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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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Furuhashi H, Dobashi A, Tamai N, Shimamoto N, Kobayashi M, Ono S, Hara Y, Matsui H, Kamba S, Horiuchi H, Koizumi A, Ohya TR, Kato M, Ikeda K, Arakawa H, Sumiyama K. Blood group O is a risk factor for delayed post-polypectomy bleeding. Surg Endosc 2020; 35:6882-6891. [PMID: 33258034 DOI: 10.1007/s00464-020-08195-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/17/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Blood group O of ABO blood group system is considered as a risk factor for various bleeding events, but the relationship with endoscopic treatment-associated bleeding has yet to be investigated. This study aimed to evaluate whether blood group O is associated with delayed bleeding after colorectal endoscopic resection. METHODS This was a retrospective observational study based on medical records at four university hospitals in Japan. We reviewed the records for consecutive patients who underwent colorectal endoscopic resection from January 2014 through December 2017. The primary outcome was the incidence of delayed bleeding, defined as hematochezia or melena, requiring endoscopy, transfusion, or any hemostatic intervention up to 28 days after endoscopic resection. Multivariate logistic regression analysis was performed to adjust the impact of blood group O on the delayed bleeding. RESULTS Among 10,253 consecutive patients who underwent colorectal endoscopic resection during the study period, 8625 patients met the criteria. In total, delayed bleeding occurred in 255 patients (2.96%). The O group had significantly more bleeding events compared with the non-O group (A, B, and AB) (relative risk, 1.62 [95% confidence interval, 1.24-2.10]; P < 0.001). In multivariate logistic regression analysis, blood group O remained an independent risk factor for the bleeding (adjusted odds ratio, 1.60 [95% confidence interval, 1.18-2.17]; P = 0.002). CONCLUSIONS Blood group O was associated with an increased risk of delayed bleeding in patients undergoing colorectal endoscopic resection. Preoperative screening for ABO blood group could improve risk assessments.
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Affiliation(s)
- Hiroto Furuhashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Naoto Tamai
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Nana Shimamoto
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shingo Ono
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuko Hara
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroaki Matsui
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Kamba
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hideka Horiuchi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akio Koizumi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Tomohiko R Ohya
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keiichi Ikeda
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroshi Arakawa
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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3
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Chan A, Philpott H, Lim AH, Au M, Tee D, Harding D, Chinnaratha MA, George B, Singh R. Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence. World J Gastrointest Endosc 2020; 12:408-450. [PMID: 33269053 PMCID: PMC7677885 DOI: 10.4253/wjge.v12.i11.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/01/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).
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Affiliation(s)
- Andrew Chan
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Hamish Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Amanda H Lim
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Minnie Au
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Derrick Tee
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Damian Harding
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Mohamed Asif Chinnaratha
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Biju George
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
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Albéniz E, Gimeno-García AZ, Fraile M, Ibáñez B, Guarner-Argente C, Alonso-Aguirre P, Álvarez MA, Gargallo CJ, Pellisé M, Ramos Zabala F, Herreros de Tejada A, Nogales Ó, Martínez-Ares D, Múgica F, de la Peña J, Espinós J, Huerta A, Álvarez A, Gonzalez-Santiago JM, Navajas F, Martínez-Cara JG, Redondo-Cerezo E, Merlo Mas J, Sábado F, Rivero L, Saperas E, Soto S, Rodríguez-Sánchez J, López-Roses L, Rodríguez-Téllez M, Rullán Iriarte M, Elosua González A, Pardeiro R, Valdivielso Cortázar E, Concepción-Martín M, Huelin Álvarez P, Colán Hernández J, Cobian J, Santiago J, Jiménez A, Remedios D, López-Viedma B, García O, Martínez-Alcalá F, Pérez-Roldán F, Carbó J, Enguita M. Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions. Gastrointest Endosc 2020; 91:868-878.e3. [PMID: 31655045 DOI: 10.1016/j.gie.2019.10.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models. METHODS A multicenter cohort study was performed in patients with nonpedunculated lesions ≥20 mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies. RESULTS DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets. CONCLUSIONS The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT03050333.).
