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Kobayashi T, Takeuchi M, Hojo Y, Ishii Y, Koseki Y, Kobayashi Y, Azumi M, Kobayashi Y, Kohisa J, Yoshikawa S, Terai S. Risk of delayed bleeding after hot snare polypectomy and endoscopic mucosal resection in the colorectum with continuation of anticoagulants. J Gastrointest Oncol 2021; 12:1518-1530. [PMID: 34532107 DOI: 10.21037/jgo-21-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background Current guidelines recommend the temporary discontinuation of anticoagulants before colonoscopic polypectomy, but the effect of this practice on reducing the risk of delayed bleeding after hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR) remains unclear. Our aim was to assess the impact of anticoagulants on the risk of colorectal delayed bleeding after HSP and EMR, and evaluate the necessity of drug withdrawal. Methods We reviewed the clinical data of patients with colorectal polyps using antithrombotic drugs who underwent HSP and/or EMR between January 2016 and September 2020 at Nagaoka Red Cross Hospital. After excluding antiplatelet users, patients were classified into those who continued anticoagulants [continuation group: 50 patients (93 lesions)] and those who discontinued anticoagulants [discontinuation group: 87 patients (190 lesions)]. Results Delayed bleeding occurred in 12 lesions, and there was no significant difference in the incidence rates between the continuation and the discontinuation groups (3.2% vs. 4.7%; P=0.756). Logistic regression analysis showed that continued use of anticoagulants was not a significant risk factor for delayed bleeding compared to anticoagulant discontinuation (odds ratio, 0.670; 95% CI, 0.177-2.537; P=0.556). There was no significant difference in the incidence rate and risk of delayed bleeding, regardless of the length of the anticoagulant withdrawal period. Conclusions Continued use of anticoagulants, compared to their discontinuation, did not increase the risk of colorectal delayed bleeding after HSP and EMR. Our results suggest that current guideline recommendations for anticoagulant withdrawal before colonoscopic polypectomy may be reconsidered. Trial Registration UMIN000040449.
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Affiliation(s)
- Takamasa Kobayashi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yuki Hojo
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yui Ishii
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Youhei Koseki
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yoko Kobayashi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Motoi Azumi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yuji Kobayashi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Junji Kohisa
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Seiichi Yoshikawa
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Inoue T, Ishihara R, Nishida T, Akasaka T, Hayashi Y, Nakamatsu D, Ogiyama H, Yamaguchi S, Yamamoto K, Mukai A, Kinoshita K, Yakushijin T, Iijima H, Takehara T. Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial. J Gastroenterol Hepatol 2021; 36:383-390. [PMID: 32511792 DOI: 10.1111/jgh.15134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Prophylactic clipping (PC) after polypectomy has the potential to prevent post-polypectomy bleeding (PPB). We aimed to evaluate the effectiveness of PC in preventing PPB for < 20-mm polyps. METHODS This multicenter, open-label, randomized controlled trial conducted from December 2013 to June 2017 at 10 institutions randomly assigned 1080 patients with < 20-mm colon polyps to the non-PC and PC groups. Allocation factors were institution, antiplatelet drug use, and polyp number. The primary endpoint was differences in PPB rates between the groups. The severity of PPB and post-procedural abdominal symptoms were also investigated. These endpoints in intention-to-treat and per-protocol (PP) analyses were evaluated. RESULTS We investigated 1039 patients with 2960 lesions. There was no significant difference between the groups in characteristics including age, sex, hypertension, diabetes, hyperlipidemia, antiplatelet drug use, and lesion characteristics such as type and size. Excluding the clip used in the non-PC group, intraoperative bleeding, and deviation of protocol, 903 patients were investigated in PP analysis. There was no significant difference in the PPB rate between the non-PC and PC groups (2.7% vs 2.3%, P = 0.6973 [intention-to-treat analysis]; 3.0 vs 2.4%, P = 0.7353 [PP analysis]). Severe PPB (≥ grade 3) was similar between the groups. Total procedure time was significantly shorter in the non-PC group than in the PC group (31 vs 36 min, P = 0.0002). Post-procedural abdominal fullness was less common in the non-PC group than in the PC group (20.8% vs 25.6%, P = 0.0833). CONCLUSION Prophylactic clipping is not effective in preventing PBB for < 20-mm colon polyps (UMIN000012163).
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Affiliation(s)
- Takuya Inoue
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan
- Department of Gastroenterology and Hepatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
- Department of Gastroenterology, Kaizuka City Hospital, Kaizuka, Japan
| | - Hideharu Ogiyama
- Department of Gastroenterology, Itami City Hospital, Itami, Japan
| | | | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Akira Mukai
- Department of Gastroenterology, Sumitomo Hospital, Osaka, Japan
| | - Kazuo Kinoshita
- Department of Gastroenterology, Otemae Hospital, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
- Osaka Gut Forum, Osaka, Japan
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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: 0.2] [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: 05/19/2020] [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.
