1
|
Tsonev N, Vandeva D, Toncheva K, Zvezdov D. Anticoagulant and Antiplatelet Therapy in Periprocedural Period of Elective Gastrointestinal Endoscopy. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. Gastrointestinal endoscopy is related to bleeding risk – there is bleeding risk stratification according to endoscopic procedures (high- and low-risk ones). Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. It is recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures and to consider the use of “bridging” therapy with LWMH for patients on Vitamin K antagonists who are at high thrombotic risk. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore, collaboration with a cardiologist is of great importance, at least for some patients.
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. [Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 76:282-296. [PMID: 33361705 DOI: 10.4166/kjg.2020.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/03/2022]
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
Collapse
Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
| |
Collapse
|
5
|
Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Clin Endosc 2020; 53:663-677. [PMID: 33242928 PMCID: PMC7719428 DOI: 10.5946/ce.2020.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
Collapse
Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
| |
Collapse
|
6
|
Abstract
Decisions surrounding periprocedural anticoagulation management must balance thromboembolic and procedural bleed risk. The interruption of both warfarin and DOACs requires consideration of anticoagulant pharmacokinetics, procedural bleed risk and patient characteristics. There is a diminishing role for periprocedural bridging LMWH overall and no role for bridging LMWH for the procedural interruption of DOACs. A clinical approach to perioperative DOAC management based on operative bleeding risk and renal function is safe and effective, and at present, is preferred over preprocedural DOAC levels testing. Clear communication of the anticoagulation interruption plan to both the patient and the patient's care team is essential.
Collapse
Affiliation(s)
- Joseph R Shaw
- Ottawa Blood Disease Center, Division of Hematology, The Ottawa Hospital, Box 206, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. https://twitter.com/JRand083
| | - Eric Kaplovitch
- Department of Medicine, University Health Network, The University of Toronto, 585 University Avenue, Norman Urquhart Building, 7th Floor, Room 739, Toronto, Ontario M5G 2N2, Canada. https://twitter.com/kaplovitch
| | - James Douketis
- Department of Medicine, Division of General Internal Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada; Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada.
| |
Collapse
|
7
|
Maida M, Sferrazza S, Maida C, Morreale GC, Vitello A, Longo G, Garofalo V, Sinagra E. Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature. World J Gastrointest Endosc 2020; 12:172-192. [PMID: 32843928 PMCID: PMC7415229 DOI: 10.4253/wjge.v12.i6.172] [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: 02/27/2020] [Revised: 05/09/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients’ comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential.
This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.
Collapse
Affiliation(s)
- Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38123, Italy
| | - Carlo Maida
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Palermo 93100, Italy
| | | | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Giovanni Longo
- Cardiology Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Vincenzo Garofalo
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Istituto San Raffaele Giglio, Cefalù 90015, Italy
| |
Collapse
|
8
|
Abstract
Colonoscopy with polypectomy is the means by which the incidence of colon cancer may be reduced; however, polypectomy is not without risk. Physicians must carefully weigh the risks and benefits of colonoscopy, particularly when patients are given prescriptions for antiplatelet agents and anticoagulants. This article discusses the risks of colonoscopy and polypectomy and reviews the most recent data for managing antiplatelet agents and anticoagulants in the periendoscopic period.
Collapse
Affiliation(s)
- Linda Anne Feagins
- Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas VA Medical Center, 4500 South Lancaster Road (111B1), Dallas, TX 75216, USA.
| |
Collapse
|
9
|
Doorey AJ, Weintraub WS, Schwartz JS. Should Procedures or Patients Be Safe? Bias in Recommendations for Periprocedural Discontinuation of Anticoagulation. Mayo Clin Proc 2018; 93:1173-1176. [PMID: 30100193 DOI: 10.1016/j.mayocp.2018.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 04/10/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - J Sanford Schwartz
- Perelman School of Medicine at the University of Pennsylvania and Wharton School of Business, Philadelphia, PA
| |
Collapse
|
10
|
Heublein V, Pannach S, Daschkow K, Tittl L, Beyer-Westendorf J. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry. J Gastroenterol 2018; 53:236-246. [PMID: 28493007 DOI: 10.1007/s00535-017-1346-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients receiving direct-acting, non-vitamin K oral anticoagulants (NOAC) frequently undergo gastrointestinal endoscopies (GIE) but little is known on the management and outcome of these interventions. METHODS With use of data from an ongoing, prospective, noninterventional registry of NOAC patients, the management and outcome of GIE were evaluated with use of standard event definitions. Patients undergoing GIE were categorized into two subgroups: (1) scheduled GIE (scheduled appointment, no acute bleeding) and (2) unscheduled GIE (unscheduled including management of acute gastrointestinal bleeding). The rates of major bleeding complications, cardiovascular complications, and all-cause death within 30 days after the procedure were evaluated. RESULTS Between October 1, 2011, and March 31, 2015, 492 patients underwent a total of 713 GIE (44.5% gastroscopies, 53.0% colonoscopies, 2.5% endoscopic retrograde cholangiopancreatography procedures), with 70.0% being scheduled procedures and 30.0% being unscheduled procedures. Endoscopies were performed within 24 h after the last NOAC intake in 45 of 713 cases (6.3%), between 24 and 48 h after the last intake in 336 cases (47.1%), and after NOAC therapy interruption for more than 48 h in 213 cases (29.9%). Heparin bridging therapy was used in 180 of 713 procedures (25.3%) and predominantly (170/180; 94.4%) in cases of NOAC therapy interruption for longer than 72 h. Until day 30 after the procedure, the event rates were 1.4% for cardiovascular events and 0.7% for major bleeding events. CONCLUSION Continuation or short-term interruption of NOAC therapy seems to be a safe strategy for GIE. Heparin bridging therapy is predominantly used in cases of prolonged NOAC therapy interruption.