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Affiliation(s)
| | | | | | - Berta Ibáñez
- Navarrabiomed-Complejo Hospitalario de Navarra-UPNA and REDISSEC, Pamplona, Spain
| | - Carlos Guarner-Argente
- Hospital de la Santa Creu y Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | - Óscar Nogales
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Múgica
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | | | | | | | - Alberto Álvarez
- Complejo Asistencial Universitario de Salamanca, IBSAL, Salamanca, Spain
| | | | | | | | | | | | - Fernando Sábado
- Consorcio Hospitalario Provincial Castellón, Castellón, Spain
| | | | | | | | | | | | | | | | | | | | | | - Mar Concepción-Martín
- Hospital de la Santa Creu y Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | - Juan Colán Hernández
- Hospital de la Santa Creu y Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Julyssa Cobian
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - José Santiago
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | | | | | | | | | - Jorge Carbó
- Hospital Universitario La Paz, Madrid, Spain
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5
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Effect of antiplatelet agent number, types, and pre-endoscopic management on post-polypectomy bleeding: validation of endoscopy guidelines. Surg Endosc 2020; 35:317-325. [DOI: 10.1007/s00464-020-07402-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/30/2020] [Indexed: 12/17/2022]
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6
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Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants. Gastroenterol Res Pract 2019; 2019:5743561. [PMID: 31929785 PMCID: PMC6935785 DOI: 10.1155/2019/5743561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/07/2019] [Accepted: 11/28/2019] [Indexed: 12/28/2022] Open
Abstract
Backgrounds and Aims Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors. Materials and Methods This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients' clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups. Results The rates of POH were 7.9%∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6%∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively (∗ vs. ∗∗, p < 0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2 ± 8.3 vs. 7.2 ± 4.9, p < 0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment. Conclusions Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics.
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Yao C, Chiu Y, Wu K, Tai W, Hu M, Chou Y, Liang C, Lu L, Chuah S. The effect of discontinuation of aspirin on colonoscopic postpolypectomy bleeding. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Chih‐Chien Yao
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Yi‐Chun Chiu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Keng‐Liang Wu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
- Graduate Institute of Clinical Medical SciencesChang Gung University Taoyuan Taiwan
| | - Wei‐Chen Tai
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Ming‐Luen Hu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
| | - Yeh‐Pin Chou
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Chih‐Ming Liang
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Lung‐Sheng Lu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of MedicineChang Gung University College of Medicine Kaohsiung Taiwan
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Kim SY, Kim HS, Park HJ. Adverse events related to colonoscopy: Global trends and future challenges. World J Gastroenterol 2019; 25:190-204. [PMID: 30670909 PMCID: PMC6337013 DOI: 10.3748/wjg.v25.i2.190] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/22/2018] [Accepted: 12/01/2018] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.
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Affiliation(s)
- Su Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, South Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, South Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, South Korea
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Park SK, Seo JY, Lee MG, Yang HJ, Jung YS, Choi KY, Kim H, Kim HO, Jung KU, Chun HK, Park DI. Prospective analysis of delayed colorectal post-polypectomy bleeding. Surg Endosc 2018; 32:3282-3289. [PMID: 29344790 DOI: 10.1007/s00464-018-6048-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 01/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUNDS/AIMS Although post-polypectomy bleeding is the most frequent complication after colonoscopic polypectomy, only few studies have investigated the incidence of bleeding prospectively. The aim of this study was to investigate the incidence of delayed post-polypectomy bleeding and its associated risk factors prospectively. METHODS Patients who underwent colonoscopic polypectomy at Kangbuk Samsung Hospital from January 2013 to December 2014 were prospectively enrolled in this study. Trained nurses contacted patients via telephone 7 and 30 days after polypectomy and completed a standardized questionnaire regarding the development of bleeding. Delayed post-polypectomy bleeding was categorized as minor or major and early or late bleeding. Major delayed bleeding was defined as a > 2-g/dL drop in the hemoglobin level, requiring hospitalization for control of bleeding or blood transfusion; late delayed bleeding was defined as bleeding occurring later than 24 h after polypectomy. RESULTS A total of 8175 colonoscopic polypectomies were performed in 3887 patients. Overall, 133 (3.4%) patients developed delayed post-polypectomy bleeding. Among them, 90 (2.3%) and 43 (1.1%) patients developed minor and major delayed bleeding, respectively, and 39 (1.0%) patients developed late delayed bleeding. In the polyp-based multivariate analysis, young age (< 50 years; odds ratio [OR] 2.10; 95% confidence interval [CI] 1.18-3.68), aspirin use (OR 2.78; 95% CI 1.23-6.31), and polyp size of > 10 mm (OR 2.45; 95% CI 1.38-4.36) were significant risk factors for major delayed bleeding, while young age (< 50 years; OR 2.6; 95% CI 1.35-5.12) and immediate bleeding (OR 3.3; 95% CI 1.49-7.30) were significant risk factors for late delayed bleeding. CONCLUSIONS Young age, aspirin use, polyp size, and immediate bleeding were found to be independent risk factors for delayed post-polypectomy bleeding.
