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Wehbe H, Gutta A, Gromski MA. Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon. Gastrointest Endosc Clin N Am 2024; 34:363-381. [PMID: 38395489 DOI: 10.1016/j.giec.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.
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Affiliation(s)
- Hisham Wehbe
- Department of Internal Medicine, Indiana University School of Medicine, 550 University Boulevard, UH 3533, Indianapolis, IN 46202, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA
| | - Mark A Gromski
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA.
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2
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Bi D, Zhang LY, Alqaisieh M, Shrigiriwar A, Farha J, Mahmoud T, Akiki K, Almario JA, Shah-Khan SM, Gordon SR, Adler JM, Radetic M, Draganov PV, David YN, Shinn B, Mohammed Z, Schlachterman A, Yuen S, Al-Taee A, Yunseok N, Trasolini R, Bejjani M, Ghandour B, Ramberan H, Canakis A, Ngamruengphong S, Storm AC, Singh S, Pohl H, Bucobo JC, Buscaglia JM, D'Souza LS, Qumseya B, Kumta NA, Kumar A, Haber GB, Aihara H, Sawhney M, Kim R, Berzin TM, Khashab MA. Novel through-the-scope suture closure of colonic EMR defects (with video). Gastrointest Endosc 2023; 98:122-129. [PMID: 36889364 DOI: 10.1016/j.gie.2023.02.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND AND AIMS Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS. METHODS A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding. RESULTS A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate). CONCLUSION TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.
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Affiliation(s)
- Danse Bi
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | | | | | - Jad Farha
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Tala Mahmoud
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Karl Akiki
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | | | | | - Stuart R Gordon
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jeffrey M Adler
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mark Radetic
- University of Florida, Gainesville, Florida, USA
| | | | | | - Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Zahraa Mohammed
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Sofia Yuen
- NYU Langone Health, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | | | - Heiko Pohl
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | | | | | | | - Anand Kumar
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Mandeep Sawhney
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raymond Kim
- University of Maryland, Baltimore, Maryland, USA
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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3
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Lau LHS, Guo CLT, Lee JKK, Chan CST, Mak JWY, Wong SH, Yip TCF, Wong GLH, Wong VWS, Chan FKL, Tang RSY. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in oral anticoagulant users: a propensity-score analysis. Gastrointest Endosc 2022; 96:530-542.e1. [PMID: 35413329 DOI: 10.1016/j.gie.2022.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Evidence of prophylactic clipping is inconsistent except for proximal and large colonic lesions in the general population. Although warfarin and direct oral anticoagulants (DOACs) are significant risk factors of postpolypectomy bleeding (PPB), dedicated studies to examine the benefit of prophylactic clipping in these high-risk patients remain limited. METHODS We performed a propensity score-weighted retrospective cohort study from 2012 to 2020. Patients who received an oral anticoagulant and underwent colonoscopic polypectomy were included. Data were collected on baseline demographics, medications (anticoagulant, antiplatelet, and heparin bridging), and endoscopies (polyp number, location, size, morphology, histopathology, resection method and prophylactic clipping). Propensity-score models with inverse probability of treatment weighting were developed between prophylactic clipping and no clipping groups. Unbalanced variables were included in a doubly robust model with multivariate analysis. The primary outcome was clinically significant delayed PPB, defined as a composite endpoint of hemoglobin drop ≥2 g/dL, blood transfusion, or repeat colonoscopy for hemostasis within 30 days. RESULTS Five hundred forty-seven patients with 1485 polyps were included. Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio [OR], 1.19; 95% confidence interval [CI], .73-1.95; P = .497). The hot resection method was associated with a significantly higher risk of PPB (OR, 9.76; 95% CI, 3.94-32.60; P < .001) compared with cold biopsy or snare polypectomy. In a subgroup analysis, prophylactic clipping was associated with a lower PPB risk in patients on DOACs (OR, .36; 95% CI, .16-.82; P = .015). CONCLUSIONS Prophylactic clipping was not associated with an overall reduced risk of PPB in patients on oral anticoagulants. The use of cold snare polypectomy should be maximized in anticoagulated patients.
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Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Joyce K K Lee
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Clive S T Chan
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Sunny H Wong
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Terry C F Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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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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Bendall O, James J, Pawlak KM, Ishaq S, Tau JA, Suzuki N, Bollipo S, Siau K. Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients. Clin Exp Gastroenterol 2022; 14:477-492. [PMID: 34992406 PMCID: PMC8714413 DOI: 10.2147/ceg.s282699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022] Open
Abstract
Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3–1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.