Collapse
Affiliation(s)
- Vera Heublein
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sven Pannach
- Division of Gastroenterology, Department of Medicine I, Carl Gustav Carus University Hospital, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Katharina Daschkow
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Luise Tittl
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany.
- Kings Thrombosis Service, Department of Hematology, Kings College London, London, UK.
| |
Collapse
|
11
|
Feagins LA. Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med 2017; 130:786-795. [PMID: 28344132 DOI: 10.1016/j.amjmed.2017.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/14/2023]
Abstract
Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.
Collapse
Affiliation(s)
- Linda Anne Feagins
- Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas and the University of Texas Southwestern Medical Center at Dallas.
| |
Collapse
|
12
|
Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
Collapse
|
13
|
Lange CM, Fichtlscherer S, Miesbach W, Zeuzem S, Albert J. The Periprocedural Management of Anticoagulation and Platelet Aggregation Inhibitors in Endoscopic Interventions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:129-35. [PMID: 26976713 DOI: 10.3238/arztebl.2016.0129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND In Germany, more than half a million persons, most of them elderly, are under long-term treatment with anticoagulants. The approval of new oral anticoagulants and platelet aggregation inhibitors, as well as new data on periprocedural bridging with heparins, have introduced marked complexity to the management of treatment with anticoagulants and platelet aggregation inhibitors for endoscopic interventions in visceral surgery. METHODS This review is based on pertinent publications retrieved by a selective literature search in PubMed, as well as on the relevant guidelines. RESULTS Robust data are available on the management of vitamin K antagonists (VKA) and platelet aggregation inhibitors for endoscopic procedures; on the other hand, the data on the periprocedural management of non-VKA oral anticoagulants (NOAC) are still inadequate. Endoscopic procedures that carry a low risk of bleeding can be performed under treatment with anticoagulants or platelet aggregation inhibitors. Before any procedure with a high risk of bleeding (≥ 1.5%) oral anticoagulants of any type and P2Y12 inhibitors should generally be discontinued. Patients in whom VKA are temporarily discontinued for this reason need bridging treatment with heparin only if they are at high risk of thromboembolic events (≥ 10% per year). For patients who are anticoagulated with NOAC, timely discontinuation of the drug depending on renal function is of key importance, and bridging is usually unnecessary. CONCLUSION Adequate scientific evidence supports the current recommendations and treatment algorithms for the periprocedural management of oral anticoagulants and platelet aggregation inhibitors in endoscopic procedures. Larger-scale studies are still needed to provide a sound basis for the corresponding recommendations about NOAC.