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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
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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: 0.1] [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
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Chan FKL, Goh KL, Reddy N, Fujimoto K, Ho KY, Hokimoto S, Jeong YH, Kitazono T, Lee HS, Mahachai V, Tsoi KKF, Wu MS, Yan BP, Sugano K. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. Gut 2018; 67:405-417. [PMID: 29331946 PMCID: PMC5868286 DOI: 10.1136/gutjnl-2017-315131] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/06/2017] [Accepted: 12/09/2017] [Indexed: 12/12/2022]
Abstract
This Guideline is a joint official statement of the Asian Pacific Association of Gastroenterology (APAGE) and the Asian Pacific Society for Digestive Endoscopy (APSDE). It was developed in response to the increasing use of antithrombotic agents (antiplatelet agents and anticoagulants) in patients undergoing gastrointestinal (GI) endoscopy in Asia. After reviewing current practice guidelines in Europe and the USA, the joint committee identified unmet needs, noticed inconsistencies, raised doubts about certain recommendations and recognised significant discrepancies in clinical practice between different regions. We developed this joint official statement based on a systematic review of the literature, critical appraisal of existing guidelines and expert consensus using a two-stage modified Delphi process. This joint APAGE-APSDE Practice Guideline is intended to be an educational tool that assists clinicians in improving care for patients on antithrombotics who require emergency or elective GI endoscopy in the Asian Pacific region.
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Affiliation(s)
- Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Khean-Lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
| | - Nageshwar Reddy
- Asian Healthcare Foundation, AAll India Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Kazuma Fujimoto
- Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical College, Saga, Japan
| | - Khek Yu Ho
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Singapore, Singapore, Singapore
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang, Republic of Korea
| | | | - Hong Sik Lee
- Department of Gastroenterology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Varocha Mahachai
- Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kelvin K F Tsoi
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Bryan P Yan
- Department of Medicine and Therapeutics, Institute of Vascular Research, The Chinese University of Hong Kong, Hong Kong, China
| | - Kentaro Sugano
- Department of Medicine, Division of Gastroenterology, Jichi Medical School, Tochigi, Japan
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Abe Y, Nabeta H, Koyanagi R, Nakamichi T, Hirashima H, Lefor AK, Shinozaki S. Extended cold snare polypectomy for small colorectal polyps increases the R0 resection rate. Endosc Int Open 2018; 6:E254-E258. [PMID: 29423436 PMCID: PMC5803002 DOI: 10.1055/s-0043-125312] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/29/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Despite widespread use of cold snare polypectomy (CSP), the R0 resection rate is not well documented. We perform extended CSP, resecting polyps with a > 1 mm circumferential margin. The aim of this study is to compare the R0 resection rate of extended CSP with conventional CSP and to assess safety. PATIENTS AND METHODS From April 2014 to September 2016, 712 non-pedunculated colorectal polyps, < 10 mm in size, resected using CSP from 316 patients were retrospectively analyzed. RESULTS We divided lesions into conventional CSP (n = 263) and extended CSP groups (n = 449). The baseline characteristics of these two groups were not significantly different in univariate or multivariate analyses. Sessile polyps comprised 94 % (668/712), and the remaining were flat-elevated polyps. Mean size of polyps (±standard deviation) was 4.2 ± 1.5 mm. The most frequent pathology was low grade adenoma (97 %, 689/712). The R0 resection rate was significantly higher in the extended CSP group (439/449 [98 %]) than in the conventional CSP group (222/263 [84 %], P < 0.001). There was no delayed bleeding or perforation in either group (conventional CSP group, 0/263, 95 % confidence interval: 0.0 - 1.4 % and extended CSP group, 0/449, 95 % confidence interval: 0.0 - 0.8 %). CONCLUSIONS Extended CSP results in a higher R0 resection rate compared with conventional CSP. Extended CSP did not result in a higher rate of delayed bleeding or perforation. Extended CSP is a safe and promising procedure for endoscopic resection of non-pedunculated colorectal polyps < 10 mm in size.