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Affiliation(s)
- Soo-Kyung Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Jeong Yeon Seo
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Min-Gu Lee
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Hyo-Joon Yang
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Yoon Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Kyu Yong Choi
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Hungdai Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Hyung Ook Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea
| | - Dong Il Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea. .,Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, South Korea.
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10
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Pigò F, Bertani H, Grande G, Abate F, Vavassori S, Conigliaro RL. Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis. Dig Liver Dis 2018; 50:20-26. [PMID: 29089272 DOI: 10.1016/j.dld.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/12/2017] [Accepted: 10/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM The aim of this systematic review and meta-analysis was to assess the risk of post-polypectomy bleeding (PPB) in patients that underwent colorectal polypectomy and exposed to ASA/NSAIDs. METHODS Relevant publications were identified in MEDLINE/EMBASE for the period 1950-2016. Studies with specified ASA/NSAIDs exposure and bleeding rate were included. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was based on fixed or random effect models in relation to the heterogeneity. RESULTS 11 studies (4 prospective and 7 retrospective) including 9307 patients were included in the analyses. Overall, 344 patients (OR 1.8; 95% CI 1.2-2.7; p-value 0.001, I2 52%) experienced rectal bleeding after procedure. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR 1.1; CI 95% 0.6-2.1; d.f.=1, p=0.64, I2 0%), the risk of delayed PPB was augmented (OR 1.7; 95% CI 1.2-2.2; d.f.=8, p=0.127, I2 36%). CONCLUSIONS ASA/NSAIDs are not a risk factor for immediate PPB but the chance of delayed is increased.
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Affiliation(s)
- Flavia Pigò
- Endoscopy Unit, New Civil Hospital S. Agostino Estense, Modena, Italy.
| | - Helga Bertani
- Endoscopy Unit, New Civil Hospital S. Agostino Estense, Modena, Italy
| | - Giuseppe Grande
- Endoscopy Unit, New Civil Hospital S. Agostino Estense, Modena, Italy
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11
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Thomsen AML, Pedersen AB, Kristensen NR, Møller BK, Erikstrup C, Christiansen PM, Nørgaard M, Cronin-Fenton D. Use of prescription drugs and risk of postoperative red blood cell transfusion in breast cancer patients: a Danish population-based cohort study. Breast Cancer Res 2017; 19:135. [PMID: 29273074 PMCID: PMC5741918 DOI: 10.1186/s13058-017-0926-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 12/05/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Several frequently used prescription drugs may affect bleeding risk. We investigated use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), and statins and risk of postoperative red blood cell transfusion in breast cancer patients. METHODS Using Danish population-based registries, we identified a cohort of women who underwent surgery for primary breast cancer (n = 22,238) during 2005-2012 and ascertained their use of aspirin, NSAIDs, SSRIs, and statins. For each drug, patients were categorized as users if they filled ≥1 prescription in the 60 days prior to surgery. We calculated the 14-day risk of red blood cell transfusion and relative risks (RRs) with 95% confidence intervals (CIs), comparing users with nonusers for each drug and adjusting for age, cancer stage, and Charlson Comorbidity Index score. RESULTS In our cohort, 1385 (6.2%) women were aspirin users, 1794 (8.0%) were NSAID users, 1110 (4.9%) were SSRI users, and 2053 (9.1%) were statin users. The overall risk of red blood cell transfusion was 1.3%. The 14-day risk of RBC transfusion was 3.5% among aspirin users versus 1.1% among aspirin nonusers (adjusted RR = 1.9, 95% CI: 1.4-2.7), and 1.8% among SSRI users versus 1.2% among SSRI nonusers (adjusted RR = 1.2, 95% CI: 0.7-1.9). Red blood cell transfusion risk was increased among NSAID users, but not in a sensitivity analysis with a 30-day exposure window. Red blood cell transfusion risk was not increased among SSRI and statin users. CONCLUSIONS Primary breast cancer surgery confers a low risk of RBC transfusion. Still, use of aspirin and possibly NSAIDs, but not SSRIs and statins, is associated with increased red blood cell transfusion. This increased risk is not explained by differences in age, stage, or comorbidity level.