Collapse
Affiliation(s)
- Christian M Lange
- Gastroenterology and Hepatology, Department of Medicine 1, Frankfurt University Hospital, Frankfurt am Main, Cardiology, Department of Medicine 3, Frankfurt University Hospital, Frankfurt am Main, Hemostaseology, Department of Medicine 2, Frankfurt University Hospital, Frankfurt am Main
| | | | | | | | | |
Collapse
|
14
|
Zullo A, Hassan C, Radaelli F. Gastrointestinal endoscopy in patients on anticoagulant therapy and antiplatelet agents. Ann Gastroenterol 2016; 30:7-14. [PMID: 28042233 PMCID: PMC5198250 DOI: 10.20524/aog.2016.0096] [Citation(s) in RCA: 5] [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: 06/28/2016] [Accepted: 09/10/2016] [Indexed: 12/15/2022] Open
Abstract
Periprocedural management of antithrombotics for gastrointestinal endoscopy is a common clinical issue, given the widespread use of these drugs for primary and secondary cardiovascular prevention. For diagnostic procedures, with or without biopsy, no adjustments in antithrombotics are usually needed. For operative procedures, balancing the risk of periprocedural hemorrhage with the continuation of antithrombotics against the chance of recurrent thromboembolic events with their discontinuation may be challenging. Oral anticoagulants need to be temporarily withheld, and consideration must be given to whether a periendoscopic "bridge" therapy, typically a low-molecular-weight heparin, should be used in order to minimize the risk of thromboembolic events. Although some emerging evidence has shown that patients receiving heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to controls, bridging therapy is still recommended for patients on vitamin K antagonists who are at high thrombotic risk. Conversely, bridging therapy is usually not needed for patients taking new oral agents, which are characterized by shorter half-lives, and a rapid offset and onset of action. Management of antiplatelet therapy requires special care in patients on secondary prevention, especially those with coronary stents. This review is intended to summarize the recommendations of updated International Guidelines designed to help the decision-making process in such an intricate field.
Collapse
Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo, Cesare Hassan)
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo, Cesare Hassan)
| | - Franco Radaelli
- Gastroenterology and Digestive Endoscopy, Valduce Hospital, Como (Franco Radaelli), Italy
| |
Collapse
|
15
|
Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
Collapse
Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | | |
Collapse
|
16
|
Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83:3-16. [PMID: 26621548 DOI: 10.1016/j.gie.2015.09.035] [Citation(s) in RCA: 397] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/28/2015] [Indexed: 02/07/2023]
|
17
|
Tang RSY, Chan FKL. Prevention of gastrointestinal events in patients on antithrombotic therapy in the peri-endoscopy period: review of new evidence and recommendations from recent guidelines. Dig Endosc 2015; 27:562-71. [PMID: 25819537 DOI: 10.1111/den.12478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/24/2015] [Indexed: 01/14/2023]
Abstract
Management of patients on antithrombotic therapy undergoing endoscopic procedures can be challenging. Although guidelines from major gastrointestinal endoscopy societies provide useful recommendations in this regard, data are limited concerning the bleeding risk of new complex endoscopic procedures and the management of novel anticoagulants in patients needing invasive procedures. The approach to the management of antithrombotic therapy often needs to be formulated on an individual basis, especially in patients with high thrombotic risk undergoing a high-risk endoscopic procedure. In addition to the procedure-related bleeding risk, endoscopists also need to consider the urgency of the endoscopic procedure, the thromboembolic risk of the patient if antithrombotic therapy is temporarily withheld, and the timing of discontinuation/resumption of antithrombotic therapy in the decision-making process. Diagnostic endoscopic procedures with or without biopsy can often be done without interruption of antithrombotic therapy. If possible, elective procedures with high bleeding risk should be delayed in patients on antithrombotic therapy for conditions with high thrombotic risk. If high-risk procedures cannot be delayed in these patients, thienopyridines, traditional and novel anticoagulants are usually withheld, whereas aspirin withdrawal is decided on a case by case basis. In patients with high thrombotic risk, communication with the prescribing clinician before proceeding to procedures with high bleeding risk is particularly important in optimizing the peri-procedural management plan of antithrombotic therapy.
Collapse
Affiliation(s)
- Raymond S Y Tang
- Institute of Digestive Disease, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| |
Collapse
|
18
|
The prophylactic placement of hemoclips to prevent delayed post-polypectomy bleeding: an unnecessary practice? A case control study. Dig Dis Sci 2014; 59:823-8. [PMID: 24526499 DOI: 10.1007/s10620-014-3055-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/30/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND With the recent, widespread availability of endoscopic hemoclips, it has become common clinical practice to apply hemoclips to some non-bleeding polypectomy sites "prophylactically" to prevent delayed post-polypectomy bleeding (PPB). Few published data support this practice, however. AIM The aim of this study was to compare rates of delayed PPB in matched patients who had polypectomies performed with and without the prophylactic placement of hemoclips. METHODS We reviewed medical records of patients who had elective colonoscopy at our VA Medical Center between July 2008 and December 2009. We identified patients who had hemoclips applied prophylactically (cases) and compared their rate of delayed PPB within 30 days to that of patients who had polypectomy without hemoclipping (controls). Controls were matched 1:1 to cases based on age and on factors known to contribute to the risk of PPB including polyp size, morphology, technique of polyp removal, number of polyps removed, and use of anticoagulants. RESULTS We identified 184 patients (cases) who underwent prophylactic hemoclipping and 184 well-matched controls. An average of 3.8 polyps per patient were removed in the case group compared to 3.3 polyps per patient in controls (p = 0.6). Delayed PPB occurred in three patients in the prophylactic hemoclip group and in one patient in the control group (1.6 vs. 0.5 %, p = 0.62). CONCLUSIONS We found no significant difference in the rate of delayed PPB between patients who had prophylactic hemoclipping of polypectomy sites and a well-matched control group of patients who had polypectomy without prophylactic hemoclipping. These data call into question the expensive practice of prophylactic hemoclipping.