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Affiliation(s)
- Yasuhiro Abe
- Department of Gastroenterology, Department of Medicine, Utsunomiya Memorial Hospital, Tochigi, Japan
| | - Haruaki Nabeta
- Department of Gastroenterology, Department of Medicine, Utsunomiya Memorial Hospital, Tochigi, Japan
| | - Ryota Koyanagi
- Department of Gastroenterology, Department of Medicine, Utsunomiya Memorial Hospital, Tochigi, Japan
| | - Taro Nakamichi
- Department of Gastroenterology, Department of Medicine, Utsunomiya Memorial Hospital, Tochigi, Japan
| | - Hayato Hirashima
- Department of Gastroenterology, Department of Medicine, Utsunomiya Memorial Hospital, Tochigi, Japan
| | | | - Satoshi Shinozaki
- Shinozaki Medical Clinic, Tochigi, Japan,Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
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Yun JH, Jung HI, Lee HU, Baek MJ, Bae SH. The efficacy of laparoscopic cholecystectomy without discontinuation in patients on antithrombotic therapy. Ann Surg Treat Res 2017; 92:143-148. [PMID: 28289668 PMCID: PMC5344804 DOI: 10.4174/astr.2017.92.3.143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/10/2016] [Accepted: 10/20/2016] [Indexed: 01/12/2023] Open
Abstract
Purpose Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries in the world today. However, there is no consensus regarding whether LC can be performed in patients with acute cholecystitis while on antithrombotic therapy. The objective of our study was to describe postoperative outcomes of patients who underwent emergent LC without interruption to antithrombotic therapy. Methods We performed a retrospective review of patients who underwent LC for acute cholecystitis while on antithrombotic therapy from 2010 to 2015 at Soonchunhyang Universtiy Cheonan Hospital. Patients were divided into 2 groups as underwent emergent LC and elective LC. Results A total of 67 patients (emergent group, 22; elective group, 45) were included in the analysis. Elective group had significantly longer duration between the admission and operation (8 [7–10] days vs. 2 [1–3] days, P < 0.001) and longer duration of antithrombotic drugs discontinuation (7 days vs. 1 [0–3] days, P < 0.001). Emergent group had significantly more postoperative anemia (6 patients vs. 0 patient, P = 0.001) and 3 of 6 patients received packed RBC transfusion in postoperative period. However, there was no significant difference in length of postoperative stays, length of intensive care unit stays and mortality rates. Conclusion Emergent LC without interruption to antithrombotic therapy was relatively safe and useful. A well-designed multicenter study is needed to confirm the safety and efficacy of LC without suspension of antithrombotic therapy and to provide a simple guideline.
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Affiliation(s)
- Jong Hyuk Yun
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hae Il Jung
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyoung Uk Lee
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Moo-Jun Baek
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Sang Ho Bae
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Ishigami H, Arai M, Matsumura T, Maruoka D, Minemura S, Okimoto K, Kasamatsu S, Saito K, Nakagawa T, Katsuno T, Yokosuka O. Heparin-bridging therapy is associated with a high risk of post-polypectomy bleeding regardless of polyp size. Dig Endosc 2017; 29:65-72. [PMID: 27368065 DOI: 10.1111/den.12692] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/08/2016] [Accepted: 06/29/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM 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. METHODS 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). RESULTS 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 <10 mm and ≥10 mm 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. CONCLUSIONS Heparin-bridging therapy is associated with a high risk of PPB regardless of polyp size.
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Affiliation(s)
- Hideaki Ishigami
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shoko Minemura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shingo Kasamatsu
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tatsuro Katsuno
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
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9
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Greenwald DA. Managing antithrombotic agents during endoscopy. Best Pract Res Clin Gastroenterol 2016; 30:679-687. [PMID: 27931629 DOI: 10.1016/j.bpg.2016.10.009] [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: 10/16/2016] [Accepted: 10/21/2016] [Indexed: 02/06/2023]
Abstract
Antithrombotic agents are used widely to reduce the risks of thromboembolic events in patients with a variety of cardiovascular and other conditions. This review focuses on the management of patients undergoing endoscopic procedures who are taking antithrombotic medications, and includes specific information and recommendations.
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Affiliation(s)
- David A Greenwald
- Division of Gastroenterology, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA.
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10
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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: 450] [Impact Index Per Article: 50.0] [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]
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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.
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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
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Burgess NG, Bahin FF, Bourke MJ. Colonic polypectomy (with videos). Gastrointest Endosc 2015; 81:813-35. [PMID: 25805461 DOI: 10.1016/j.gie.2014.12.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/04/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.
