Colorectal endoscopic mucosal resection with submucosal injection of epinephrine versus hypertonic saline in patients taking antithrombotic agents: propensity-score-matching analysis

Daisuke Yamaguchi,Takahiro Yukimoto,Tomohito Morisaki,Amane Jubashi,Naoyuki Tominaga,Wataru Yoshioka,Kazuma Fujimoto,Hisako Yoshida,Shota Yamashita,Hiroko Fukuda,Eri Takeshita,Nanae Tsuruoka,Yuki Takeuchi,Kei Ikeda,Seiji Tsunada,Keisuke Ario

doi:10.1186/s12876-019-1114-x

Abstract

BackgroundEndoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents. The safety of EMR with submucosal saline injection has not been clearly demonstrated in this population.AimsThe present study aimed to evaluate the efficacy and safety of submucosal injection of saline–epinephrine versus hypertonic saline in colorectal EMR of patients taking antithrombotic agents.MethodsThis study enrolled 204 patients taking antithrombotic agents among 995 consecutive patients who underwent colonic EMR from April 2012 to March 2018 at Ureshino Medical Center. Patients were divided into two groups according to the injected solution: saline–epinephrine or hypertonic (10%) saline (n = 102 in each group). Treatment outcomes and adverse events were evaluated in each group and risk factors for immediate and post-EMR bleeding were investigated.ResultsThere were no differences between groups in patient or polyp characteristics. The main antithrombotic agents were low-dose aspirin, warfarin, and clopidogrel. Propensity-score matching created 80 matched pairs. Adjusted comparisons between groups showed similar en bloc resection rates (95.1% with saline–epinephrine vs. 98.0% with hypertonic saline). There were no significant differences in adverse events (immediate EMR bleeding, post-EMR bleeding, perforation, or mortality) between groups. Multivariate analyses revealed that polyp size over 10 mm was associated with an increased risk of immediate EMR bleeding (odds ratio 12.1, 95% confidence interval 2.0–74.0; P = 0.001).ConclusionsTwo tested solutions in colorectal EMR were considered to be both safe and effective in patients taking antithrombotic agents.

Highlights

Endoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents
Several clinical practice guidelines on gastrointestinal endoscopic procedures published in Europe, North America, Japan, and the Asia Pacific recommend that antithrombotic agents, especially aspirin, be continued during colonoscopic polypectomy
EMR procedures were performed by trainees more frequently in Group A than in Group B (72/102 vs. 50/102, respectively; P = 0.003)

Summary

Introduction

Endoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents. EMR with submucosal injection of epinephrine–saline or hypertonic saline solution enhances complete resection of lesions compared with simple polypectomy [17–20)]. Both epinephrine solution and hypertonic saline have hemostatic effects that can prevent post-EMR bleeding, the efficacy of these two solutions in decreasing post-EMR bleeding in patients taking antithrombotic agents has not been clearly demonstrated [21–25)]. Several clinical practice guidelines on gastrointestinal endoscopic procedures published in Europe, North America, Japan, and the Asia Pacific recommend that antithrombotic agents, especially aspirin, be continued during colonoscopic polypectomy These clinical guidelines recommend that anticoagulants be discontinued during colorectal polypectomy in patients with low thromboembolic risks and be replaced with heparin for those with high thromboembolic risks [33–37)]. Several studies demonstrated that heparin replacement increased post-polypectomy and/or post-

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