Collapse
|
19
|
Saito Y, Sakamoto T, Nakajima T, Matsuda T. Colorectal ESD: current indications and latest technical advances. Gastrointest Endosc Clin N Am 2014; 24:245-55. [PMID: 24679235 DOI: 10.1016/j.giec.2013.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The number of medical facilities that perform colorectal endoscopic submucosal dissection (ESD) has been growing, and its effectiveness has been increasingly reported in recent years. Indications approved by the Japanese government's medical insurance system are early colorectal cancers with a maximum tumor size of 2-5 cm. ESD was an effective procedure for treating noninvasive colorectal tumors difficult to resect en bloc by conventional EMR, resulting in a higher en bloc resection rate that is less invasive than surgery. Based on the excellent clinical results of colorectal ESDs, the Japanese health care insurance system has approved colorectal ESD for coverage.
Collapse
Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Takeshi Nakajima
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| |
Collapse
|
20
|
Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N, Sano K, Graham DY. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014; 79:417-23. [PMID: 24125514 DOI: 10.1016/j.gie.2013.08.040] [Citation(s) in RCA: 213] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/29/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The bleeding risk after cold snare polypectomy in anticoagulated patients is not known. OBJECTIVE To compare the bleeding risk after cold snare polypectomy or conventional polypectomy for small colorectal polyps in anticoagulated patients. DESIGN Prospective randomized controlled study. SETTING Municipal hospital in Japan. INTERVENTIONS Anticoagulated patients with colorectal polyps up to 10 mm in diameter were enrolled. Patients were randomized to polypectomy with either cold snare technique (Cold group) or conventional polypectomy (Conventional group) without discontinuation of warfarin. The primary outcome measure was delayed bleeding (ie, requiring endoscopic intervention within 2 weeks after polypectomy). Secondary outcome measures were immediate bleeding and retrieval rate of colorectal polyps. RESULTS Seventy patients were randomized (159 polyps): Cold group (n = 35, 78 polyps) and Conventional group (n = 35; 81 polyps). The patients' demographic characteristics including international normalized ratio and the number, size, and shape of polyps removed were similar between the 2 techniques. Immediate bleeding during the procedure was more common with conventional polypectomy (23% [8/35]) compared with cold polypectomy (5.7% [2/35]) (P = .042). No delayed bleeding occurred in the Cold group, whereas 5 patients (14%) required endoscopic hemostasis in the Conventional group (P = .027). Complete polyp retrieval rates were identical (94% [73/78] vs 93% [75/81]). The presence of histologically demonstrated injured arteries in the submucosal layer with cold snare was significantly less than with conventional snare (22% vs 39%, P = .023). LIMITATION Small sample size, single-center study. CONCLUSIONS Delayed bleeding requiring hemostasis occurred significantly less commonly after cold snare polypectomy than conventional polypectomy despite continuation of anticoagulants. Cold snare polypectomy is preferred for removal of small colorectal polyps in anticoagulated patients. ( CLINICAL TRIAL REGISTRATION NUMBER NCT 01553565.).
Collapse
Affiliation(s)
- Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Yoshiko Nakayama
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan; Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masashi Kajiyama
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Naoki Tanaka
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Kenji Sano
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - David Y Graham
- Deparment of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
21
|
Kim HG, Friedland S. Safe and effective colon polypectomy in patients receiving uninterrupted anticoagulation: can we do it? Gastrointest Endosc 2014; 79:424-6. [PMID: 24528826 DOI: 10.1016/j.gie.2013.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 10/02/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Hyun Gun Kim
- Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Shai Friedland
- Department of Gastroenterology, Stanford University School of Medicine and VA Palo Alto HCS, Stanford, California, USA
| |
Collapse
|
22
|
Baron TH, Kamath PS, McBane RD. New anticoagulant and antiplatelet agents: a primer for the gastroenterologist. Clin Gastroenterol Hepatol 2014; 12:187-95. [PMID: 23735447 DOI: 10.1016/j.cgh.2013.05.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 02/07/2023]
Abstract
A large number of patients worldwide receive anticoagulant and antiplatelet agents, collectively known as antithrombotic agents. Several new anticoagulants and antiplatelet agents recently were approved for use. Gastroenterologists may be unfamiliar with the mechanism of action, indications for use, and pharmacokinetics of these newer drugs. In patients undergoing elective and urgent endoscopic procedures, clinicians must be familiar with these medications to optimize outcomes. When the decision is made to continue the newer antithrombotic agents for elective procedures, the clinician must understand the risk that these agents may impart on procedural-induced bleeding. Finally, it is important to understand how to manage these agents in the presence of acute gastrointestinal bleeding. In this article the use of newer antithrombotic agents is reviewed.