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Affiliation(s)
- Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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Zaca V, Marcucci R, Parodi G, Limbruno U, Notarstefano P, Pieragnoli P, Di Cori A, Bongiorni MG, Casolo G. Management of antithrombotic therapy in patients undergoing electrophysiological device surgery. Europace 2015; 17:840-54. [DOI: 10.1093/europace/euu357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/13/2014] [Indexed: 11/14/2022] Open
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Choung BS, Kim SH, Ahn DS, Kwon DH, Koh KH, Sohn JY, Park WS, Kim IH, Lee SO, Lee ST, Kim SW. Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study. J Clin Gastroenterol 2014; 48:784-789. [PMID: 24231934 DOI: 10.1097/mcg.0000000000000027] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM Delayed bleeding is a serious complication that occurs after polypectomy. Many risk factors for delayed bleeding have been suggested, but there is little analysis of procedure-related risk factors. The purpose of this study is to identify a wide range of risk factors for delayed postpolypectomy bleeding (DPPB) and analyze the correlations of those potential DPPB risk factors. MATERIALS AND METHODS In this retrospective cohort study, 5981 polypectomies in 3788 patients were evaluated between January 2010 and February 2012. Patient-related, polyp-related, and procedure-related factors were evaluated as potential DPPB risk factors. RESULTS Delayed bleeding occurred in 42 patients (1.1%). Multivariate analysis revealed that polyp size >10 mm [odds ratio (OR), 2.785; 95% confidence interval (CI), 1.406-5.513; P=0.003], location in the right hemi-colon (OR, 2.289; 95% CI, 1.117-4.693; P=0.024), and endoscopist's experience (<300 total cases of colonoscopy performed; OR, 4.803; 95% CI, 2.631-8.766; P=0.001) were significant risk factors for DPPB. Especially protruded type polyps (Ip, Isp) larger than 1 cm in the right-side colon were associated with increased risk. Right-side polypectomy by a nonexpert endoscopist was a significant risk factor for DPPB, especially with procedures in the cecum area. Taking the 1.5% DPPB incidence as cutoff value, the learning curve of colonoscopic polypectomy may be estimated as 400 cases of polypectomy. CONCLUSIONS Polyp size, endoscopist's experience, and right hemi-colon location were identified as potential risk factors for DPPB development.
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Affiliation(s)
- Bum Su Choung
- *Department of Internal Medicine †Research Institute of Clinical Medicine, Chonbuk National University Hospital, Chonbuk National University, Jeonbuk ‡Department of Internal Medicine, Daejeon St. Mary's Hospital, Daejeon, South Korea
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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; 79:417-423. [PMID: 24125514 DOI: 10.1016/j.gie.2013.08.040] [Citation(s) in RCA: 238] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [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.).
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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
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Inoue T, Nishida T, Maekawa A, Tsujii Y, Akasaka T, Kato M, Hayashi Y, Yamamoto S, Kondo J, Yamada T, Shinzaki S, Iijima H, Tsujii M, Takehara T. Clinical features of post-polypectomy bleeding associated with heparin bridge therapy. Dig Endosc 2014; 26:243-249. [PMID: 23730922 DOI: 10.1111/den.12123] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 04/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND 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. PATIENTS AND METHODS 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. RESULTS 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. CONCLUSIONS PPB associated with HB is characterized by high incidence, late onset and recurrent bleeding, resulting in long hospitalization.
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Affiliation(s)
- Takuya Inoue
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
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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
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19
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Abstract
Colonoscopic polypectomy is fundamental to effective colonoscopy. Through its impact on the polyp-cancer sequence, colonoscopic polypectomy reduces colorectal cancer incidence and mortality. Because it eliminates electrosurgical risk, cold snaring has emerged as the preferred technique for most small and all diminutive polyps. Few clinical trial data are available on the effectiveness and safety of specific techniques. Polypectomy technique seems highly variable between endoscopists, with some techniques more effective than others are. Further research is needed to investigate operator variation in polypectomy outcomes and establish an evidence base for best practice.
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Affiliation(s)
- David G Hewett
- School of Medicine, The University of Queensland, Mayne Medical Building, Herston Road, Herston, Brisbane, Queensland 4006, Australia.
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20
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Wu XR, Church JM, Jarrar A, Liang J, Kalady MF. Risk factors for delayed postpolypectomy bleeding: how to minimize your patients' risk. Int J Colorectal Dis 2013; 28:1127-34. [PMID: 23440363 DOI: 10.1007/s00384-013-1661-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Secondary bleeding after colonoscopic polypectomy is a serious complication. Most studies show polyp size, location, and shape to be important risk factors but other factors may allow refinement of risk. The aim of this study is to look for other factors associated with delayed postpolypectomy bleeding. METHODS This case-matched study compares patients who developed postpolypectomy bleeding with those who underwent uncomplicated polypectomy. Matching was performed for known risk factors: polyp size, location and shape, with a ratio of three controls to one subject. RESULTS Postpolypectomy bleeding occurred in 19/494 patients with polyps >2.0 cm diameter (3.8%) and 11/4161 patients with polyps <2.0 cm (0.3%). There was a median interval of 3 days (range 0-9 days) from polypectomy to hemorrhage. Twenty-five patients were readmitted to this institution. Ten (40.0%) were transfused and 19 (76.0%) were re-colonoscoped, with 13 needing either cautery (n = 7) or adrenaline injection (n = 6). Ninety patients were selected as controls, matched for polyp size, location, and shape. Mean age at polypectomy was 69.9 ± 9.2 years for patients and 64.9 ± 12.2 for controls (p = 0.042); 63.3% subjects were male, compared to 47.8% of controls (p = 0.140). Univariate analysis showed that older age, piecemeal polypectomy, need for additional sedation, concurrent diverticulosis and intraprocedural bleeding were significantly associated with increased risk of delayed bleeding. The associations between delayed bleeding and additional sedation, concurrent diverticulosis and intraprocedural bleeding were confirmed by multivariate logistic regression analysis. CONCLUSION Difficult colonoscopy and intraprocedural bleeding identify patients with a particularly high risk of secondary postpolypectomy bleeding. Preventive measures should be considered in such cases.
