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Safety of Cold Snare Polypectomy in Patients Receiving Treatment with Antithrombotic Agents

  • Jun Arimoto
  • Hideyuki ChibaEmail author
  • Keiichi Ashikari
  • Ryo Fukui
  • Hideyuki Anan
  • Jun Tachikawa
  • Takuma Suto
  • Naoya Kawano
  • Toshihiro Niikura
  • Hiroki Kuwabara
  • Michiko Nakaoka
  • Shingo Kato
  • Tomonori Ida
  • Taiki Morohashi
  • Tohru Goto
  • Atsushi Nakajima
Original Article
  • 24 Downloads

Abstract

Background

With the aging of the population and rising incidence of thromboembolic events, the clinical use of antithrombotic agents is also increasing. There are few reports yet on the management of antithrombotic agent use in patients undergoing cold snare polypectomy (CSP).

Aims

The aim of this study was to evaluate whether continued administration of antithrombotic agents in patients undergoing CSP would be associated with an increased rate of delayed post-polypectomy bleeding (DPPB).

Methods

A total of 1177 colorectal polyps in 501 patients were resected at Omori Red Cross Hospital between October 2017 and March 2018. The polyps were divided into two groups depending on whether the patients received antithrombotic agent treatment or not: the antithrombotic group (911 polyps) and the no-antithrombotic group (266 polyps).

Results

Among the 1177 polyp resections, there was no case of DPPB, including in the antithrombotic group. Immediate bleeding occurred in a total of 63 (5.4%) cases. Polyp location in the rectum (OR (95% CI) 2.64 (1.223–5.679); p = 0.013), polyp size ≥ 6 mm (OR (95% CI) 4.64 (2.719–7.933); p < 0.001), polypoid growth pattern (OR (95% CI) 2.78 (1.607–4.793); p < 0.001), and antithrombotic agent use (OR (95% CI) 2.98 (1.715–5.183); p < 0.001) were identified as significant risk factors of immediate bleeding.

Conclusions

Continued use of antithrombotic agents does not increase the risk of DPPB, even in those receiving multiple antithrombotic agents. Thus, it is safe to perform CSP even in multiple agent users. Prospective, randomized studies are necessary to confirm our results.

Keywords

Colorectal polyps Cold snare polypectomy Antithrombotic agent Delayed bleeding post-polypectomy 

Abbreviations

CRC

Colorectal cancer

HP

Hot polypectomy

EMR

Endoscopic mucosal resection

DPPB

Delayed post-polypectomy bleeding

CSP

Cold snare polypectomy

DOAC

Direct oral anticoagulants

PEG

Polyethylene glycol

SD

Standard deviation

OR

Odds ratio

95% CI

95% Confidence interval

Notes

Acknowledgments

The authors would like to thank the staff of the participating institutions for their support in recruiting eligible patients, and also the patients who participated in this study.

Author's contribution

JA, HC, SK, TG, and AN conceived of the study. JA, KA, HA, JT, TS, NK, TN, HK, MN, TI, and TM performed the CSP. JA and RF recruited the study participants. Analysis and interpretation of the data were conducted by JA and HC. All the authors have read the final manuscript and approve of its submission for publication.

Compliance with ethical standards

Conflicts of interest

No support from any organization was received for the submitted work; there were no financial relationships with any organizations that might have had an interest in the submitted work in the previous 3 years, and there are no other relationships or activities to declare that could have potentially influenced the outcomes of the submitted work. The authors have no conflicts of interests to disclose.