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Affiliation(s)
- Oliver Bendall
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Joel James
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Katarzyna M Pawlak
- Endoscopy Unit, Department of Gastroenterology, Ministry of Interior and Administration, Szczecin, Poland
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, UK.,Medicine, Birmingham City Hospital, Birmingham, UK
| | - J Andy Tau
- Austin Gastroenterology, Austin, TX, USA
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St. Mark's Hospital, London, UK
| | - Steven Bollipo
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
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6
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Lau LH, Guo CL, Yip TC, Mak JW, Wong SH, Lam KL, Wong GL, Ng SC, Chan FK. Risks of post-colonoscopic polypectomy bleeding and thromboembolism with warfarin and direct oral anticoagulants: a population-based analysis. Gut 2022; 71:100-110. [PMID: 33619167 DOI: 10.1136/gutjnl-2020-323600] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND There were limited data on the risk of post-polypectomy bleeding (PPB) in patients on direct oral anticoagulants (DOAC). We aimed to evaluate the PPB and thromboembolic risks among DOAC and warfarin users in a population-based cohort. METHODS We performed a territory-wide retrospective cohort study involving patients in Hong Kong from 2012 to 2020. Patients who received an oral anticoagulant and had undergone colonoscopy with polypectomy were identified. Propensity-score models with inverse probability of treatment weighting were developed for the warfarin-DOAC and between-DOAC comparisons. The primary outcome was clinically significant delayed PPB, defined as repeat colonoscopy requiring haemostasis within 30 days. The secondary outcomes were 30-day blood transfusion requirement and new thromboembolic event. RESULTS Apixaban was associated with lower PPB risk than warfarin (adjusted HR (aHR) 0.39, 95% CI 0.24 to 0.63, p<0.001). Dabigatran (aHR 2.23, 95% CI 1.04 to 4.77, adjusted p (ap)=0.035) and rivaroxaban (aHR 2.72, 95% CI 1.35 to 5.48, ap=0.002) were associated with higher PPB risk than apixaban. In subgroup analysis, apixaban was associated with lower PPB risk in patients aged ≥70 years and patients with right-sided colonic polyps.For thromboembolic events, apixaban was associated with lower risk than warfarin (aHR 0.22, 95% CI 0.11 to 0.45, p<0.001). Dabigatran (aHR 2.60, 95% CI 1.06 to 6.41, ap=0.033) and rivaroxaban (aHR 2.96, 95% CI 1.19 to 7.37, ap =0.013) were associated with higher thromboembolic risk than apixaban. CONCLUSIONS Apixaban was associated with a significantly lower risk of PPB and thromboembolism than warfarin, dabigatran and rivaroxaban, particularly in older patients with right-sided polyps.
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Affiliation(s)
- Louis Hs Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Cosmos Lt Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Terry Cf Yip
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Joyce Wy Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Kelvin Ly Lam
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Grace Lh Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Siew C Ng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR.,State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Francis Kl Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR .,Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
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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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8
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Zhu H, Li F, Tao K, Liu M, Xu H. Bleeding after endoscopic resection between direct oral anticoagulants or warfarin: Systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:2363-2374. [PMID: 33893748 DOI: 10.1111/jgh.15527] [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: 11/23/2020] [Revised: 02/15/2021] [Accepted: 04/16/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Oral anticoagulants are risk factors for post-endoscopic resection bleeding. We aimed to conduct a systematic review and meta-analysis for the risks of post-procedural bleeding (PPB) for direct oral anticoagulants (DOACs) and warfarin following endoscopic resection. METHODS Two independent reviewers searched PubMed, Web of Science, Embase, and Cochrane Library. The Newcastle-Ottawa Scale score was used to assess the quality of the studies, the pooled odds ratio (OR) to present PPB results, and the funnel plots to assess publication bias. The Higgins I2 statistic was employed to determine the variation across studies due to heterogeneity. RESULTS We reviewed 30 articles. PPB occurred in 586 patients on DOACs and 1782 on warfarin. The patients on DOACs had a significantly lower overall risk of PPB compared with those on warfarin (OR, 0.867, 95% confidence interval, 0.771-0.975; P = 0.017, I2 = 1.6%). Cumulative meta-analysis showed that the PPB rate of DOACs has the trend to be lower than that of warfarin with publication year and sample size. For the subgroup of endoscopic submucosal dissection, the PPB of DOACs was significantly lower than that of warfarin (OR, 0.786; 95% confidence interval, 0.633-0.976; P = 0.029, I2 = 0%). No significant difference was observed between DOACs and warfarin for anticoagulant strategies, endoscopic procedures, and lesion location. CONCLUSIONS Compared with warfarin, DOACs have the possibility to significantly decrease the risk of PPB following endoscopic resection, especially for endoscopic submucosal dissection.