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Affiliation(s)
- Xian-rui Wu
- Department of Colorectal Surgery, Digestive Disease Institute, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
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21
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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: 1.1] [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
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22
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Khor CJ, Hartono JL. Current guidelines for endoscopy in patients receiving antithrombotic medication. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abu Daya H, Younan L, Sharara AI. Endoscopy in the patient on antithrombotic therapy. Curr Opin Gastroenterol 2012; 28:432-441. [PMID: 22885943 DOI: 10.1097/mog.0b013e328355e26f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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.
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Affiliation(s)
- Hussein Abu Daya
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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24
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Matsumoto M, Fukunaga S, Saito Y, Matsuda T, Nakajima T, Sakamoto T, Tamai N, Kikuchi T. Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors. Jpn J Clin Oncol 2012; 42:1028-34. [PMID: 22914322 DOI: 10.1093/jjco/hys131] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures. METHODS This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection. RESULTS The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04). CONCLUSIONS Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.
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Affiliation(s)
- Minori Matsumoto
- Endoscopy Division, National Cancer Center Hospital, and Department of Endoscopy, The Jikei University School of Medicine, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1078] [Impact Index Per Article: 82.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Kim DH, Lim SW. Analysis of delayed postpolypectomy bleeding in a colorectal clinic. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2011; 27:13-6. [PMID: 21431091 PMCID: PMC3053495 DOI: 10.3393/jksc.2011.27.1.13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 10/19/2010] [Indexed: 12/11/2022]
Abstract
PURPOSE The colonoscopic polypectomy has become a valuable procedure for removing precursors of colorectal cancer, but some complications can be occurred. The most common complication after colonoscopic polypectomy is bleeding, which is reported to range from 1% to 6% and which can be immediate or delayed. Because the management of delayed postpolypectomy bleeding could be difficult, the use of preventive technique and reductions of risk factors are essential. METHODS From January 2007 to December 2008, delayed hemorrhage occurred in 18 of the 1,841 polypectomy patients examined by one endoscopist. These cases were reviewed retrospectively for risk factors, pathologic findings, and treatment methods. RESULTS Delayed bleeding occurred in 18/1,841 patients (0.95%). The mean age was 55.9 ± 10.9 years, and the male-to-female ratio was 8:1. The most common site was the right colon (11 cases, 61.1%), and the average polyp size was 9.2 ± 2.8 mm. Delayed bleeding was identified from 1 to 5 days after resection (mean, 1.6 ± 1.2 days). The most common macroscopic type of polyp was a sessile polyp (10 cases, 55.6%), and histologic finding was a tubular adenoma in 13 cases (72.2%). Seventeen cases were treated with clipping for hemostasis and 1 case with epinephrine injection. CONCLUSION The right colon and a sessile polyp were associated with an increase in delayed postpolypectomy bleeding. Reducing risk factors and close observation were essential in high risk patients, and prompt management with hemoclips was effective.
