Incidence Of Postpolypectomy Bleeding Research Articles

Colonoscopic post-polypectomy bleeding in patients on uninterruptedclopidogrel therapy: A systematic review and meta-analysis.

Current guidelines recommend temporary cessation of clopidogrel for 7-10 days for patients on clopidogrel undergoing colonoscopy with polypectomy. However, recent prospective randomized controlled trials have advocated for uninterrupted clopidogrel, due to similar post-polypectomy bleeding (PPB) rates with and without continued clopidogrel therapy. Thus, a meta-analysis was conducted to assess the risk of PPB rate in patients on continued clopidogrel therapy. Systemically identified publications were used to compare the rate of PPB in patients on continued clopidogrel therapy with those who had interrupted clopidogrel therapy. The primary outcome was the incidence of PPB. The secondary outcomes were immediate PPB, delayed PPB and serious cardio-thrombotic events. This study has been registered in PROSPERO (no. CRD42018118325). A total of five studies were identified, which included 655 patients in the continued clopidogrel group and 6620 patients in the control group. There was an increased risk of PPB with continued clopidogrel [P=0.0003; risk ratio (RR), 1.96; 95% confidence interval (CI), 1.36-2.83). The rate of immediate PPB was slightly higher in the continued clopidogrel group (5.77% vs. 1.77%, respectively), but was not statistically significant (P=0.06; RR, 1.57; 95%CI, 0.98-2.51). The rate of delayed PPB was increased in the continued clopidogrel group (P=0.0008; RR, 3.10; 95%CI, 1.60-5.98). However, no significant difference in serious cardio-thrombotic events was observed within 30 days (P=0.74; RR, 0.78; 95%CI, 0.18-3.40). Although continued clopidogrel therapy decreased the incidence of serious cardio-thrombotic events, the risk of delayed PPB was increased. Therefore, endoscopists should make all preparations to prevent bleeding in the perioperative period for patients at high thrombotic risk and on continued clopidogrel therapy, if polypectomy cannot be reasonably postponed.

Post-polypectomy bleeding in hot-snare polypectomy of colonic polyps under continued warfarin or short interruption of direct oral anticoagulants.

Newly published guidelines of the Japanese Gastroenterological Endoscopy Society (JGES) suggest to consider endoscopic procedures with high risk of bleeding without stopping warfarin and with stopping direct oral anticoagulants (DOACs) only on the day of the procedure. In this study, we aimed to test the validity of these recommendations. We retrospectively reviewed medical records of 344 patients with anticoagulant therapy who underwent hot-snare polypectomy between January 2012 and October 2018. Patients (n= 132) with interruption of anticoagulants (3-7days for warfarin and 2-3days for DOACs before the procedure) and without heparin-bridging were excluded. Among the remaining 212 patients, the incidence of post-polypectomy bleeding was compared between the following 2 patient groups: patients who had interruption of anticoagulants with heparin-bridging (HB group, n= 139) and patients treated according to the new JGES guideline (FG group, n= 73). The rate of post-polypectomy bleeding (PPB) in FG group (9.6%) was not significantly different from that in HB group (12.9%, p = 0.5). In subgroup analysis, the incidence of bleeding in patients with warfarin (12.2%) and with DOAC (6.3%) in FG group was not significantly different from corresponding figures in HB group (14.2%, 0%). In multivariate analysis, number of resected polyps was associated with PPB, but the administration of anticoagulants according to the new guidelines was not a significant risk factor for PPB (p= .98). Our study affirms the recommendations of JGES for the management of anticoagulants in patients who undergo colonic polypectomy regarding post-polypectomy bleeding.

Heparin-bridging therapy is associated with post-colorectal polypectomy bleeding in patients whose oral anticoagulation therapy is interrupted