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Affiliation(s)
- Anne Marie L. Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Alma B. Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Nickolaj R. Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Bjarne Kuno Møller
- Department of Clinical Immunology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Peer M. Christiansen
- Breast Surgery Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus C, Denmark
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Deirdre Cronin-Fenton
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
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12
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Shibuya T, Nomura O, Kodani T, Murakami T, Fukushima H, Tajima Y, Matsumoto K, Ritsuno H, Ueyama H, Inami Y, Ishikawa D, Matsumoto K, Sakamoto N, Osada T, Nagahara A, Ogihara T, Watanabe S. Continuation of antithrombotic therapy may be associated with a high incidence of colonic post-polypectomy bleeding. Dig Endosc 2017; 29:314-321. [PMID: 27809364 DOI: 10.1111/den.12760] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/31/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Post-polypectomy bleeding (PPB) is the most common complication of endoscopic procedures. To reduce the risk of thromboembolic incidents, Japanese guidelines for gastroenterological endoscopy were revised to indicate that antithrombotic agents were not to be discontinued for endoscopic treatment. However, carrying out endoscopic procedures under antithrombotic medication potentially increases the incidence of hemorrhagic complications. The present study investigated the impact of the revised guidelines on the frequency of complications after colonoscopic procedures. METHODS The surveillance period comprised the year before the initiation of the new guidelines (2012), which served as a control period, and 2 years after initiation of the new guidelines (2013 and 2014). During the control period, 3955 cases were examined colonoscopically and 1601 lesions were treated endoscopically. During the 2-year period under the new guidelines, 8749 colonoscopies and 3768 endoscopic treatments were carried out. Changes in treatment methods and rates of complications were compared. RESULTS PPB rate was not significantly different before and after the revision (0.87% vs 1.01%). With the new guidelines, PPB rates in antithrombotic non-users and users were 0.60% and 3.13%, respectively (OR 5.11, P = 0.000). Multivariable analysis showed that the risks for PPB were as follows: heparin bridging therapy (OR 6.34, P = 0.0002); low-dose aspirin (LDA) continuation (OR 5.30, P = 0.0079); and lesion size (OR 1.06, P < 0.0001). CONCLUSION The present study showed that the overall PPB rate under the new guidelines was not significantly higher when compared with the previous data obtained before the new guidelines were introduced.
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Affiliation(s)
- Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Osamu Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomohiro Kodani
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hirofumi Fukushima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuzuru Tajima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kohei Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hideaki Ritsuno
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshihiro Inami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Taro Osada
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tatsuo Ogihara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Sumio Watanabe
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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13
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Pigò F, Bertani H, Manno M, Mirante VG, Caruso A, Mangiafico S, Manta R, Rebecchi AM, Conigliaro RL. Colonic Postpolypectomy Bleeding Is Related to Polyp Size and Heparin Use. Clin Endosc 2017; 50:287-292. [PMID: 28183158 PMCID: PMC5475522 DOI: 10.5946/ce.2016.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/15/2016] [Accepted: 10/04/2016] [Indexed: 12/16/2022] Open
Abstract
Background/Aims We studied factors influencing colon postpolypectomy bleeding (PPB), with a focus on antithrombotic and anticoagulation therapy. Methods We conducted a retrospective case-control study of all patients who underwent polypectomy at our tertiary referral center in Italy between 2007 and 2014. Polyp characteristics (number of polyps removed per patient, size, morphology, location, resection technique, prophylactic hemostasis methods) and patient characteristics (age, sex, comorbidities, medication) were analyzed. Results The case and control groups included 118 and 539 patients, respectively. The two groups differed in the frequency of comorbidities (69% vs. 40%, p=0.001), polyps removed (27% vs. 18%, p=0.02), and use of heparin therapy (23% vs. 1%, p<0.001). A total of 279 polyps in the case group and 966 in the control group were nonpedunculated (69% vs. 81%, p=0.01) and measured ≥10 mm (78% vs. 32%, p=0.001). Multivariate analysis showed that polyps ≥10 mm (odds ratio [OR], 6.1; 95% confidence interval [CI], 2.3–15.5), administration of heparin (OR, 16.5; 95% CI, 6.2–44), comorbidity (OR, 2.3; 95% CI, 1.4–3.9), and presence of ≥2 risk factors (OR, 3.2; 95% CI, 1.7–6.0) were associated with PPB. Conclusions The incidence of PPB increases with polyp size ≥10 mm, heparin use, comorbidity, and presence of ≥2 risk factors.
