuhara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takanori Maruo
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Gensho Tanke
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryota Sada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Mio Taki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yoshiaki Ohara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Azusa Sakamoto
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shinichiro Henmi
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yugo Sawai
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Sumio Saito
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Norihiro Nishijima
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akihiro Nasu
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hideyuki Komekado
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akira Sekikawa
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takehiko Tumura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryuichi Kita
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Toru Kimura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yukio Osaki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
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Feagins LA. Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med 2017; 130:786-795. [PMID: 28344132 DOI: 10.1016/j.amjmed.2017.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/14/2023]
Abstract
Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.
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Affiliation(s)
- Linda Anne Feagins
- Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas and the University of Texas Southwestern Medical Center at Dallas.
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40
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Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
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EBUS-TBNA and EUS-FNA: Risk Assessment for Patients Receiving Clopidogrel. J Bronchology Interv Pulmonol 2017; 23:303-307. [PMID: 27479011 DOI: 10.1097/lbr.0000000000000312] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Clopidogrel is widely used for the prevention of thrombotic vascular complications. Its primary potential toxicity is bleeding. Management of clopidogrel therapy for patients undergoing invasive procedures is an area of ongoing study. We sought to evaluate the bleeding risk for patients undergoing needle aspiration biopsy by endobronchial ultrasound (EBUS) or esophageal ultrasound (EUS) while taking clopidogrel. METHODS Retrospective review of sequential cases of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound fine needle aspiration (EUS-FNA). RESULTS Three hundred ninety-five consecutive procedures were reviewed. Thirty-seven patients were taking clopidogrel at time of biopsy. The patients taking clopidogrel were significantly older than those in the control group. Two patients (1%) in the control group were admitted for observation, but neither was found to have a significant bleed. There were no clinically significant bleeding complications in either of the study groups. CONCLUSIONS It is reasonable to proceed with EBUS-TBNA or EUS-FNA when both, (1) clopidogrel cannot be stopped and, (2) an important diagnostic question is at stake.
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Pieper M, Schmitz J, McBane R, Knudsen J, McMenomy B, Wennberg P, Atwell T. Bleeding Complications following Image-Guided Percutaneous Biopsies in Patients Taking Clopidogrel—A Retrospective Review. J Vasc Interv Radiol 2017; 28:88-93. [DOI: 10.1016/j.jvir.2016.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 08/25/2016] [Accepted: 09/13/2016] [Indexed: 11/25/2022] Open
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Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc 2016; 8:733-740. [PMID: 28042387 PMCID: PMC5159671 DOI: 10.4253/wjge.v8.i20.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.
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Plumé Gimeno G, Bustamante-Balén M, Satorres Paniagua C, Díaz Jaime FC, Cejalvo Andújar MJ. Endoscopic resection of colorectal polyps in patients on antiplatelet therapy: an evidence-based guidance for clinicians. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:49-59. [PMID: 27809553 DOI: 10.17235/reed.2016.4114/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Due to the rising prevalence of coronary heart disease, endoscopists are more frequently performing a polypectomy in patients on antiplatelet therapy (APT) and dual antiplatelet therapy (DATP). Despite the availability of several guidelines with regard to the management of antiplatelet drugs during the periprocedure period, there is still variability in the current clinical practice. This may be influenced by the low quality of the evidence supporting recommendations, because most of the studies dealing with APT and polypectomy are observational and retrospective, and include mainly small (< 10 mm) polyps. However, some recommendations can still be made. An estimation of the bleeding and thrombotic risk of the patient should be made in advance. In the case of DAPT the procedure should be postponed, at least until clopidogrel can be safely withheld. If possible, non-aspirin antiplatelet drugs should be withheld 5-7 days before the procedure. Polyp size is the main factor related with post-polypectomy bleeding and it is the factor that should drive clinical decisions regarding the resection method and the use of endoscopic prophylactic measures. Non-aspirin antiplatelet agents can be reintroduced 24-48 hours after the procedure. In conclusion, there is little data with regard to the management of DAPT in patients with a scheduled polypectomy. Large randomized controlled trials are needed to support clinical recommendations.