References

  1. 1.
    Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65:87–108.CrossRefGoogle Scholar
  2. 2.
    Anderson WF, Umar A, Brawley OW. Colorectal carcinoma in black and white race. Cancer Metastasis Rev. 2003;22:67–82.CrossRefGoogle Scholar
  3. 3.
    Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal-tumor development. N Engl J Med. 1988;319:525–532.CrossRefGoogle Scholar
  4. 4.
    Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366:687–696.CrossRefGoogle Scholar
  5. 5.
    Levin TR, Zhao W, Conell C, et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med. 2006;145:880–886.CrossRefGoogle Scholar
  6. 6.
    Watabe H, Yamaji Y, Okamoto M, et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc. 2006;64:73–78.CrossRefGoogle Scholar
  7. 7.
    Sonnenberg A. Management of delayed postpolypectomy bleeding: a decision analysis. Am J Gastroenterol. 2012;107:339–342.CrossRefGoogle Scholar
  8. 8.
    Choung BS, Kim SH, Ahn DS, et al. Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study. J Clin Gastroenterol. 2014;48:784–789.CrossRefGoogle Scholar
  9. 9.
    Ichise Y, Horiuchi A, Nakayama Y, et al. Prospective randomized comparison of cold snare polypectomy and conventional polypectomy for small colorectal polyps. Digestion. 2011;84:78–81.CrossRefGoogle Scholar
  10. 10.
    Fujiya M, Sato H, Ueno N, et al. Efficacy and adverse events of cold versus hot polypectomy: a meta-analysis. World J Gastroenterol. 2016;22:5436–5444.CrossRefGoogle Scholar
  11. 11.
    Aslan F, Camci M, Alper E, et al. Cold snare polypectomy versus hot snare polypectomy in endoscopic treatment of small polyps. Turk J Gastroenterol. 2014;25:279–283.CrossRefGoogle Scholar
  12. 12.
    Takeuchi Y, Yamashina T, Matsuura N, et al. Feasibility of cold snare polypectomy in Japan: a pilot study. World J Gastrointest Endosc. 2015;7:1250–1256.CrossRefGoogle Scholar
  13. 13.
    Paspatis GA, Tribonias G, Konstantinidis K, et al. A prospective randomized comparison of cold versus hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps. Colorectal Dis. 2011;13:345–348.CrossRefGoogle Scholar
  14. 14.
    Yamashina T, Fukuhara M, Maruo T, et al. Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis. Endosc Int Open. 2017;5:E587–E594.CrossRefGoogle Scholar
  15. 15.
    Mozaffarian D, Benjamin EJ, Go AS, et al. American Heart Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322.PubMedGoogle Scholar
  16. 16.
    Humbert X, Roule V, Chequel M, et al. Non-vitamin K oral anticoagulant treatment in elderly patients with atrial fibrillation and coronary heart disease. Int J Cardiol. 2016;222:1079–1083.CrossRefGoogle Scholar
  17. 17.
    Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol. 2009;104:3085–3097.CrossRefGoogle Scholar
  18. 18.
    Cho SJ, Choi I, Kim C, et al. Aspirin use and bleeding risk after endoscopic submucosal dissection in patients with gastric neoplasms. Endoscopy. 2012;44:114–121.CrossRefGoogle Scholar
  19. 19.
    Lim J, Kim S, Kim J, et al. Do antiplatelets increase the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms? Gastrointest Endosc. 2012;75:719–727.CrossRefGoogle Scholar
  20. 20.
    Arimoto J, Higurashi T, Chiba H, et al. Continued use of a single antiplatelet agent does not increase the risk of delayed bleeding after colorectal endoscopic submucosal dissection. Dig Dis Sci. 2018;63:218–227.  https://doi.org/10.1007/s10620-017-4843-0.CrossRefPubMedGoogle Scholar
  21. 21.
    Repici A, Hassan C, Vietta E, et al. Safety of cold polypectomy for < 10 mm polyps at colonoscopy: a prospective multicenter study. Endoscopy. 2012;44:27–31.CrossRefGoogle Scholar
  22. 22.
    Horiuchi A, Nakayama Y, Kajiyama M, et al. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastroinetest Endosc. 2014;79:417–423.CrossRefGoogle Scholar