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Affiliation(s)
- Do Hyoung Kim
- Department of Surgery, Hang Clinic of Coloproctology, Seoul, Korea
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27
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Velayos Jiménez B, Fernández Salazar L, del Olmo Martínez L, Aller de la Fuente R, Ruíz Rebollo L, de la Calle Valverde F, Macho Conesa A, Gómez de la Cuesta S, Arranz Santos T, González Hernández JM. [Primary prophylaxis of post-polylipectomy bleeding with clips]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:57-8. [PMID: 21216048 DOI: 10.1016/j.gastrohep.2010.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 09/07/2010] [Indexed: 10/18/2022]
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Adverse events associated with anticoagulation therapy in the periendoscopic period. Gastrointest Endosc 2010; 71:1211-1217.e2. [PMID: 20598248 PMCID: PMC3848307 DOI: 10.1016/j.gie.2009.12.054] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 12/17/2009] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic anticoagulation has been demonstrated to be a risk factor for GI bleeding (GIB) in patients undergoing endoscopic procedures. OBJECTIVE The aim of this study was to determine the incidence of GIB prospectively in a large cohort of patients enrolled in the Clinical Outcomes Research Initiative (CORI) database. DESIGN Anticoagulated patients undergoing endoscopic procedures were interviewed by phone 30 to 45 days after the procedure to determine potential adverse events and management of warfarin therapy in the periendoscopic period. SETTING Participating CORI sites, Stanford University Hospital, Veterans Administration Palo Alto Health Care System. MAIN OUTCOME MEASUREMENT Postprocedural hemorrhagic or thrombotic events. RESULTS Thirteen CORI sites agreed to participate, including 120,886 procedures in 95,807 patients. We contacted 929 patients on warfarin therapy and enrolled 483 patients (52%). The majority of the patients were men with atrial fibrillation undergoing colonoscopy. Warfarin was temporarily suspended in 437 (90%) of the patients before the procedure, and 114 (22%) received periprocedural heparin therapy. There were 10 major hemorrhagic events (2%), and the rate of hemorrhage was not higher in the patients receiving periprocedural heparin therapy (P = .1). However, polypectomy was a risk factor for postprocedural hemorrhage (P = .02). One fatal stroke (0.2%) occurred in a patient 2 weeks after endoscopy; however, information regarding warfarin management was not available. LIMITATIONS Small number of enrolled patients and lack of control group. Lack of information regarding prothrombin time before procedure, concurrent antiplatelet agents, and timing of bleeding in 50% of the cases. The study was underpowered to definitively conclude benefits of current guidelines regarding thrombosis or bleeding. CONCLUSIONS Postprocedural hemorrhagic events were not increased in anticoagulated patients. Most patients receiving bridging therapy were managed according to current society guidelines.
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Aplicaciones de los clips en la terapéutica endoscópica actual. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:171-8. [DOI: 10.1016/j.gastrohep.2009.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/13/2009] [Accepted: 04/17/2009] [Indexed: 12/17/2022]
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Becker RC, Scheiman J, Dauerman HL, Spencer F, Rao S, Sabatine M, Johnson DA, Chan F, Abraham NS, Quigley EMM. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol 2010; 54:2261-76. [PMID: 19942393 DOI: 10.1016/j.jacc.2009.09.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 09/09/2009] [Accepted: 09/15/2009] [Indexed: 01/02/2023]
Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
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Affiliation(s)
- Richard C Becker
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27705, USA.
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Becker RC, Scheiman J, Dauerman HL, Spencer F, Rao S, Sabatine M, Johnson DA, Chan F, Abraham NS, Quigley EMM. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Am J Gastroenterol 2009; 104:2903-17. [PMID: 19935784 DOI: 10.1038/ajg.2009.667] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
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Affiliation(s)
- Richard C Becker
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina 27705, USA.
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Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol 2009; 104:3085-97; quiz 3098. [PMID: 19672250 DOI: 10.1038/ajg.2009.469] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.
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Affiliation(s)
- Avelyn Kwok
- Department of Gastroenterology, Concord Hospital, University of Sydney, Sydney, Australia
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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: 21.2] [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]
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Hokama A, Kishimoto K, Kinjo F, Fujita J. Endoscopic clipping in the lower gastrointestinal tract. World J Gastrointest Endosc 2009; 1:7-11. [PMID: 21160644 PMCID: PMC2999077 DOI: 10.4253/wjge.v1.i1.7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 08/26/2009] [Accepted: 09/02/2009] [Indexed: 02/05/2023] Open
Abstract
Endoscopic clipping has been established as a safe and effective method for the treatment of nonvariceal upper gastrointestinal bleeding in numerous randomized studies. Recently, clipping has been applied to various lesions in the lower gastrointestinal tract, including diverticular bleeding, postpolypectomy bleeding, and repair of perforations with successful outcomes. We review the safety and efficacy of this maneuver for the management of diseases in the lower gastrointestinal tract.
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Affiliation(s)
- Akira Hokama
- Akira Hokama, Jiro Fujita, Department of Medicine and Therapeutics (First Department of Internal Medicine), Control and Prevention of Infectious Diseases, Faculty of Medicine, University of the Ryukyus, Okinawa 903-0125, Japan
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The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding. Surg Laparosc Endosc Percutan Tech 2009; 19:2-10. [PMID: 19238058 DOI: 10.1097/sle.0b013e31818e9297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.
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Abstract
AIM: To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation.
METHODS: Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically.