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Affiliation(s)
- He Zhu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Fudong Li
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Ke Tao
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Mingqing Liu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Hong Xu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
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9
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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10
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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11
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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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12
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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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13
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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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14
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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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15
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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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16
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Chen CW, Kuo CJ, Chiu CT, Su MY, Lin CJ, Le PH, Lim SN, Yeh CT, Alison MR, Lin WR. The effect of prophylactic hemoclip placement and risk factors of delayed post-polypectomy bleeding in polyps sized 6 to 20 millimeters: a propensity score matching analysis. BMC Gastroenterol 2020; 20:309. [PMID: 32962643 PMCID: PMC7510104 DOI: 10.1186/s12876-020-01454-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022] Open
Abstract
Background Delayed post-polypectomy bleeding (PPB) is a major complication of polypectomy. The effect of prophylactic hemoclipping on delayed PPB is uncertain. The aim of this study was to evaluate the effectiveness of prophylactic hemoclipping and identify the risk factors of delayed PPB. Methods Patients with polyps sized 6 to 20 mm underwent snare polypectomy from 2015 to 2017 were retrospectively reviewed. The patients with prophylactic hemoclipping for delayed PPB prevention were included in the clipping group, and those without prophylactic hemoclipping were included in the non-clipping group. The incidence of delayed PPB and time to bleeding were compared between the groups. Multivariate analysis was used to identify the risk factors of delayed PPB. Propensity score matching was used to minimize potential bias. Results After propensity score matching, 612 patients with 806 polyps were in the clipping group, and 576 patients with 806 polyps were in the non-clipping group. There were no significant differences in the incidence of delayed PPB and days to bleeding between two groups (0.8% vs 1.3%, p = 0.4; 3.4 ± 1.94 days vs 4.13 ± 3.39 days, p = 0.94). In the multivariate analysis, the polyp size [Odds ratio (OR):1.16, 95% confidence interval (CI):1.01–1.16, p = 0.03), multiple polypectomies (OR: 4.64, 95% CI:1.24–17.44, p = 0.02) and a history of anticoagulant use (OR:37.52, 95% CI:6.49–216.8, p < 0.001) were associated with delayed PPB. Conclusions In polyps sized 6 to 20 mm, prophylactic hemoclip placement did not decrease the risk of delayed PPB. Patients without risk factors including multiple polypectomies and anticoagulant use are no need to performing prophylactic hemoclipping.
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Affiliation(s)
- Chun-Wei Chen
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Gastroenterology and Hepatology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chun-Jung Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan
| | - Siew-Na Lim
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chau-Ting Yeh
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Liver Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Malcolm R Alison
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, No 5, Fu Hsing Street, Guishan Dist., Taoyuan, 333, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Liver Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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Kamal F, Khan MA, Khan S, Marella HK, Nelson T, Khan Z, Ahmad D, Tombazzi C, Ismail MK, Howden CW. Prophylactic hemoclips in prevention of delayed post-polypectomy bleeding for ≥ 1 cm colorectal polyps: meta-analysis of randomized controlled trials. Endosc Int Open 2020; 8:E1102-E1110. [PMID: 32904803 PMCID: PMC7458729 DOI: 10.1055/a-1164-6315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/01/2020] [Indexed: 10/26/2022] Open
Abstract
Background and aim Studies evaluating the role of prophylactic hemoclips (HC) in prevention of delayed post-polypectomy bleeding (DPPB) have reported conflicting results. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the role of prophylactic HC placement in prevention of DPPB for polyps ≥ 1 cm in size. Methods We reviewed several databases to identify RCTs evaluating the role of HC in prevention of DPPB. The outcomes assessed included prevention of DPPB with polyps 1 to 1.9 cm, ≥ 2 cm, any polyp ≥ 1 cm, proximal colon polyps, distal colon polyps, and perforation. We analyzed data using a fixed effect model and reported summary pooled risk ratios (RR) with 95 % confidence intervals (CI). We assessed heterogeneity with the I 2 statistic. Results We included nine RCTs with 4550 patients. For polyps ≥ 2 cm, there was a statistically significantly lower risk of DPPB with use of HC; RR 0.55, 95 % CI 0.36, 0.86. There was also a statistically significantly lower risk for proximal colon polyps ≥ 2 cm; RR 0.41 (0.24, 0.70) but no significant difference for distal polyps; RR 1.23 (0.45, 3.32). There was also no significant difference in risk for polyps 1 to 1.9 cm; RR 1.07 (0.59, 1.97). There was no significant reduction in risk of perforation with HC use for any polyp size. Conclusions Prophylactic HC placement is effective in prevention of DPPB from proximal colon polyps ≥ 2 cm, but of no significant benefit for polyps 1 to 1.9 cm in size or for distal colon polyps ≥ 2 cm.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Muhammad A. Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Salman Khan