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Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy. Best Pract Res Clin Gastroenterol 2016; 30:705-718. [PMID: 27931631 DOI: 10.1016/j.bpg.2016.09.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/27/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
Endoscopy is an inherent and an invaluable tool in every gastroenterologist's armamentarium. The prerequisite for quality and safety remains foremost. Adverse events should be minimized and proactive steps should taken before, during and after the endoscopic procedure. Upper endoscopy and colonoscopy are part of basic endoscopy and their major complications will be reviewed here, together with those of enteroscopy. The most common of all endoscopy related complications are cardiopulmonary and thus they will be addressed in detail first. Colonoscopy's major complications are bleeding and perforation. Their epidemiology, mechanisms/risk factors, diagnosis, treatment and prevention will be addressed. The incidence of both of these complications increases significantly with polypectomy. Thus clinical judgment and experience in both polypectomy techniques and the ways to treat these complications, especially with the advanced endoscopic options advanced in the last decade, are of paramount importance. Post-polypectomy syndrome, infection and gas explosion are less frequent and will be reviewed briefly. Bleeding and perforation are upper endoscopy's major complications as well. Advances in endoscopic techniques in recent years offer endoscopic treatment instead of directly resorting to surgery, as was used to be the case and still is if the first fails. Enteroscopy is generally a more advanced procedure and overall complication rate is often quoted as 1%, most of them have been attributed to the passage of the overtube. Perforation and bleeding are the major complications, and a unique upper enteroscopy-associated complication is pancreatitis.
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Ma MX, Bourke MJ. Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon. Best Pract Res Clin Gastroenterol 2016; 30:749-767. [PMID: 27931634 DOI: 10.1016/j.bpg.2016.09.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 08/25/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
Endoscopic resection (ER), including endoscopic polypectomy (EP), endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are used to remove superficial neoplasms from the colon. Snare resection is used for EP and EMR, whereas endoscopic knives are used to perform dissection in the submucosal space in ESD. 80-90% colonic polyps are <10 millimetres (mm) and are effectively managed by conventional EP. Increasingly cold snare polypectomy is preferred. Large laterally spreading lesions (LSLs) and sessile polyps ≥20 mm are primarily removed by EMR. ESD may be used when superficial invasive disease is suspected and for some LSLs, particularly non-granular subtypes. Resection of colonic lesions by ER is associated with a small but definite incidence of significant complications, most commonly bleeding and perforation. This review discusses complications of ER with a particular focus on their prevention, early recognition and management. In many cases, complications from all three procedures share similar mechanisms and management principles and these are described at the start of each section, followed by a description of specific aspects for individual procedures.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia.
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Park CH, Jung YS, Nam E, Eun CS, Park DI, Han DS. Comparison of Efficacy of Prophylactic Endoscopic Therapies for Postpolypectomy Bleeding in the Colorectum: A Systematic Review and Network Meta-Analysis. Am J Gastroenterol 2016; 111:1230-43. [PMID: 27402502 DOI: 10.1038/ajg.2016.287] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/09/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although various endoscopic therapies have been suggested for preventing bleeding after colorectal polypectomy, the optimal therapy has yet to be fully clarified. We assessed the comparative efficacy of prophylactic therapies for postpolypectomy bleeding through a network meta-analysis combining direct and indirect comparisons. METHODS We searched for all relevant randomized controlled trials published up until January 2016 examining the effects of prophylactic therapy for bleeding after colorectal polypectomy. The types of prophylactic therapy were classified as mechanical therapy, epinephrine-saline injection therapy, coagulation therapy, combined therapy, or no prophylactic therapy. Combined therapy was defined as a combination of two or more types of therapy including mechanical therapy, epinephrine-saline injection therapy, and coagulation therapy. We performed a Bayesian network meta-analysis for all prophylactic therapies. RESULTS Fifteen studies with 3,462 patients were included in the meta-analysis. Compared with no prophylactic therapy, both epinephrine-saline injection and mechanical therapy showed superiority for preventing early postpolypectomy bleeding