Risk factors for delayed postpolypectomy bleeding: how to minimize your patients' risk

A dynamic online nomogram for predicts delayed postoperative bleeding after colorectal polyp surgery

This study aims to analyze the risk factors associated with delayed postoperative bleeding (DPPB) following colorectal polyp surgery, develop a dynamic nomogram and evaluate the model efficacy, provide a reference for clinicians to identify the patients at high risk of DPPB. Retrospective study was done on patients who underwent endoscopic colorectal polypectomy at the First Hospital of Lanzhou University from January 2020 to March 2023. Differences between the group with and without DPPB were compared, and independent risk factors for DPPB occurrence were identified through univariate analysis and combination LASSO and logistic regression. A dynamic nomogram was constructed based on multiple logistic regression to predict DPPB following colorectal polyp surgery. Model evaluation included receiver operating characteristic (ROC), Calibration curve, Decision curve analysis (DCA). DPPB occurred in 38 of the 1544 patients included. multivariate analysis showed that direct oral anticoagulants (DOACs), polyp location in the right hemi colon, polyp diameter, drink, and prophylactic hemoclips were the independent risk factors for DPPB and dynamic nomogram were established. Model validation indicated area under the ROC curve values of 0.936, 0.796, and 0.865 for the training set, validation set, and full set, respectively. The calibration curve demonstrated a strong alignment between the predictions of the column-line diagram model and actual observations. The decision curve analysis (DCA) displayed a significant net clinical benefit across the threshold probability range of 0-100%. The dynamic nomogram aids clinicians in identifying high-risk patients, enabling personalized diagnosis and treatment.

Risk factors for delayed colorectal postpolypectomy bleeding: a meta-analysis

BACKGROUND

To systematically analyze risk factors for delayed postpolypectomy bleeding (DPPB) in colorectum.

METHODS

We searched seven large databases from inception to July 2022 to identify studies that investigated risk factors for DPPB. The effect sizes were expressed by relative risk (RR) and 95% confidence interval (95% CI). The heterogeneity was analyzed by calculating I2 values and performing sensitivity analyses.

RESULTS

A total of 15 articles involving 24,074 subjects were included in the study. The incidence of DPPB was found to be 0.02% (95% CI, 0.01-0.03), with an I2 value of 98%. Our analysis revealed that male sex (RR = 1.64), history of hypertension (RR = 1.54), anticoagulation (RR = 4.04), polyp size (RR = 1.19), polyp size ≥ 10 mm (RR = 2.43), polyp size > 10 mm (RR = 3.83), polyps located in the right semicolon (RR = 2.48) and endoscopic mucosal resection (RR = 2.99) were risk factors for DPPB.

CONCLUSIONS

Male sex, hypertension, anticoagulation, polyp size, polyp size ≥ 10 mm, polyps located in the right semicolon, and endoscopic mucosal resection were the risk factors for DPPB. Based on our findings, we recommend that endoscopists should fully consider and implement effective intervention measures to minimize the risk of DPPB.

Onset Time and Characteristics of Postprocedural Bleeding after Endoscopic Resection of Colorectal Lesions: A Multicenter Retrospective Study

INTRODUCTION

Postprocedural bleeding is a major adverse event after endoscopic resection of colorectal lesions, but the optimal surveillance time after endoscopy is unclear. In this study, we determined onset time and characteristics of postprocedural bleeding events.

METHODS

We retrospectively screened patients who underwent endoscopic resection of colorectal lesions at three German hospitals between 2010 and 2019 for postprocedural bleeding events using billing codes. Only patients who required re-endoscopy were included for analysis. For identified patients, we collected demographic data, clinical courses, characteristics of colorectal lesions, and procedure-related variables. Factors associated with late-onset bleeding were determined by univariate and multivariate logistic regression analysis.

RESULTS

From a total of 6,820 patients with eligible billing codes, we identified 113 cases with postprocedural bleeding after endoscopic mucosal (61.9%) or snare resection (38.1%) that required re-endoscopy. The median size of the culprit lesion was 20 mm (interquartile range 14-30 mm). The median onset time of postprocedural bleeding was day 3 (interquartile range: 1-6.5 days), with 48.7% of events occurring within 48 h. Multivariate logistic regression analysis demonstrates that a continued intake of antiplatelet drugs (OR: 3.98, 95% CI: 0.89-10.12, p = 0.025) and a flat morphology of the colorectal lesion (OR: 2.98, 95% CI: 1.08-8.01, p = 0.031) were associated with an increased risk for late postprocedural bleeding (>48 h), whereas intraprocedural bleeding was associated with a decreased risk (OR: 0.12, 95% CI: 0.04-0.50, p = 0.001).