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Affiliation(s)
- Flavia Pigò
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Helga Bertani
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Mauro Manno
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Vincenzo Giorgio Mirante
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Angelo Caruso
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Santi Mangiafico
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Raffaele Manta
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | | | - Rita Luisa Conigliaro
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
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14
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Post-Colonoscopy Complications: A Systematic Review, Time Trends, and Meta-Analysis of Population-Based Studies. Am J Gastroenterol 2016; 111:1092-101. [PMID: 27296945 DOI: 10.1038/ajg.2016.234] [Citation(s) in RCA: 213] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Many studies around the world addressed the post-colonoscopy complications, but their pooled prevalence and time trends are unknown. We performed a systematic review and meta-analysis of population-based studies to examine the pooled prevalence of post-colonoscopy complications ("perforation", "bleeding", and "mortality"), stratified by colonoscopy indication. Temporal variability in the complication rate was assessed. METHODS We queried Pubmed, Embase, and the Cochrane library for population-based studies examining post-colonoscopy complications (within 30 days), performed from 2001 to 2015 and published by 1 December 2015. We determined pooled prevalence of perforations, post-colonoscopy bleeding, post-polypectomy bleeding, and mortality. RESULTS We retrieved 1,074 studies, of which 21 met the inclusion criteria. Overall, pooled prevalences for perforation, post-colonoscopy bleeding, and mortality were 0.5/1,000 (95% confidence interval (CI) 0.4-0.7), 2.6/1,000 (95% CI 1.7-3.7), and 2.9/100,000 (95% CI 1.1-5.5) colonoscopies. Colonoscopy with polypectomy was associated with a perforation rate of 0.8/1,000 (95% CI 0.6-1.0) and a post-polypectomy bleeding rate of 9.8/1,000 (95% CI 7.7-12.1). Complication rate was lower for screening/surveillance than for diagnostic examinations. Time-trend analysis showed that post-colonoscopy bleeding declined from 6.4 to 1.0/1,000 colonoscopies, whereas the perforation and mortality rates remained stable from 2001 to 2015. Overall, considerable heterogeneity was observed in most of the analyses. CONCLUSIONS Worldwide, the post-colonoscopy complication rate remained stable or even declined over the past 15 years. The findings of this meta-analysis encourage continued efforts to achieve and maintain safety targets in colonoscopy practice.
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15
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Albéniz E, Fraile M, Ibáñez B, Alonso-Aguirre P, Martínez-Ares D, Soto S, Gargallo CJ, Ramos Zabala F, Álvarez MA, Rodríguez-Sánchez J, Múgica F, Nogales Ó, Herreros de Tejada A, Redondo E, Pin N, León-Brito H, Pardeiro R, López-Roses L, Rodríguez-Téllez M, Jiménez A, Martínez-Alcalá F, García O, de la Peña J, Ono A, Alberca de Las Parras F, Pellisé M, Rivero L, Saperas E, Pérez-Roldán F, Pueyo Royo A, Eguaras Ros J, Zúñiga Ripa A, Concepción-Martín M, Huelin-Álvarez P, Colán-Hernández J, Cubiella J, Remedios D, Bessa I Caserras X, López-Viedma B, Cobian J, González-Haba M, Santiago J, Martínez-Cara JG, Valdivielso E, Guarner-Argente C. A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions. Clin Gastroenterol Hepatol 2016; 14:1140-7. [PMID: 27033428 DOI: 10.1016/j.cgh.2016.03.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. METHODS We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. RESULTS Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. CONCLUSIONS The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.