- Division of Gastroenterology, University of Arkansas Medical Sciences, Little Rock, AR
| | - Hemnishil K. Marella
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Tamara Nelson
- Medical Sciences Library, University of Tennessee Health Science Center, Memphis, TN
| | - Zubair Khan
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Division of Gastroenterology, University of Texas-Houston, Houston, Texas, United
States
| | - Dina Ahmad
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Claudio Tombazzi
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mohammad K. Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Colin W. Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
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18
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Turan AS, Didden P, Peters Y, Moons LMG, Schreuder RM, Siersema PD, van Geenen EJM. Factors involved in endoscopists' choice for prophylactic clipping after colorectal endoscopic mucosal resection: a discrete choice experiment. Scand J Gastroenterol 2020; 55:737-744. [PMID: 32516002 DOI: 10.1080/00365521.2020.1770851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Delayed bleeding (DB) occurs in ∼10% after colorectal EMR. Prophylactic clipping (PC) was reported to significantly decrease DB-rate in proximal lesions ≥2 cm.Objective: Our aim was to determine which predefined variables contribute to using PC in clinical practice.Methods: We performed an international discrete choice experiment (DCE) among ∼500 endoscopists. Relevant variables for PC use were selected by EMR experts: previous DB, anticoagulants, polyp size, morphology, location, intraprocedural bleeding and visible vessel(s). Respondents answered case scenarios with various variable combinations, each time choosing only one scenario for PC, or the 'none' option. Part-worth utilities and importance weights were calculated using HB regression. Subsequently, a predictive model was created to calculate the likelihood of endoscopists choosing PC in any given case.Results: The survey was completed by 190 EMR endoscopists from 17 countries. In total, 8% would never use PC, whereas 30.9% never chose the 'none' option. All variables except polyp type were significant in decision-making for PC (p < .01). The most important factor was anticoagulant use, accounting for 22.5% in decision-making. Polyps <2 cm were considered eligible for PC by 14% in the presence of high-weighing factors such as anticoagulant use. No significant differences were found between high and low-to-moderately experienced endoscopists.Conclusions: PC after EMR is often considered useful by endoscopists, usually based on risk factors for DB. Anticoagulant use was the most important factor in decision-making for PC, independent of endoscopist experience. Although not considered cost-effective, one in seven endoscopists chose PC for adenomas <2 cm.
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
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19
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Rebello D, Bakhit M, McCarty TR, Machan JT, Nagar A, Moss SF. Heparin bridge is associated with more post-polypectomy bleeding and emergency department visits among anticoagulated patients. Ann Gastroenterol 2020; 33:73-79. [PMID: 31892801 PMCID: PMC6928471 DOI: 10.20524/aog.2019.0430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/07/2019] [Indexed: 01/23/2023] Open
Abstract
Background: Among patients undergoing colonoscopy, anticoagulants are usually stopped and are sometimes substituted by a heparin bridge (hep-bridge). We aimed to assess adverse events associated with hep-bridge compared to temporary cessation of anticoagulants (no-bridge). Methods: This was a single-center, retrospective cohort study that included anticoagulated patients undergoing colonoscopy between 2013 and 2016 at a Veterans Affairs Medical Center. In the no-bridge cohort, warfarin was stopped for 5 days and novel anticoagulants for 2 days pre-procedure. In the hep-bridge cohort, anticoagulants were stopped and were substituted by subcutaneous enoxaparin. The primary outcome was post-polypectomy bleeding. Secondary outcomes included cardiovascular events, all-cause adverse events and emergency department or unscheduled ambulatory office visits within 30 days. The predictive values of the HAS-BLED and CHADS2 scores were evaluated. Results: A total of 662 patients were included, of whom 551 underwent polypectomy (mean age 68.6 years; 97.6% male). Four hundred seventy colonoscopies were performed with no-bridge and 192 with hep-bridge. Post-polypectomy bleeding occurred in 6.0% of procedures: 5.7% in the no-bridge cohort compared to 13.0% of hep-bridge procedures (P=0.0038). Cardiovascular or thrombotic events occurred after 2.6% of the no-bridge and 5.2% of the hep-bridge procedures (P=0.1176). Emergency department or unscheduled office visits within 30 days were reported after 18.7% of the no-bridge procedures and 29.7% of the hep-bridge procedures (P<0.0001). Neither CHADS2 nor HASBLED scores predicted bleeding. Conclusion: The use of hep-bridge was associated with a greater incidence of post-polypectomy bleeding and more emergency department and unscheduled office visits compared with cessation of all anticoagulants.