  23. 23.
    Matsumoto M, Yoshii S, Shigesawa T, et al. Safety of cold polypectomy for colorectal polyps in patients on antithrombotic medication. Digestion. 2018;97:76–81.CrossRefGoogle Scholar
  24. 24.
    Participants in the Paris Workshop. The Paris endoscopic classification od superficial neoplastic lesions: esophagus, stomach, and colon-November 30 to December 1, 2002. Gastrointest Endosc. 2003;58:3–43.CrossRefGoogle Scholar
  25. 25.
    Tajiri H, Kitano S. Complication associated with endoscopic mucosal resection: definition of bleeding that can be viewed as accidental. Dig Endosc. 2004;16:S134–S136.CrossRefGoogle Scholar
  26. 26.
    Fujimoto K, Fujishiro M, Kato M, et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2014;26:1–14.CrossRefGoogle Scholar
  27. 27.
    ASGE standards of Practice Committee, Anderson MA, Ben-Menachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70:1060–1070.CrossRefGoogle Scholar
  28. 28.
    Sibon I, Orgogozo JM. Antiplatelet drug discontinuation is a risk factor for ischemic stroke. Neurology. 2004;62:1187–1189.CrossRefGoogle Scholar
  29. 29.
    Maulaz AB, Bezerra DC, Michel P, et al. Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol. 2005;62:1217–1220.CrossRefGoogle Scholar
  30. 30.
    Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med. 1998;158:1610–1616.CrossRefGoogle Scholar
  31. 31.
    Blacker DJ, Wijdicks EF, McClelland RL. Stroke risk in anticoagulated patients with atrial fibrillation undergoing endoscopy. Neurology. 2003;61:964–968.CrossRefGoogle Scholar
  32. 32.
    Palareti G, Legnani C, Guazzaloca G, et al. Activation of blood coagulation after abrupt or stepwise withdrawal of oral anticoagulants—a prospective study. Thromb Haemost. 1994;72:222–226.CrossRefGoogle Scholar
  33. 33.
    Oka S, Tanaka S, Kanao H, et al. Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan. Dig Endosc. 2010;22:376–380.CrossRefGoogle Scholar
  34. 34.
    Takayanagi D, Nemoto D, Isohata N, et al. Histological comparison of cold versus hot snare resection of the colorectal mucosa. Dis Colon Rectum. 2018;61:964–970.PubMedGoogle Scholar
  35. 35.
    Liaquat H, Rohn E, Rex DK. Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions. Gastrointest Endosc. 2013;77:401–407.CrossRefGoogle Scholar
  36. 36.
    Matsumoto M, Fukunaga S, Saito Y, et al. Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors. Jpn J Clin Oncol. 2012;42:1028–1034.CrossRefGoogle Scholar
  37. 37.
    Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc. 2003;57:691–694.CrossRefGoogle Scholar
  38. 38.
    Makino T, Horiuchi A, Kajiyama M, et al. Delayed bleeding following cold snare polypectomy for small colorectal polyps in patients taking antithrombotic agents. J Clin Gastroenterol. 2018;52:502–507.PubMedGoogle Scholar
  39. 39.
    Chiba H, Ohata K, Tachikawa J, et al. Delayed bleeding after colorectal endoscopic submucosal dissection: When is emergency colonoscopy needed? Dig Dis Sci. 2018.  https://doi.org/10.1007/s10620-018-5310-2.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Jun Arimoto
    • 1
  • Hideyuki Chiba
    • 1
    Email author
  • Keiichi Ashikari
    • 2
  • Ryo Fukui
    • 1
  • Hideyuki Anan
    • 1
  • Jun Tachikawa
    • 1
  • Takuma Suto
    • 1
  • Naoya Kawano
    • 1
  • Toshihiro Niikura
    • 1
  • Hiroki Kuwabara
    • 1
  • Michiko Nakaoka
    • 1
  • Shingo Kato
    • 2
  • Tomonori Ida
    • 1
  • Taiki Morohashi
    • 1
  • Tohru Goto
    • 1
  • Atsushi Nakajima
    • 2
  1. 1.Department of GastroenterologyOmori Red Cross HospitalTokyoJapan
  2. 2.Department of Gastroenterology and HepatologyYokohama City University School of MedicineYokohamaJapan

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