Collapse
Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Robert D McBane
- Division of Cardiovascular Diseases, Division of Hematology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
23
|
Saito Y, Yamada M, So E, Abe S, Sakamoto T, Nakajima T, Otake Y, Ono A, Matsuda T. Colorectal endoscopic submucosal dissection: Technical advantages compared to endoscopic mucosal resection and minimally invasive surgery. Dig Endosc 2014; 26 Suppl 1:52-61. [PMID: 24191896 DOI: 10.1111/den.12196] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 09/25/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In recent years, the effectiveness of colorectal endoscopic submucosal dissection (ESD) has been increasingly reported. Herein, we highlight the most recent developments and technical advantages of colorectal ESD compared to EMR and minimally invasive surgery. METHODS All candidate lesions for ESD were confirmed as being intramucosal tumors by colonoscopy. Presently, the indications for colorectal ESD approved by the Japanese government's medical insurance system are early colorectal cancers with a maximum tumor size of 2-5 cm; however, many early cancers >5 cm have been treated by ESD in referral centers. RESULTS The primary advantage of ESD compared to endoscopic mucosal resection (EMR) is a higher en-bloc resection rate for large colonic tumors that had previously been treated by surgery. ESD has several advantages compared to other therapeutic modalities, such as being a safer technique and providing better quality of life. For rectal cancer treatment, a longer procedure time is required for laparoscopic assisted colectomy, whereas trans-anal resection and trans-anal endoscopic microsurgery are more invasive than ESD with a significantly higher recurrence rate. Accordingly, ESD is the preferred choice for early colorectal cancers when there is no risk of lymph-node metastasis. CONCLUSION ESD is an effective procedure for treating non-invasive non-polypoid colorectal tumors. These tumors may be difficult to resect en bloc by conventional EMR. The use of ESD results in a higher en-bloc resection rate and is less invasive than surgery.
Collapse
Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Carter D, Beer-Gabel M, Eliakim R, Novis B, Avidan B, Bardan E. Management of antithrombotic agents for colonoscopic polypectomies in Israeli gastroenterologists relative to published guidelines. Clin Res Hepatol Gastroenterol 2013; 37:514-8. [PMID: 23702477 DOI: 10.1016/j.clinre.2013.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 03/20/2013] [Accepted: 03/27/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic procedures are commonly performed in patients taking antithrombotic agents. OBJECTIVE To examine the correlation between the management of antithrombotic drugs for colonoscopic polypectomies and the published guidelines. DESIGN AND SETTINGS A structured survey delivered to gastroenterologists in 15 major Israeli hospitals and three central HMO clinics. RESULTS We collected 100 filled out surveys. Polypectomies on aspirin were performed by 78%. Most physicians did not perform polypectomies on clopidogrel. None of the physicians performed polypectomies on warfarin. Cessation of aspirin for ≥ 3 days post-polypectomy was recommended by 60%. Renewal of LMWH or warfarin was recommended ≥ 2 days post-polepectomy in 91% and 71%, respectively. The greatest variation in recommendations was found for clopidogrel, where the majority of gastroenterologists advised renewal after 1-2 days (38%). Years in practice and increasing colonoscopy volume work had no significant association with management of antithrombotic agents. Working in a HMO clinic was associated with lower rates of polypectomies on aspirin (P=0.036). DISCUSSION When the guidelines are clear, most gastroenterologists practice according to the existing recommendation. However, lack of prospective studies limits the ability to publish evidence-based recommendation and guidelines. We found that the practice of our cohort study varies in these situations.