Objectives: The American and Japanese Societies for Gastrointestinal Endoscopy Guidelines recommend heparin-bridging therapy for patients whose oral anticoagulants are interrupted for endoscopic procedures. However, little is known about the potential association between heparin-bridging therapy and post-polypectomy bleeding (PPB). The aim was to investigate the incidence of PPB associated with heparin-bridging therapy administered to patients whose anticoagulants were interrupted.Materials and methods: This was a retrospective observational study using inverse propensity analysis. Between 2013 and 2015, 1004 patients with 2863 lesions were included. The primary outcomes were the rates of PPB and thromboembolism associated with heparin-bridging therapy. The risk factors associated with PPB were identified using multivariate logistic regression analysis involving probability of treatment weighting (IPTW).Results: The patients were categorized into a heparin-bridging therapy group (78 patients with 255 lesions) or a control group (926 patients with 2608 lesions). The PPB rate in the heparin-bridging therapy group (10.2%, 8/78) was significantly higher than in the control group (1.1%, 11/926) (p <.01). Thromboembolism occurred in one patient in the control group. The multivariate analysis revealed that heparin-bridging therapy was an independent risk factor associated with PPB (odds ratio [OR], 8.21; 95% confidence interval [95% CI], 2.32–29.10; p <.01). IPTW showed heparin-bridging therapy increased PPB (OR, 7.68; 95% CI, 1.83–32.28; p <.01).Conclusions: Heparin-bridging therapy administered to patients whose oral anticoagulants were interrupted was associated with an increased PPB risk.

Validation of treatment algorithm based on the Japan narrow-band imaging expert team classification for sub-centimeter colorectal polyps.

Background and study aims Although cold polypectomy (CP) is widely used for colorectal polyps < 10 mm, appropriateness of indications for CP or endoscopic mucosal resection (EMR) are still unclear. The aim of this study was to validate the endoscopic treatment algorithm based on the Japan NBI Expert Team (JNET) classification. Patients and methods Consecutive patients with at least one colorectal non-pedunculated polyp < 10 mm between July 2014 and October 2016 were included in this retrospective study. During the period, EMR was performed for JNET ≥ 2B lesions and CP for JNET < 2A. Among a total of 3966 lesions, 3368 lesions with JNET ≤ 2A were resected by CP in compliance with the treatment algorithm but 565 resections for JNET ≤ 2A were not compliant (by EMR), while all 24 JNET > 2B lesions were removed by EMR in compliance with the algorithm. Polypectomy outcomes were compared between the compliant and non-compliant groups. Histological outcomes were analyzed in accordance with JNET classification. Results Post-polypectomy bleeding rate in the compliant group (0 %) was lower than that in the non-compliant group (0.53 %, P < 0.01). Proportion of lesions diagnosed as cancer (38 % vs 0.36 %, P < 0.01) or submucosal cancer (4.2 % vs 0.03 %, P = 0.012), and the lesion with free resection margin (91 % vs 64 %, P < 0.01) was higher in the JNET ≥ 2B than JNET ≤ 2A. Conclusion This study indicated our algorithm would be valid: CP is suitable for most polyps < 10 mm as incidence of post-polypectomy bleeding is low, whereas EMR is recommended for JNET ≥ 2B lesions for histological complete removal.

Heparin-bridging therapy is associated with a high risk of post-polypectomy bleeding regardless of polyp size.

Evidence regarding safety and efficacy of heparin-bridging therapy for colonoscopic polypectomy remains scarce. The aim of the present study was to evaluate the risk of post-polypectomy bleeding (PPB) in patients receiving heparin-bridging therapy. We retrospectively reviewed the database of patients who underwent colonoscopic polypectomy with prophylactic clip closure between January 2007 and December 2014 at our institution. We evaluated patients receiving heparin-bridging therapy (HB group) compared with those who did not receive antithrombotic therapy (No-HB group). A total of 1421 polypectomies were carried out on 773 patients; 45 patients were in the HB group and 728 patients were in the No-HB group. The incidence of PPB per patient was significantly higher in the HB group (22.2% vs 1.9%, P<0.0001), and multivariate analysis showed that heparin-bridging therapy was an independent risk factor for PPB (OR 9.80, 95% CI 4.23-22.3, P<0.0001). In the HB group, the polyp size was not a risk factor for PPB (OR 0.67, 95% CI 0.19-2.26, P=0.55); the incidence of PPB in lesions of <10mm and ≥10mm in size was 14.6% and 10.2% respectively. In contrast, that was a significant risk factor in the No-HB group (OR 4.71, 95% CI 1.41-21.3, P=0.011). Activated partial thromboplastin time and international normalized ratio were in or under the therapeutic range in the HB group when PPB occurred. Heparin-bridging therapy is associated with a high risk of PPB regardless of polyp size.

Prediction and prevention of postpolypectomy bleeding: current challenging issues.