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Affiliation(s)
| | - María Fraile
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Berta Ibáñez
- NavarraBiomed-Fundación Miguel Servet and Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Pamplona, Spain
| | | | | | | | | | | | | | | | - Fernando Múgica
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - Óscar Nogales
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Noel Pin
- Hospital Juan Canalejo, La Coruña, Spain
| | | | | | | | | | | | | | | | | | - Akiko Ono
- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | | | | | | | | | | | | | | | - Mar Concepción-Martín
- Hospital de la Santa Creu y Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Colán-Hernández
- Hospital de la Santa Creu y Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Julyssa Cobian
- Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | | | - José Santiago
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | - Carlos Guarner-Argente
- Hospital de la Santa Creu y Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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16
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Fang X, Baillargeon JG, Jupiter DC. Continued Antiplatelet Therapy and Risk of Bleeding in Gastrointestinal Procedures: A Systematic Review. J Am Coll Surg 2016; 222:890-905.e11. [PMID: 27016908 DOI: 10.1016/j.jamcollsurg.2016.01.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated with perioperative use of antiplatelet medication. However, cessation of these drugs may be unsafe for patients who are required to maintain antiplatelet use due to cardiovascular conditions. The objective of this systematic review was to compare the risk of intraoperative or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy) with the risk among those not taking continuous antiplatelet medication. STUDY DESIGN We reviewed articles published between January 2000 and July 2015 from the Medline Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies involving any GI procedures were included if the articles met our inclusion criteria (listed in Methods). The following key words were used for the search: clopidogrel, Plavix, aspirin, antiplatelet, bleeding, hemorrhage, and digestive system surgical procedures. Quality of the studies was assessed, depending on their study design, using the Newcastle-Ottawa score or the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Twenty-two studies were eligible for inclusion in the systematic review. Five showed that the risk of intraoperative bleeding or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy was higher compared that for those not on continuous therapy. The remaining 17 studies reported that there was no statistically significant difference in the risks of bleeding between the continuous antiplatelet therapy group and the group without continuous antiplatelet therapy. CONCLUSIONS The risk of bleeding associated with GI procedures in patients receiving antiplatelet therapy was not significantly higher than in patients with no antiplatelet or interrupted antiplatelet therapy.
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Affiliation(s)
- Xiao Fang
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
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17
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Shalman D, Gerson LB. Systematic review with meta-analysis: the risk of gastrointestinal haemorrhage post-polypectomy in patients receiving anti-platelet, anti-coagulant and/or thienopyridine medications. Aliment Pharmacol Ther 2015; 42:949-56. [PMID: 26290157 DOI: 10.1111/apt.13367] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/06/2014] [Accepted: 07/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND For patients undergoing colonoscopy with polypectomy, current guidelines recommend temporary cessation of blood-thinning medications. The data regarding periprocedural management of these medications are sparse. AIM To perform a systematic review and meta-analysis to determine the risk of post-polypectomy bleeding (PPB) in patients taking anti-platelet, anti-coagulant and/or thienopyridine medications. METHODS We searched Pubmed, Scopus, Web of Science, Biosis and Proceedings First from 1970 to 2015. PPB was defined as overt haemorrhage or drop in haemoglobin of at least 2 g/dL. RESULTS Of 1490 articles identified, we included 3 papers and 1 abstract with patients on aspirin and/or NSAIDs, 1 paper on warfarin, 2 abstracts on clopidogrel, and 2 papers on clopidogrel plus aspirin and/or NSAIDs. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR = 1.1, 95% CI 0.7-1.9, P = 0.7), the risk of delayed PPB was increased (OR = 1.7, 95% CI 1.0-2.4, P = 0.0009, I(2) = 60%) but rendered non-significant with elimination of a small study. There was an elevated risk of delayed PPB on clopidogrel (OR = 9.7, 95% CI 3.1-30.8, P = 0.0, I(2) = 0). There was an increased risk of delayed PPB in patients on clopidogrel + aspirin and/or NSAIDs (OR = 3.4, 95% CI 1.3-8.8, P = 0.01, I(2) = 0). Based on a single study on warfarin, the PPB rate was elevated. There were no data regarding PPB and usage of the newer anti-coagulant agents. CONCLUSIONS Usage of aspirin or NSAIDs does not increase risk of post-polypectomy bleeding. Clopidogrel and warfarin should be discontinued in the periprocedural period to prevent the occurrence of post-polypectomy bleeding.
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Affiliation(s)
- D Shalman
- Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - L B Gerson
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA
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18
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Li LY, Qu CM, Zeng BL, Wang XY, Liang SW. Combined endoloop and endoclip application for prevention of postpolypectomy bleeding. Shijie Huaren Xiaohua Zazhi 2015; 23:4119-4124. [DOI: 10.11569/wcjd.v23.i25.4119] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of combined endoloop and hemoclip application as a prophylactic method for postpolypectomy bleeding in patients with large (≥2 cm) pedunculated colonic polyps.
METHODS: Patients with pedunculated colonic polyps (≥2 cm) were included in this study retrospectively and divided into a control group and an experimental group. In the control group, endoclips were used after conventional polypectomy. In the experimental group, an endoloop was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. The efficacy in preventing early and late postpolypectomy bleeding, rate of severe bleeding, and days of hospitalization were evaluated.