with a moderate quality of evidence (injection therapy, risk ratio (RR; 95% credible interval (CrI))=0.32 (0.11-0.67); mechanical therapy, RR (95% CrI)=0.13 (0.03-0.37)). Combined therapy did not show a statistically significant difference for decreasing the risk of early bleeding compared with injection or mechanical therapies, respectively (combined vs. injection therapy: RR (95% CrI)=0.35 (0.10-1.00); combined vs. mechanical therapy: RR (95% CrI)=0.88 (0.23-3.00)). In cases of delayed bleeding, no type of prophylactic therapy decreased the risk of bleeding compared with no prophylactic therapy. CONCLUSIONS Either mechanical therapy or injection therapy reduced the risk of early postpolypectomy bleeding. As for delayed bleeding, none of the prophylactic therapies was associated with a lower risk of bleeding compared with no prophylactic therapy.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yoon Suk Jung
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Dong Il Park
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Kataoka Y, Tsuji Y, Sakaguchi Y, Minatsuki C, Asada-Hirayama I, Niimi K, Ono S, Kodashima S, Yamamichi N, Fujishiro M, Koike K. Bleeding after endoscopic submucosal dissection: Risk factors and preventive methods. World J Gastroenterol 2016; 22:5927-5935. [PMID: 27468187 PMCID: PMC4948274 DOI: 10.3748/wjg.v22.i26.5927] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/30/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has become widely accepted as a standard method of treatment for superficial gastrointestinal neoplasms because it enables en block resection even for large lesions or fibrotic lesions with minimal invasiveness, and decreases the local recurrence rate. Moreover, specimens resected in an en block fashion enable accurate histological assessment. Taking these factors into consideration, ESD seems to be more advantageous than conventional endoscopic mucosal resection (EMR), but the associated risks of perioperative adverse events are higher than in EMR. Bleeding after ESD is the most frequent among these adverse events. Although post-ESD bleeding can be controlled by endoscopic hemostasis in most cases, it may lead to serious conditions including hemorrhagic shock. Even with preventive methods including administration of acid secretion inhibitors and preventive hemostasis, post-ESD bleeding cannot be completely prevented. In addition high-risk cases for post-ESD bleeding, which include cases with the use of antithrombotic agents or which require large resection, are increasing. Although there have been many reports about associated risk factors and methods of preventing post-ESD bleeding, many issues remain unsolved. Therefore, in this review, we have overviewed risk factors and methods of preventing post-ESD bleeding from previous studies. Endoscopists should have sufficient knowledge of these risk factors and preventive methods when performing ESD.
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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Fang X, Baillargeon JG, Jupiter DC. Continued Antiplatelet Therapy and Risk of Bleeding in Gastrointestinal Procedures: A Systematic Review. J Am Coll Surg 2016; 222:890-905.e11. [PMID: 27016908 DOI: 10.1016/j.jamcollsurg.2016.01.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated with perioperative use of antiplatelet medication. However, cessation of these drugs may be unsafe for patients who are required to maintain antiplatelet use due to cardiovascular conditions. The objective of this systematic review was to compare the risk of intraoperative or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy) with the risk among those not taking continuous antiplatelet medication. STUDY DESIGN We reviewed articles published between January 2000 and July 2015 from the Medline Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies involving any GI procedures were included if the articles met our inclusion criteria (listed in Methods). The following key words were used for the search: clopidogrel, Plavix, aspirin, antiplatelet, bleeding, hemorrhage, and digestive system surgical procedures. Quality of the studies was assessed, depending on their study design, using the Newcastle-Ottawa score or the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Twenty-two studies were eligible for inclusion in the systematic review. Five showed that the risk of intraoperative bleeding or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy was higher compared that for those not on continuous therapy. The remaining 17 studies reported that there was no statistically significant difference in the risks of bleeding between the continuous antiplatelet therapy group and the group without continuous antiplatelet therapy. CONCLUSIONS The risk of bleeding associated with GI procedures in patients receiving antiplatelet therapy was not significantly higher than in patients with no antiplatelet or interrupted antiplatelet therapy.
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Affiliation(s)
- Xiao Fang
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
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