Collapse
Affiliation(s)
- Dan Carter
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | | | | | |
Collapse
|
25
|
Birnie DH, Healey JS, Wells GA, Verma A, Tang AS, Krahn AD, Simpson CS, Ayala-Paredes F, Coutu B, Leiria TLL, Essebag V. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368:2084-93. [PMID: 23659733 DOI: 10.1056/nejmoa1302946] [Citation(s) in RCA: 382] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many patients requiring pacemaker or implantable cardioverter-defibrillator (ICD) surgery are taking warfarin. For patients at high risk for thromboembolic events, guidelines recommend bridging therapy with heparin; however, case series suggest that it may be safe to perform surgery without interrupting warfarin treatment. There have been few results from clinical trials to support the safety and efficacy of this approach. METHODS We randomly assigned patients with an annual risk of thromboembolic events of 5% or more to continued warfarin treatment or to bridging therapy with heparin. The primary outcome was clinically significant device-pocket hematoma, which was defined as device-pocket hematoma that necessitated prolonged hospitalization, interruption of anticoagulation therapy, or further surgery (e.g., hematoma evacuation). RESULTS The data and safety monitoring board recommended termination of the trial after the second prespecified interim analysis. Clinically significant device-pocket hematoma occurred in 12 of 343 patients (3.5%) in the continued-warfarin group, as compared with 54 of 338 (16.0%) in the heparin-bridging group (relative risk, 0.19; 95% confidence interval, 0.10 to 0.36; P<0.001). Major surgical and thromboembolic complications were rare and did not differ significantly between the study groups. They included one episode of cardiac tamponade and one myocardial infarction in the heparin-bridging group and one stroke and one transient ischemic attack in the continued-warfarin group. CONCLUSIONS As compared with bridging therapy with heparin, a strategy of continued warfarin treatment at the time of pacemaker or ICD surgery markedly reduced the incidence of clinically significant device-pocket hematoma. (Funded by the Canadian Institutes of Health Research and the Ministry of Health and Long-Term Care of Ontario; BRUISE CONTROL ClinicalTrials.gov number, NCT00800137.).
Collapse
Affiliation(s)
- David H Birnie
- University of Ottawa Heart Institute, Ottawa, ON, Canada.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Davis A, Walsh M, McCarthy P, Brown G, Roberts S, Tran H, Street A, Fong CY, Kemp W. Tranexamic acid without prophylactic factor replacement for prevention of bleeding in hereditary bleeding disorder patients undergoing endoscopy: a pilot study. Haemophilia 2013; 19:583-9. [DOI: 10.1111/hae.12146] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2013] [Indexed: 11/30/2022]
Affiliation(s)
- A. Davis
- Ronald Sawers Haemophilia Centre; The Alfred; Melbourne; Vic.; Australia
| | - M. Walsh
- Ronald Sawers Haemophilia Centre; The Alfred; Melbourne; Vic.; Australia
| | - P. McCarthy
- Ronald Sawers Haemophilia Centre; The Alfred; Melbourne; Vic.; Australia
| | - G. Brown
- Department of Gastroenterology; The Alfred; Melbourne; Vic.; Australia
| | - S. Roberts
- Department of Gastroenterology; The Alfred; Melbourne; Vic.; Australia
| | - H. Tran
- Ronald Sawers Haemophilia Centre; The Alfred; Melbourne; Vic.; Australia
| | - A. Street
- Ronald Sawers Haemophilia Centre; The Alfred; Melbourne; Vic.; Australia
| | - C. Y. Fong
- Ronald Sawers Haemophilia Centre; The Alfred; Melbourne; Vic.; Australia
| | - W. Kemp
- Department of Gastroenterology; The Alfred; Melbourne; Vic.; Australia
| |
Collapse
|
27
|
Saito Y, Otake Y, Sakamoto T, Nakajima T, Yamada M, Haruyama S, So E, Abe S, Matsuda T. Indications for and technical aspects of colorectal endoscopic submucosal dissection. Gut Liver 2013; 7:263-9. [PMID: 23710305 PMCID: PMC3661956 DOI: 10.5009/gnl.2013.7.3.263] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 10/08/2012] [Accepted: 10/08/2012] [Indexed: 12/15/2022] Open
Abstract
Due to the widespread acceptance of gastric and esophageal endoscopic submucosal dissections (ESDs), the number of medical facilities that perform colorectal ESDs has grown and the effectiveness of colorectal ESD has been increasingly reported in recent years. The clinical indications for colorectal ESD at the National Cancer Center Hospital, Tokyo, Japan include laterally spreading tumor (LST) nongranular type lesions >20 mm and LST granular type lesions >30 mm. In addition, 0-IIc lesions >20 mm, intramucosal tumors with nonlifting signs and large sessile lesions, all of which are difficult to resect en bloc by conventional endoscopic mucosal resection (EMR), represent potential candidates for colorectal ESD. Rectal carcinoid tumors less than 1 cm in diameter can be treated simply, safely, and effectively by endoscopic submucosal resection using a ligation device and are therefore not indications for ESD. The en bloc resection rate was 90%, and the curative resection rate was 87% for 806 ESDs. The median procedure time was 60 minutes, and the mean size for resected specimens was 40 mm (range, 15 to 150 mm). Perforations occurred in 23 (2.8%) cases, and postoperative bleeding occurred in 15 (1.9%) cases, but only two perforation cases required emergency surgery (0.25%). ESD was an effective procedure for treating colorectal tumors that are difficult to resect en bloc by conventional EMR. ESD resulted in a higher en bloc resection rate as well as decreased invasiveness in comparison to surgery. Based on the excellent clinical results of colorectal ESDs in Japan, the Japanese healthcare insurance system has approved colorectal ESD for coverage.