RESULTS: Overall, bleeding complications occurred in 5/72 polyps (6.94%). In the control group (endoclips alone), 4/42 (9.52%) had a bleeding episode: three (7.14%) occurred during the first 24 h and one (2.3%) between days 1 and 30 from the procedure. In the experimental group only 1 of 32 polyps (3.12%) had a late bleeding episode (P = 0.275). Severity of late bleeding in the experimental group (one case of moderate bleeding) vs the control group (3 cases of moderate and one case of severe bleeding) and need for transfusions (0 vs 2 blood units) were lower. Colonoscopy time was significantly higher in the experimental group vs the control group (P = 0.027), but hospitalization days were shorter in the experimental group (P = 0.047).
CONCLUSION: Endoloop combined with endoclip technique seems to be more effective than endoclip alone in preventing postpolypectomy bleeding in large pedunculated colonic polyps.
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Matsumoto M, Mabe K, Tsuda M, Ono M, Omori S, Takahashi M, Yoshida T, Ono S, Nakagawa M, Nakagawa S, Shimizu Y, Kudo T, Sakamoto N, Kato M. Multicenter study on hemorrhagic risk of heparin bridging therapy for periendoscopic thromboprophylaxis. BMC Gastroenterol 2015. [PMID: 26215103 PMCID: PMC4515926 DOI: 10.1186/s12876-015-0315-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background For endoscopic interventions, heparin bridging therapy is recommended in patients who are at high risk from interruption of antithrombotic therapy. Although heparin bridging has been reported to be effective in preventing thrombosis, several reports have raised concerns about increased risk of bleeding. The aim of this study was to clarify complications of hepari bridging therapy in therapeutic endoscopy. Methods A nationwide multicenter survey using questionnaire was performed about patients undergoing therapeutic endoscopy with heparin bridging. Patients who underwent therapeutic endoscopy without heparin bridging therapy were considered as controls. Compliance scores of heparin bridging therapy guideline were employed, and association was analyzed between the score and occurrence of post-procedural bleeding. Results The incidence of post-procedural bleeding was significantly higher (13.5 %, 33/245) in the heparin group compared with the control group (2.7 %, 299/11102)(p < 0.001). Thrombosis occurred in 1 patient each in the two groups. In the heparin group, post-procedural bleeding was more likely to be delayed bleeding. Dose adjustment of heparin was a significant factor contributing to bleeding. The compliance score of heparin bridging therapy guideline was significantly higher in those who suffered bleeding. Conclusions Heparin bridging therapy significantly increased the risk of post-procedural bleeding compared with the control. The bleeding risk was associated with greater adherence with guidelines for heparin bridging therapy.
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Affiliation(s)
- Mio Matsumoto
- Department of Gastroenterology, Sapporo Medical Center NTT EC, 〒060-0061 South 1 West 15, Chuo-ku, Sapporo, Hokkaido, Japan.
| | - Katsuhiro Mabe
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Momoko Tsuda
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Masayoshi Ono
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Saori Omori
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Masakazu Takahashi
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Takeshi Yoshida
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Manabu Nakagawa
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Soichi Nakagawa
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Yuichi Shimizu
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Takahiko Kudo
- Department of Gastroenterology, Sapporo City General Hospital, 〒060-8604 North 11, West 13, Chuo-ku, Sapporo, Hokkaido, Japan.
| | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, 〒060-0814 North 14, West 7, Kita-ku, Sapporo, Hokkaido, Japan.
| | - Mototsugu Kato
- Division of Endoscopy, Hokkaido University Hospital, 〒060-0814 North 14, West 5, Kita-ku, Sapporo, Hokkaido, Japan.