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Affiliation(s)
- Dionne Rebello
- Department of Internal Medicine, Brown University, Providence, RI (Dionne Rebello)
| | - Mena Bakhit
- Division of Gastroenterology, Brown University, Providence, RI (Mena Bakhit, Steven F. Moss)
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA (Thomas R. McCarty).,Harvard Medical School, Boston, MA (Thomas R. McCarty)
| | - Jason T Machan
- Biostatistics and Research, RI Hospital, Providence, RI (Jason T. Machan)
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT (Anil Nagar).,West Haven Veteran Affairs Medical Center, West Haven, CT (Anil Nagar)
| | - Steven F Moss
- Division of Gastroenterology, Brown University, Providence, RI (Mena Bakhit, Steven F. Moss).,Providence Veteran Affairs Medical Center, Providence, RI (Steven F. Moss), USA
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20
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Yamaguchi D, Yoshida H, Ikeda K, Takeuchi Y, Yamashita S, Jubashi A, Yukimoto T, Takeshita E, Yoshioka W, Fukuda H, Tominaga N, Tsuruoka N, Morisaki T, Ario K, Tsunada S, Fujimoto K. Colorectal endoscopic mucosal resection with submucosal injection of epinephrine versus hypertonic saline in patients taking antithrombotic agents: propensity-score-matching analysis. BMC Gastroenterol 2019; 19:192. [PMID: 31744465 PMCID: PMC6862827 DOI: 10.1186/s12876-019-1114-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Endoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents. The safety of EMR with submucosal saline injection has not been clearly demonstrated in this population. Aims The present study aimed to evaluate the efficacy and safety of submucosal injection of saline–epinephrine versus hypertonic saline in colorectal EMR of patients taking antithrombotic agents. Methods This study enrolled 204 patients taking antithrombotic agents among 995 consecutive patients who underwent colonic EMR from April 2012 to March 2018 at Ureshino Medical Center. Patients were divided into two groups according to the injected solution: saline–epinephrine or hypertonic (10%) saline (n = 102 in each group). Treatment outcomes and adverse events were evaluated in each group and risk factors for immediate and post-EMR bleeding were investigated. Results There were no differences between groups in patient or polyp characteristics. The main antithrombotic agents were low-dose aspirin, warfarin, and clopidogrel. Propensity-score matching created 80 matched pairs. Adjusted comparisons between groups showed similar en bloc resection rates (95.1% with saline–epinephrine vs. 98.0% with hypertonic saline). There were no significant differences in adverse events (immediate EMR bleeding, post-EMR bleeding, perforation, or mortality) between groups. Multivariate analyses revealed that polyp size over 10 mm was associated with an increased risk of immediate EMR bleeding (odds ratio 12.1, 95% confidence interval 2.0–74.0; P = 0.001). Conclusions Two tested solutions in colorectal EMR were considered to be both safe and effective in patients taking antithrombotic agents.
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Affiliation(s)
- Daisuke Yamaguchi
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan. .,Department of Internal Medicine, Saga Medical School, Saga, Japan.
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kei Ikeda
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Yuki Takeuchi
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Shota Yamashita
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Amane Jubashi
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | | | - Eri Takeshita
- Department of Internal Medicine, Saga Medical School, Saga, Japan
| | - Wataru Yoshioka
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Hiroko Fukuda
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Naoyuki Tominaga
- Department of Internal Medicine, Saga Medical School, Saga, Japan
| | - Nanae Tsuruoka
- Department of Internal Medicine, Saga Medical School, Saga, Japan
| | - Tomohito Morisaki
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Keisuke Ario
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Seiji Tsunada
- Department of Gastroenterology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Kazuma Fujimoto
- Department of Internal Medicine, Saga Medical School, Saga, Japan.,Faculty of Medicine, International University of Health and Welfare, Fukuoka, Japan
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21
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Shimodate Y, Ueno M, Sunami T, Takayama H, Takezawa R, Doi A, Nishimura N, Mouri H, Matsueda K, Yamamoto H, Mizuno M. Post-polypectomy bleeding in hot-snare polypectomy of colonic polyps under continued warfarin or short interruption of direct oral anticoagulants. Int J Colorectal Dis 2019; 34:1705-1712. [PMID: 31471698 DOI: 10.1007/s00384-019-03373-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Newly published guidelines of the Japanese Gastroenterological Endoscopy Society (JGES) suggest to consider endoscopic procedures with high risk of bleeding without stopping warfarin and with stopping direct oral anticoagulants (DOACs) only on the day of the procedure. In this study, we aimed to test the validity of these recommendations. PATIENTS AND METHODS We retrospectively reviewed medical records of 344 patients with anticoagulant therapy who underwent hot-snare polypectomy between January 2012 and October 2018. Patients (n = 132) with interruption of anticoagulants (3-7 days for warfarin and 2-3 days for DOACs before the procedure) and without heparin-bridging were excluded. Among the remaining 212 patients, the incidence of post-polypectomy bleeding was compared between the following 2 patient groups: patients who had interruption of anticoagulants with heparin-bridging (HB group, n = 139) and patients treated according to the new JGES guideline (FG group, n = 73). RESULTS The rate of post-polypectomy bleeding (PPB) in FG group (9.6%) was not significantly different from that in HB group (12.9%, p = 0.5). In subgroup analysis, the incidence of bleeding in patients with warfarin (12.2%) and with DOAC (6.3%) in FG group was not significantly different from corresponding figures in HB group (14.2%, 0%). In multivariate analysis, number of resected polyps was associated with PPB, but the administration of anticoagulants according to the new guidelines was not a significant risk factor for PPB (p = .98). CONCLUSIONS Our study affirms the recommendations of JGES for the management of anticoagulants in patients who undergo colonic polypectomy regarding post-polypectomy bleeding.