See Article on Page 182-185 The colonoscopic polypectomy is at the forefront in reducing the incidence of colorectal cancer. However, the endoscopic polypectomy has been reported to be accompanied by risks of complications. Postpolypectomy bleeding (PPB) is the most common complication, with an incidence ranging from 0.6% to 8% in large series [1, 2, 3]. The incidence of PPB has been reported to depend on its definition: early, delayed, and overall [4]. Many factors are associated with an increased risk for PPB and can be categorized into patient-, polyp-, and procedure-related factors. Patient-related factors include the use of an anticoagulant agent and various host comorbidities such as hypertension, severe pulmonary disease, and chronic renal failure. Recently, as more individuals are taking anticoagulant or antiplatelet agents such as warfarin, clopidogrel, aspirin, and nonsteroidal anti-inflammatory drugs, preventing PPB in these patients has become one of challenging issues in a colonoscopic polypectomy. A large retrospective cohort study reported warfarin therapy to be an independent predictor of PPB (adjusted odds ratio, 11.6; 95% confidence interval, 2.3-57.3) and suggested that additional methods to reduce the likelihood of PPB in anticoagulated patients should be investigated [5]. However, warfarin interruption for a colonoscopy also has an increased risk of a thromboembolic event. Garcia et al. [6] reported thromboembolic events in 0.7% of 1,293 patients with warfarin interruptions, and Blacker et al. [7] reported that strokes occurred in 1% of 987 patients with atrial fibrillation after temporary anticoagulation discontinuation. Until now, 2014.30.4.157whether antiplatelet agents such as aspirin increase the risk of PPB has been debatable [4]. Among polyp-related factors associated with PPB, the size of the polyp, as Moon et al. [8] showed in his retrospective study of the current issue, seems to have the most data supporting it. Polyps larger than 10 mm have been reported to have a 2- to 4.5-times increased risk of PPB [3, 9]. Several colonoscopic procedures, such as injection of an epinephrine solution, endoloops, hemoclips, and argon plasma coagulation, have been proposed for the prevention of PPB. A few randomized studies comparing these methods have been reported [10, 11, 12, 13, 14]. Each method has its own efficacy and its own advantages in reducing the risk of PPB; however, none of these methods is totally superior to the others. Kapetanos et al. [4] summarized the key points from these randomized studies as follows: (1) The injection of saline-epinephrine solution at the base of the polyp can prevent early, but not delayed, bleeding. (2) Loop placement can prevent bleeding but, especially in large (>2 cm) polyps, this effect is restricted to early bleeding. (3) Clips may also prevent hemorrhage, but this has not been proven in a randomized trial. (4) Combination techniques may be more effective than a single technique. Although the overall incidence of PPB is rare, neglecting a meticulous precolonoscopy evaluation of patients to predict the risk factors of PPB and decrease the frequency of this complication cannot be justified. Appropriate use of various methods of PPB prophylaxis can help in reducing the risk of PPB, but more controlled data seem to be needed to clarify the roles of these methods.

Clinical features of post‐polypectomy bleeding associated with heparin bridge therapy

Heparin is given to patients undergoing colonoscopic polypectomy at high risk for thromboembolism. Little is known, however, about how heparin bridge therapy (HB) affects post-polypectomy bleeding (PPB). The present study aimed to identify the clinical features of PPB associated with HB. Data of consecutive inpatients who underwent colonoscopic polypectomy with antithrombotic therapy at Osaka University Hospital were retrospectively collected and categorized into a HB group or a non-HB group. The incidence and characteristics of PPB were analyzed. A total of 117 patients with 279 lesions were identified, and the HB group included 45 patients. Nine of 10 patients with PPB were in the HB group, and the incidence of PPB was significantly higher in the HB group than in the non-HB group (20.0% vs 1.4%, respectively). PPB onset was later in the HB group than inthe non-HB group (median postoperative day: 4 vs 1, respectively). Five of the nine patients with PPB (55.6%) in the HB group experienced recurrent bleeding. One patient in the HB group required a blood transfusion as a result of massive PPB. All bleeding was eventually controlled endoscopically. Hospitalization was significantly longer in the HB group than in the non-HB group (median hospitalization: 14 vs 4 days, respectively). The univariate analysis showed that the predictors of PPB were warfarin use, HB and pedunculated polyps. PPB associated with HB is characterized by high incidence, late onset and recurrent bleeding, resulting in long hospitalization.

Postpolypectomy Bleeding

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.