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Hassan C, Zullo A. Anti-platelet therapy and endoscopic procedures: eyes wide shut? Endosc Int Open 2015; 3:E179-80. [PMID: 26171426 PMCID: PMC4486034 DOI: 10.1055/s-0034-1392368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/06/2015] [Indexed: 12/02/2022] Open
Affiliation(s)
- Cesare Hassan
- Department of Gastroenterology, ONRM Hospital, Rome, Italy,Corresponding author Cesare Hassan, MD Department of GastroenterologyONRM HospitalVia Morosini 30Rome 00153Italy+39-06-58446533
| | - Angelo Zullo
- Department of Gastroenterology, ONRM Hospital, Rome, Italy
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Kwon MJ, Kim YS, Bae SI, Park YI, Lee KJ, Min JH, Jo SY, Kim MY, Jung HJ, Jeong SY, Yoon WJ, Kim JN, Moon JS. Risk factors for delayed post-polypectomy bleeding. Intest Res 2015; 13:160-5. [PMID: 25932001 PMCID: PMC4414758 DOI: 10.5217/ir.2015.13.2.160] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 12/13/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Among the many complications that can occur following therapeutic endoscopy, bleeding is the most serious, which occurs in 1.0-6.1% of all colonoscopic polypectomies. The aim of this study was to identify risk factors of delayed post-polypectomy bleeding (PPB). Methods We retrospectively reviewed the data of patients who underwent colonoscopic polypectomy between January 2003 and December 2012. We compared patients who experienced delayed PPB with those who did not. The control-to-patient ratio was 3:1. The clinical data analyzed included polyp size, number, location, and shape, patient' body mass index (BMI), preventive hemostasis, and endoscopist experience. Results Of 1,745 patients undergoing colonoscopic polypectomy, 21 (1.2%) experienced significant delayed PPB. We selected 63 age- and sex-matched controls. Multivariate logistic regression analysis showed that polyps >10 mm (odds ratio [OR], 2.605; 95% confidence interval [CI], 1.035-4.528; P=0.049), a pedunculated polyp (OR, 3.517; 95% CI, 1.428-7.176; P=0.045), a polyp located in the right hemicolon (OR, 3.10; 95% CI, 1.291-5.761; P=0.013), and a high BMI (OR, 3.681; 95% CI, 1.876-8.613; P=0.013) were significantly associated with delayed PPB. Conclusions Although delayed PPB is a rare event, more caution is needed during colonoscopic polypectomies performed in patients with high BMI or large polyps, pedunculated polyps, or polyps located in the right hemicolon.
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Affiliation(s)
- Min Jung Kwon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Song I Bae
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Young Il Park
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kyung Jin Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jung Hwa Min
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Soo Yeon Jo
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Mi Young Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hye Jin Jung
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seong Yeon Jeong
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Won Jae Yoon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jin Nam Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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22
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Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.
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Affiliation(s)
- Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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23
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Moon HS, Park SW, Kim DH, Kang SH, Sung JK, Jeong HY. Only the size of resected polyps is an independent risk factor for delayed postpolypectomy hemorrhage: a 10-year single-center case-control study. Ann Coloproctol 2014; 30:182-5. [PMID: 25210687 PMCID: PMC4155137 DOI: 10.3393/ac.2014.30.4.182] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 03/24/2014] [Indexed: 02/06/2023] Open
Abstract
Purpose A colonoscopic polypectomy is an important procedure for preventing colorectal cancer, but it is not free from complications. Delayed hemorrhage after a colonoscopic polypectomy is one infrequent, but serious, complication. The aim of this study was to identify the risk factors for delayed hemorrhage after a colonoscopic polypectomy. Methods This was a retrospective case-control study based on medical records from a single gastroenterology center. The records of 7,217 patients who underwent a colonoscopic polypectomy between March 2002 and March 2012 were reviewed, and 92 patients and 276 controls were selected. Data collected included comorbidity, use of antiplatelet agents, size and number of resected polyps, histology and gross morphology of resected polyps, resection method, and use of prophylactic hemostasis. Results The average time between the procedure and bleeding was 2.71 ± 1.55 days. Univariate and multivariate analyses revealed that the size of the polyps was the only and most important predictor of delayed hemorrhage after a colonoscopic polypectomy (odds ratio, 2.06; 95% confidence interval, 1.12-1.27; P = 0.03). Conclusion The size of resected polyps was the only independent risk factor for delayed bleeding after a colonoscopic polypectomy. The size of a polyp, as revealed by the colonoscopic procedure, may aid in making decisions, such as the decision to conduct a prophylactic hemostatic procedure.
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Affiliation(s)
- Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Wook Park
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Dong Hwan Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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Bogani G, Cromi A, Uccella S, Serati M, Casarin J, Pinelli C, Ghezzi F. Safety of Perioperative Aspirin Therapy in Minimally Invasive Endometrial Cancer Staging. J Minim Invasive Gynecol 2014; 21:636-41. [PMID: 24462596 DOI: 10.1016/j.jmig.2014.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 01/07/2014] [Accepted: 01/07/2014] [Indexed: 11/16/2022]
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