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Affiliation(s)
- Yuichi Shimodate
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan.
| | - Masayuki Ueno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Tomohiko Sunami
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Hiroshi Takayama
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Rio Takezawa
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Akira Doi
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Naoyuki Nishimura
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Hirokazu Mouri
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Kazuhiro Matsueda
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Hiroshi Yamamoto
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Motowo Mizuno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Okayama, 710-8602, Japan
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Gutta A, Gromski MA. Endoscopic Management of Post-Polypectomy Bleeding. Clin Endosc 2019; 53:302-310. [PMID: 31525836 PMCID: PMC7280838 DOI: 10.5946/ce.2019.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022] Open
Abstract
Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. There are multiple risk factors related to patient and polyp characteristics that should be considered. In most cases, immediate PPB can be effectively managed endoscopically when recognized and managed promptly. Delayed PPB can manifest in a myriad of ways. In severe delayed PPB, resuscitation for hemodynamic stabilization should be prioritized, followed by endoscopic evaluation and therapy once the patient is stabilized. Future areas of research in PPB include the risks of direct oral anticoagulants and of specific electrosurgical settings for hot-snare polypectomy vs. cold-snare polypectomy, benefits of closure of post-polypectomy mucosal defects using through-the-scope clips, and prospective comparative evaluation of newer hemostasis agents such as hemostatic spray powder and over-the-scope clips.
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Affiliation(s)
- Aditya Gutta
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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23
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Yu JX, Oliver M, Lin J, Chang M, Limketkai BN, Soetikno R, Bhattacharya J, Kaltenbach T. Patients Prescribed Direct-Acting Oral Anticoagulants Have Low Risk of Postpolypectomy Complications. Clin Gastroenterol Hepatol 2019; 17:2000-2007.e3. [PMID: 30503964 PMCID: PMC6541555 DOI: 10.1016/j.cgh.2018.11.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Use of direct-acting oral anticoagulants (DOACs) is increasing, but little is known about the associated risks in patients undergoing colonoscopy with polypectomy. We aimed to determine the risk of post-polypectomy complications in patients prescribed DOACs. METHODS We performed a retrospective analysis using Optum's de-identified Clinformatics Data Mart Database (2003-2016) (a de-identified administrative database from a large national insurance provider) to identify adults who underwent colonoscopy with polypectomy or endoscopic mucosal resection (EMR) from January 1, 2011, through December 31, 2015. We collected data from 11,504 patients prescribed antithrombotic agents (1590 DOAC, 3471 warfarin, and 6443 clopidogrel) and 599,983 patients not prescribed antithrombotics of interest (controls). We compared 30-day post-polypectomy complications, including gastrointestinal bleeding (GIB), cerebrovascular accident (CVA), myocardial infarction (MI), and hospital admissions, of patients prescribed DOACs, warfarin, or clopidogrel vs controls. RESULTS Post-polypectomy complications were uncommon but occurred in a significantly higher proportion of patients receiving any antithrombotic vs controls (P < .001). The percentage of patients in the DOAC group with GIB was 0.63% (95% CI, 0.3%-1.2%) vs 0.2% (95% CI, 0.2%-0.3%) in controls. The percentage of patients with CVA in the DOAC group was 0.06% (95% CI, 0.01%-0.35%) vs 0.04% (95% CI, 0.04%-0.05%) in controls. After we adjusted for bridge anticoagulation, EMR, Charlson comorbidity index (CCI), and CHADS2 (congestive heart failure, hypertension, age over 75, diabetes, stroke [double weight]) score, patients prescribed DOACs no longer had a statistically significant increase in the odds of GIB (odds ratio [OR], 0.90; 95% CI, 0.44-1.85), CVA (OR, 0.45; 95% CI, 0.06-3.28), MI (OR, 1.07; 95% CI, 0.14-7.72), or hospital admission (OR, 0.86; 95% CI, 0.64-1.16). Clopidogrel, warfarin, bridge anticoagulation, higher CHADS2, CCI, and EMR were associated with increased odds of complications. CONCLUSION In our retrospective analysis of a large national dataset, we found that patients prescribed DOACs did not have significantly increased adjusted odds of post-polypectomy GIB, MI, CVA, or hospital admission. Bridge anticoagulation, higher CHADS2 score, CCI, and EMR were risk factors for GIB, MI, CVA, and hospital admissions. Studies are needed to determine the optimal peri-procedural dose for high-risk patients.