Collapse
Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Carter D, Beer-Gabel M, Zbar A, Avidan B, Bardan E. A survey of colonoscopic polypectomy practice amongst Israeli gastroenterologists. Ann Gastroenterol 2013; 26:135-140. [PMID: 24714780 PMCID: PMC3959924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 12/23/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Polypectomy techniques have been implicated as factors in the effectiveness of polyp resection. The range of polypectomy practices among gastroenterologists in Israel is unknown. METHODS A structured survey was sent to all Israeli gastroenterology departments in all 15 major academic hospitals and to 3 central outpatient clinics. RESULTS The survey was completed by 100 clinicians (45% contacted) derived from 13 of 15 academic centers (85%) and from all 3 outpatient clinics. Significant differences were noted in the preferred polypectomy for the resection of polyps 1-3 mm and 7-9 mm in diameter whereas for those polyps 4-6 mm in diameter, both the hot forceps and hot snare were most commonly used technique. Coagulation was employed in 42% of cases, pure cutting in 20% and blend current in 38% of cases. Narrow band imaging was used by 54% of practitioners, and only 33% of gastroenterologists regularly used dye spraying techniques. When removing pedunculated polyps >1 cm in diameter, 75% did not use any specific measures designed to prevent perforation or hemorrhage. Performance of >300 colonoscopies per year was associated with a greater use of dye spraying techniques and working in a hospital was more likely to be accompanied by clip deployment to larger polypectomy stalks as part of the procedure. CONCLUSION Our results demonstrate considerable heterogeneity in the techniques used for removal of polyps <1 cm. Most practitioners do not regularly use advanced techniques for polyp detection or for the prevention of post-polypectomy bleeding.
Collapse
Affiliation(s)
- Dan Carter
- Departments of Gastroenterology (Dan Carter, Marc Beer-Gabel, Benjamin Avidan, Eytan Bardan),
Correspondence to: Dan Carter, Gastroenterology Department, Sheba Medical Center, Ramat Gan, Israel and Tel Aviv University, Tel Aviv, Israel, Tel.: +972 3 530 2197, Fax: +972 3 530 3160, e-mail:
| | - Marc Beer-Gabel
- Departments of Gastroenterology (Dan Carter, Marc Beer-Gabel, Benjamin Avidan, Eytan Bardan)
| | - Andrew Zbar
- Surgery (Andrew Zbar), Sheba Medical Center, Ramat Gan, Israel and Tel Aviv University, Tel Aviv, Israel
| | - Benjamin Avidan
- Departments of Gastroenterology (Dan Carter, Marc Beer-Gabel, Benjamin Avidan, Eytan Bardan)
| | - Eytan Bardan
- Departments of Gastroenterology (Dan Carter, Marc Beer-Gabel, Benjamin Avidan, Eytan Bardan)
| |
Collapse
|
29
|
Endoscopy in the patient on antithrombotic therapy. Curr Opin Gastroenterol 2012; 28:432-41. [PMID: 22885943 DOI: 10.1097/mog.0b013e328355e26f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW The management of antithrombotics during the periendoscopic period is a common clinical problem. This review focuses on recent literature addressing this issue, primarily on articles published from 2009 to 2012. RECENT FINDINGS A large proportion of the studies retrieved focused on the effect of antithrombotics on bleeding risk following diagnostic endoscopy, polypectomy, endoscopic mucosal resection, and submucosal dissection, whereas studies involving other endoscopic procedures were scarce. Recent American and European guidelines direct the management of antithrombotic therapy in patients undergoing endoscopy according to the procedure's risk of bleeding and the patient's thromboembolic risk. The difficulty in determining a priori the need for endotherapy and hence appropriate classification of risk of bleeding prior to the procedure is a potential limitation of such classification. Moreover, most studies have primarily addressed the risk of immediate or early bleeding by proposing interruption of antithrombotic therapy prior to endotherapy, and few have focused on the risk of delayed bleeding and the optimal time for resumption of these agents following high-risk procedures. SUMMARY Management of patients on antithrombotics remains complex, especially in high-risk settings. Existing guidelines are valuable but should not be a substitute for a careful personalized risk assessment strategy involving patient and physician.