RESULTS: One patient (0.8%, 95% CI: 0.1%-4.5%) developed major post-polypectomy bleeding that required transfusion. Two others (1.6%, 95% CI: 0.5%-5.7%) had self-limited hematochezia at home and did not seek medical attention. The average polyp size was 5.1 ± 2.2 mm.
CONCLUSION: Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.
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Székely H, Tulassay Z. [Anticoagulation and antiplatelet therapy, and gastrointestinal endoscopy]. Orv Hetil 2009; 150:541-548. [PMID: 19275971 DOI: 10.1556/oh.2009.28554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Over the past decade, the application of anticoagulant and antiplatelet agents for various cardiovascular and hematologic conditions has become more widespread. These medications can decrease the risk of thromboembolic events, meanwhile may potentiate gastrointestinal bleeding. The decision to reverse anticoagulation, thereby risking thromboembolic complications, must be carefully weighted against the increased risk of bleeding when maintaining anticoagulation. Elective procedures should be delayed in patients on temporary anticoagulation therapy (e.g. those with deep vein thrombosis). For procedures considered to have a low risk of bleeding (e.g. diagnostic endoscopy and biopsy) there is no need to discontinue or adjust anticoagulation. For procedures with a higher risk of bleeding (e.g. polypectomy and biliary sphincterotomy), an individual approach is required. This approach might include stopping oral anticoagulant therapy with or without the administration of unfractionated heparin or low-molecular-weight heparin for the pre-procedure and post-procedure periods, during which the patient's international normalized ratio is in the subtherapeutic range. Antiplatelet drugs (aspirin, clopidogrel, ticlopidine) may also increase the risk of bleeding induced by gastrointestinal endoscopic procedures. There is no indication to stop the therapy before esophagogastroduodenoscopy. Discontinuation of aspirin 4-7 days (according to the cardiovascular risk) before other endoscopic procedures is recommended. When aspirin is indicated for primary prevention, it can be resumed 14 days and 10 days after polypectomy and sphincterotomy, respectively. In cases of secondary prevention, it should be resumed after 1 week.
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Affiliation(s)
- Hajnal Székely
- Semmelweis Egyetem, Altalános Orvostudományi Kar II. Belgyógyászati Klinika Budapest Szentkirályi u. 46. 1088.
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Lee SY. Differences in Managing Anticoagulants and Antiplatelets for Gastrointestinal Endoscopy between East and West. Gastroenterology Res 2009; 2:67-80. [PMID: 27956957 PMCID: PMC5139821 DOI: 10.4021/gr2009.04.1283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2009] [Indexed: 12/25/2022] Open
Abstract
Decreasing the bleeding risk associated with gastrointestinal (GI) endoscopic procedures and minimizing the thromboembolic risk of withdrawing medications are very important for the patients taking anticoagulants and antiplatelets. Western guidelines on managing anticoagulation and antiplatelet medications in GI endoscopy suggest a polypectomy with aspirin medication or a biopsy with warfarin medication. However, Eastern endoscopists’ adherence to Western guidelines may be responsible for Easteners experiencing massive bleedings. During the cessation of drugs, it should be emphasized that Asians may be predisposed to different forms of embolism more likely to be of the cerebrovascular system, whereas Westerners more likely to be of the cardiovascular variety. To better understand the differences between the East and West, differences in drug metabolism should be considered that results in greater body weight-normalized plasma unbound clearance of drug in Easterners. Taken as a whole, different managements are required for GI endoscopy in patients on anticoagulation and/or antiplatelet medications based on differences in metabolism of drugs, risk of hemorrhage, and forms of thromboembolism.
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Affiliation(s)
- Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, 4-12 Hwayang-dong, Gwangjin-gu, Seoul 143-729, South Korea. E-mail:
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Endoscopic clipping for the management of gastrointestinal bleeding. ACTA ACUST UNITED AC 2008; 5:559-68. [PMID: 18711412 DOI: 10.1038/ncpgasthep1233] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 07/04/2008] [Indexed: 02/06/2023]
Abstract
Endoscopic clipping is a safe and effective technique for the treatment of various bleeding gastrointestinal lesions. Randomized controlled trials and a meta-analysis have shown comparable efficacy between clipping and conventional contact thermal therapy for definitive hemostasis of nonvariceal upper gastrointestinal hemorrhage. Clipping also seems to be efficacious for selected lower gastrointestinal bleeding lesions, such as diverticular bleeding and postpolypectomy bleeding. Proficiency in clip application and endoscopic identification of lesions that are amenable to clipping are key determinants of a successful outcome.