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Affiliation(s)
- Jessica X Yu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Melissa Oliver
- Department of Pediatric Rheumatology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jody Lin
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Matthew Chang
- Department of Gastroenterology, Kaiser Permanente-San Francisco, San Francisco, California
| | - Berkeley N Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Roy Soetikno
- Advanced Gastrointestinal Endoscopy, Mountain View, California
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Tonya Kaltenbach
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, California
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24
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Sakai T, Nagami Y, Shiba M, Hayashi K, Kinoshita Y, Maruyama H, Kato K, Minamino H, Ominami M, Fukunaga S, Otani K, Hosomi S, Tanaka F, Taira K, Kamata N, Yamagami H, Tanigawa T, Watanabe T, Fujiwara Y. Heparin-bridging therapy is associated with post-colorectal polypectomy bleeding in patients whose oral anticoagulation therapy is interrupted. Scand J Gastroenterol 2019; 53:1304-1310. [PMID: 30345853 DOI: 10.1080/00365521.2018.1503325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The American and Japanese Societies for Gastrointestinal Endoscopy Guidelines recommend heparin-bridging therapy for patients whose oral anticoagulants are interrupted for endoscopic procedures. However, little is known about the potential association between heparin-bridging therapy and post-polypectomy bleeding (PPB). The aim was to investigate the incidence of PPB associated with heparin-bridging therapy administered to patients whose anticoagulants were interrupted. MATERIALS AND METHODS This was a retrospective observational study using inverse propensity analysis. Between 2013 and 2015, 1004 patients with 2863 lesions were included. The primary outcomes were the rates of PPB and thromboembolism associated with heparin-bridging therapy. The risk factors associated with PPB were identified using multivariate logistic regression analysis involving probability of treatment weighting (IPTW). RESULTS The patients were categorized into a heparin-bridging therapy group (78 patients with 255 lesions) or a control group (926 patients with 2608 lesions). The PPB rate in the heparin-bridging therapy group (10.2%, 8/78) was significantly higher than in the control group (1.1%, 11/926) (p <.01). Thromboembolism occurred in one patient in the control group. The multivariate analysis revealed that heparin-bridging therapy was an independent risk factor associated with PPB (odds ratio [OR], 8.21; 95% confidence interval [95% CI], 2.32-29.10; p <.01). IPTW showed heparin-bridging therapy increased PPB (OR, 7.68; 95% CI, 1.83-32.28; p <.01). CONCLUSIONS Heparin-bridging therapy administered to patients whose oral anticoagulants were interrupted was associated with an increased PPB risk.
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Affiliation(s)
- Taishi Sakai
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Yasuaki Nagami
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Masatsugu Shiba
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Kappei Hayashi
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Yosuke Kinoshita
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Hirotsugu Maruyama
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Kunihiro Kato
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Hiroaki Minamino
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Masaki Ominami
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Shusei Fukunaga
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Koji Otani
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Shuhei Hosomi
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Fumio Tanaka
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Koichi Taira
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Noriko Kamata
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Hirokazu Yamagami
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Tetsuya Tanigawa
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Toshio Watanabe
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
| | - Yasuhiro Fujiwara
- a Department of Gastroenterology , Osaka City University, Graduate School of Medicine , Osaka , Japan
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25
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Matsumoto M, Yoshii S, Shigesawa T, Dazai M, Onodera M, Kato M, Sakamoto N. Safety of Cold Polypectomy for Colorectal Polyps in Patients on Antithrombotic Medication. Digestion 2018; 97:76-81. [PMID: 29393134 DOI: 10.1159/000484219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The cold polypectomy (CP) technique has been increasingly used in recent years. However, there have been few studies about post-polypectomy bleeding (PPB) in patients who underwent CP and who were on antithrombotic drugs. The objective of this study was to determine the safety of CP in patients on antithrombotic medication. METHODS The subjects were patients who underwent CP in our hospital between April 2014 and March 2016. PPB rates were examined in relation to the use of antithrombotic medication. RESULTS CP was performed to remove 2,466 polyps in 1,003 patients. There were 549 polyps (22.3%) in186 patients in the antithrombotic group and 1,917 polyps (77.7%) in 817 patients in the non-antithrombotic group. PPB occurred in 0.55% (3/549) of patients in the antithrombotic group and in 0.10% (2/1,917) of patients in the non-antithrombotic group, showing no significant difference (p = 0.07). Patients in the antithrombotic group in whom PPB occurred included 1 aspirin user with 1 polyp and 1 aspirin plus clopidogrel user with 2 polyps. No PPB occurred in patients on other antithrombotic agents or receiving heparin bridging. There was no significant difference between PPB rates in patients with small polyps (6-9 mm) in the antithrombotic and non-antithrombotic groups, but there was a significant difference between PPB rates in the 2 groups for patients with diminutive group (1-5 mm). CONCLUSION CP is a safe procedure even in patients on antithrombotic medication.