Collapse
|
30
|
Postpolypectomy bleeding: incidence, risk factors, prevention, and management. Surg Laparosc Endosc Percutan Tech 2012; 22:102-7. [PMID: 22487620 DOI: 10.1097/sle.0b013e318247c02e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.
Collapse
|
31
|
Petrini JL. Between Scylla and Charybdis: high-risk endoscopic procedures and anticoagulant therapy. Gastrointest Endosc 2012; 75:728-30. [PMID: 22440201 DOI: 10.1016/j.gie.2012.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/03/2012] [Indexed: 02/08/2023]
|
32
|
Richter JA, Patrie JT, Richter RP, Henry ZH, Pop GH, Regan KA, Peura DA, Sawyer RG, Northup PG, Wang AY. Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel. Gastrointest Endosc 2011; 74:22-34.e1. [PMID: 21704806 DOI: 10.1016/j.gie.2011.03.1258] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding. OBJECTIVE To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement. DESIGN Retrospective cohort study. SETTING Large quaternary-care academic medical center. PATIENTS A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009. INTERVENTIONS PEG tube placement. MAIN OUTCOME MEASUREMENTS GI bleeding. RESULTS Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04). LIMITATIONS Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients. CONCLUSIONS Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.
Collapse
|
33
|
Khubchandani IT, Heyrosa MG, Thekkeurumbil SV. Optimal timing of anticoagulation pre- and post-colonoscopy with polypectomy. Tech Coloproctol 2011; 15:185-9. [DOI: 10.1007/s10151-010-0668-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 12/13/2010] [Indexed: 01/14/2023]
|
34
|
Abstract
Polypectomy of colonic polyps has been shown to reduce the risk of colon cancer development and is considered a fundamental skill for all endoscopists who perform colonoscopy. A variety of polypectomy techniques and devices are available, and their use can vary greatly based on local availability and preferences. In general, cold forceps and cold snare have been the polypectomy methods of choice for smaller polyps, and hot snare has been the method of choice for larger polyps. The use of hot forceps has mostly fallen out of favor. Polypectomy for difficult to remove polyps may require the use of special devices and advanced techniques and has continued to evolve. As a result, the vast majority of polyps today can be removed endoscopically. Since electrocautery is frequently used for polypectomy, endoscopists should be thoroughly familiar with the basic principles of electrosurgery as it pertains to polypectomy. Tattooing of a polypectomy site is an important adjunct to polypectomy and can greatly facilitate future surgery or endoscopic surveillance. The two most common post-polypectomy complications are bleeding and perforation. Their incidence can be decreased with the use of meticulous polypectomy techniques and the application of some prophylactic maneuvers. This review will examine the technique of polypectomy and its complications from the perspective of the practicing gastroenterologist.
Collapse
|
35
|
Kaltenbach T, Soetikno R. Endoscopic mucosal resection of non-polypoid colorectal neoplasm. Gastrointest Endosc Clin N Am 2010; 20:503-14. [PMID: 20656248 DOI: 10.1016/j.giec.2010.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic mucosal resection (EMR) is preferred to standard polypectomy for the resection of non-polypoid lesions because these lesions can be technically difficult to capture with a snare; furthermore, without submucosal injection the underlying muscularis propria may be excessively coagulated or even inadvertently resected. Because the resection plane of EMR is in the middle or deeper part of the submucosa, EMR allows the precise depth of the lesion to be evaluated. Although the majority of non-polypoid lesions are adenomatous, non-polypoid colorectal neoplasm has a high association with advanced pathology, irrespective of size. Using EMR, a complete pathologic specimen is obtained, the risk of lymph node metastasis can be accurately assessed based on the depth of invasion, and patients can be suitably managed. Used according to its indications, EMR provides curative resection, and obviates the higher morbidity, mortality, and cost associated with surgical treatment.
Collapse
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA.
| | | |
Collapse
|
36
|
Saito Y, Matsuda T, Fujii T. Endoscopic submucosal dissection of non-polypoid colorectal neoplasms. Gastrointest Endosc Clin N Am 2010; 20:515-24. [PMID: 20656249 DOI: 10.1016/j.giec.2010.03.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Traditionally, endoscopic mucosal resection and surgery were the only available treatments for large colorectal tumors, even for those detected at an early stage. The endoscopic submucosal dissection (ESD) technique, which enables en-bloc resection of large tumors, is accepted as a standard minimally invasive treatment for early gastric cancer in Japan. This article explains in detail how ESD is performed and compares it with endoscopic mucosal resection.
Collapse
Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
| | | | | |
Collapse
|
37
|
Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060-70. [PMID: 19889407 DOI: 10.1016/j.gie.2009.09.040] [Citation(s) in RCA: 339] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 09/29/2009] [Indexed: 02/06/2023]
|