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Abstract
Ultrasound-guided biopsies in the abdomen and pelvis are generally more effective, safer, faster, and cheaper than those performed under computed tomography guidance. This manuscript will discuss multiple aspects of sonographic biopsies performed between the diaphragm and the symphysis pubis. We begin with systems issues, patient preparation (including bleeding profile and anticoagulant use), pain management, and infection precautions. The procedure itself is then analyzed, including needle guidance, the role of the sonographer, image optimization, patient positioning, core- versus fine-needle aspiration, coaxial versus individual pass, needle technique, and postprocedure management. Issues specific to different sites are then discussed: liver, spleen, pancreas, kidney, adrenal, bowel, retroperitoneum and mesentery, and the pelvis. We finish with a discussion of complications, future trends, and a brief summary.
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Abstract
Endoscopic clips are relatively new devices that have been shown to be effective for the control of acute gastrointestinal hemorrhage. Various different models are available and offer simplicity of use with relatively few complications. Recently, endoscopic clips have been used for a variety of non-hemorrhagic conditions. In this article we review the literature and present current thinking about the indications, efficacy and safety of these devices.
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Affiliation(s)
- Michael J Grupka
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA.
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Abstract
Colonoscopic polypectomy is the most effective visceral cancer prevention tool in clinical medicine. In general, risks associated with the technique of polyp removal should match the likelihood that the polyp will become or already is malignant (eg, low-risk technique for low risk for malignant potential). Cold techniques are preferred for most diminutive polyps. Polypectomy techniques must be effective and minimize complications. Complications can occur even with proper technique, however. Aggressive evaluation and treatment of complications helps ensure the best possible outcome.
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Grassini M, Verna C, Battaglia E, Niola P, Navino M, Bassotti G. Education improves colonoscopy appropriateness. Gastrointest Endosc 2008; 67:88-93. [PMID: 18028918 DOI: 10.1016/j.gie.2007.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Accepted: 04/09/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Appropriateness in GI endoscopy is critical to face the rising amount of demands. Education of physicians has been advocated to reduce the level of inappropriateness. OBJECTIVE Our purpose was to assess the effectiveness of an educational program in determining a reduction of inappropriate colonoscopies in an open access system. DESIGN Prospective study. SETTING A single endoscopy unit in Italy. PATIENTS A total of 495 consecutive outpatients referred to our endoscopy unit by family physicians for diagnostic colonoscopy before the educational course and 522 after its completion, for a total of 1017 patients. MAIN OUTCOME MEASUREMENTS Inappropriate colonoscopy reduction rates, cost savings, and reduction of waiting lists were evaluated. RESULTS With regard to inappropriate colonoscopies, the post-course group rate of inappropriateness was significantly lower than that of the pre-course group (P < or = .001). The economic savings for 1 year was estimated to be euro19,000. The reduction of the waiting list was about 15% of the original value. CONCLUSIONS Education has a high incidence in reducing inappropriate colonoscopies in an open-access system determining reduction of costs and waiting lists.
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Raju GS, Kaltenbach T, Soetikno R. Endoscopic mechanical hemostasis of GI arterial bleeding (with videos). Gastrointest Endosc 2007; 66:774-85. [PMID: 17905022 DOI: 10.1016/j.gie.2007.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Accepted: 04/14/2007] [Indexed: 01/09/2023]
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Khashab M, Rex DK. Persistence of resolution clips on colorectal polypectomy sites. Gastrointest Endosc 2007; 66:635-6. [PMID: 17725962 DOI: 10.1016/j.gie.2007.03.1032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 03/19/2007] [Indexed: 12/28/2022]
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Ringold DA, Jonnalagadda S. Complications of Therapeutic Endoscopy: A Review of the Incidence, Risk Factors, Prevention, and Endoscopic Management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Nagri S, Anand S. Prophylactic clip application should be the standard of care to prevent postpolypectomy bleeding. Gastrointest Endosc 2007; 65:182; author reply 183. [PMID: 17185107 DOI: 10.1016/j.gie.2006.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Accepted: 07/18/2006] [Indexed: 12/10/2022]
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Harewood GC. Prophylactic clip application after colonic polypectomy. Gastrointest Endosc 2007; 65:183; author reply 183. [PMID: 17185109 DOI: 10.1016/j.gie.2006.07.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Accepted: 07/24/2006] [Indexed: 12/10/2022]
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Fatima H, Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 2007; 17:145-56, viii. [PMID: 17397781 DOI: 10.1016/j.giec.2006.10.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Current polypectomy tools and techniques are inadequate to prevent all postpolypectomy bleeding, perforation, and postpolypectomy syndrome; however, adherence to certain principles can substantially reduce the risk of these complications. This review does not focus on technical aspects of colonoscopy that are directed toward preventing complications of failed eradication. Rather, the authors focus on the classic complications of bleeding, perforation, and their prevention. New technologies that could further reduce or eliminate perforation and bleeding after polypectomy are sorely needed.
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Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, 550 N University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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