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Affiliation(s)
- Mio Matsumoto
- Department of Gastroenterology, Hokkaido Medical Center, Sapporo, Japan
| | - Shinji Yoshii
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | - Taku Shigesawa
- Department of Gastroenterology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Masayoshi Dazai
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | - Manabu Onodera
- Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan
| | | | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Lin D, Soetikno RM, McQuaid K, Pham C, Doan G, Mou S, Shergill AK, Somsouk M, Rouse RV, Kaltenbach T. Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications. Gastrointest Endosc 2018; 87:1106-1113. [PMID: 29208464 DOI: 10.1016/j.gie.2017.11.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy. METHODS We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding. RESULTS There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001). CONCLUSION We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.
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Affiliation(s)
- David Lin
- Division of Gastroenterology, University of California Los Angeles Medical Center, Los Angeles, California, USA; Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Roy M Soetikno
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Kenneth McQuaid
- Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| | - Chi Pham
- Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Gilbert Doan
- Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Shanshan Mou
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Amandeep K Shergill
- Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Robert V Rouse
- Department of Pathology, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Tonya Kaltenbach
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA; Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
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Jaruvongvanich V, Assavapongpaiboon B, Wijarnpreecha K, Ungprasert P. Heparin-bridging therapy and risk of post-polypectomy bleeding: Meta-analysis of data reported by Japanese colonoscopists. Dig Endosc 2017; 29:743-748. [PMID: 28370508 DOI: 10.1111/den.12882] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/27/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Peri-procedural bridging (PPB) with heparin is recommended for patients with high thromboembolic risk who need to withhold antithrombotic therapy for colonoscopic polypectomy. However, little is known about the bleeding risk from heparin-bridging therapy itself. METHODS MEDLINE and EMBASE databases were searched through January 2017 for studies that compared the risk of PPB in patients who received heparin-bridging therapy in lieu of antithrombotic agents for colonoscopic polypectomy and those who discontinued antithrombotic agents without receiving heparin. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model, generic inverse variance method. Between-study heterogeneity was quantified using the Q statistic and I2 . RESULTS A total of five studies consisting of 2601 patients were identified. A significantly increased risk of PPB among bridged patients compared to non-bridged patients was demonstrated with a pooled OR of 8.29 (95% CI, 4.96-13.87). Statistical heterogeneity was low with I2 of 0%. CONCLUSION The present study demonstrated a significantly increased risk of PPB among patients who underwent colonoscopic polypectomy and received heparin-bridging therapy in lieu of antithrombotic agents compared to patients who did not receive it.
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Affiliation(s)
- Veeravich Jaruvongvanich
- Department of Internal Medicine, University of Hawaii, Honolulu, USA.,Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, USA
| | - Patompong Ungprasert
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, USA.,Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kubo T, Yamashita K, Onodera K, Iida T, Arimura Y, Nojima M, Nakase H. Heparin bridge therapy and post-polypectomy bleeding. World J Gastroenterol 2016; 22:10009-10014. [PMID: 28018108 PMCID: PMC5143747 DOI: 10.3748/wjg.v22.i45.10009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/07/2016] [Accepted: 11/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To identify risk factors for post-polypectomy bleeding (PPB), focusing on antithrombotic agents.
METHODS This was a case-control study based on medical records at a single center. PPB was defined as bleeding that occurred 6 h to 10 d after colonoscopic polypectomy and required endoscopic hemostasis. As risk factors for PPB, patient-related factors including anticoagulants, antiplatelets and heparin bridge therapy as well as polyp- and procedure-related factors were evaluated. All colonoscopic hot polypectomies, endoscopic mucosal resections and endoscopic submucosal dissections performed between January 2011 and December 2014 were reviewed.
RESULTS PPB occurred in 29 (3.7%) of 788 polypectomies performed during the study period. Antiplatelet or anticoagulant agents were prescribed for 210 (26.6%) patients and were ceased before polypectomy except for aspirin and cilostazol in 19 cases. Bridging therapy using intravenous unfractionated heparin was adopted for 73 patients. The univariate analysis revealed that anticoagulants, heparin bridge, and anticoagulants plus heparin bridge were significantly associated with PPB (P < 0.0001) whereas antiplatelets and antiplatelets plus heparin were not. None of the other factors including age, gender, location, size, shape, number of resected polyps, prophylactic clipping and resection method were correlated with PPB. The multivariate analysis demonstrated that anticoagulants and anticoagulants plus heparin bridge therapy were significant risk factors for PPB (P < 0.0001). Of the 29 PPB cases, 4 required transfusions and none required surgery. A thromboembolic event occurred in a patient who took anticoagulant.
CONCLUSION Patients taking anticoagulants have an increased risk of PPB, even if the anticoagulants are interrupted before polypectomy. Heparin-bridge therapy might be responsible for the increased PPB in patients taking anticoagulants.
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