CONCLUSION

Significant postprocedural bleeding can occur up to 18 days after endoscopic resection of colorectal lesions, but was predominantly observed within 48 h. Continued intake of antiplatelet drugs and a flat polyp morphology are associated with risk for late postprocedural bleeding.

Establishment of a model for predicting delayed post-polypectomy bleeding: A real-world retrospective study

Background

Delayed post-polypectomy bleeding (DPPB) is the most common complication which occurs within 30 days after polypectomy, it has become rather common with the widespread of colorectal cancer screening. It is important to clarified predictors of DPPB and identify patients at high risk.

Materials and methods

This was a real-world retrospective study based on medical records from The First Affiliated Hospital of Nanjing Medical University. Cases of patients who underwent colonoscopic polypectomy between January 2016 and December 2020 were reviewed to identify risk factors of DPPB. We use the LASSO-Logistic regression analysis model to identify independent predictors and create a predictive model. The model finally got visualized by developing a nomogram.

Results

Colonoscopic polypectomy was done on 16,925 patients in our study. DPPB occurred in 125 (0.74%) of these instances. In multivariate analysis, age, sex, hypertension, polyp location, polyp size, and operative modality were found to be independent risk factors and were integrated for the construction of a nomogram. The model’s C-index is 0.801 (95%CI: 0.761–0.846). We also found polyps located at the right semicolon and polyp ≥ 1 cm associated with active bleeding under the therapeutic colonoscopy.

Conclusion

Young age, male, hypertension, polyp ≥ 1 cm, proximal colon location and operative modality were finally identified as significant predictors of DPPB. We developed and validated a nomogram which performs well in predicting the incidence of DPPB, the model we established can be used as a valuable screening tool to identify patients who are at high risk of bleeding.

Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients

Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3–1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.

Risk factors for post-polypectomy bleeding; a retrospective case-control study of a high-volume colonoscopy center

BACKGROUND AND AIM

Post-polypectomy bleeding (PPB) remains an uncommon although serious complication of colonoscopy. The aim of this study is to determine the PPB-prevalence in a secondary care hospital and its associated risk factors.

PATIENTS AND METHODS

We collected data from 581 patients, with the removal of 1593 polyps between August 2017 and August 2019. A univariate binary logistic regression analysis was conducted retrospectively.

RESULTS

PPB occurred in only 10 cases, representing 1.7% of patients: immediate in 1.2% and delayed in 0.5%. The number of removed polyps per patient [4.5 (SD 2.59) for hemorrhagic vs. 2.74 (SD 1.98) for non-hemorrhagic group] and the propofol dose [232 mg (SD 93.07) for hemorrhagic vs. 133 mg (SD 57.28) for non-hemorrhagic group] were relevant patient-related risk factors. The polyp-based analysis showed the polyp size [18.4 mm (SD 10.44) for hemorrhagic vs. 4.42 mm (SD 4.29) for non-hemorrhagic group], the morphology [wide-based: OR 24.83 (95 % CI 2.76 - 223.44), pedunculated: OR 56.67 (95 % CI 5.03 - 638.29)], the location at ileocecal valve [OR 20.48, 95 % CI 1.81 - 231.97)], and the polypectomy method [hot snare piecemeal with epinephrine injection: OR 75.38 (95 % CI 7.67 - 741.21)] as significant risk factors for PPB, too.

CONCLUSIONS

The low rate of PPB confirms the safety of the procedure in non-tertiary, high-volume colonoscopy centers. The number of polyps removed per patient, the polyp size, morphology and location, as well as the sedation dose and the method of polypectomy were shown as relevant risk factors.

Endoscopic management of delayed bleeding after polypectomy of small colorectal polyps: two or more clips may be safe

Background

The resection of small colorectal polyps (≤10 mm) is routine for endoscopists. However, the management of one of its main complications, namely delayed (within 14 days) postpolypectomy bleeding (DPPB), has not been clearly demonstrated. We aimed to assess the role of coloscopy in the management of DPPB from small colorectal polyps and identify the associated factors for initial hemostatic success.

Methods

We conducted a retrospective study of 69 patients who developed DPPB after the removal of colorectal polyps of ≤10 mm and underwent hemostatic colonoscopy at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between April 2013 and June 2021. Demographics, clinical variables, and colonoscopic features were collected independently. We applied univariate and multivariate analyses to assess factors associated with initial hemostatic success.

Results

General colonoscopy without oral bowel preparation was successfully performed in all the patients, with a median duration of 23.9 (12.5–37.9) minutes. Among 69 patients, 62 (89.9%) achieved hemostasis after initial hemostatic colonoscopy and 7 (10.1%) rebled 2.7 ± 1.1 days after initial colonoscopic hemostasis and had rebleeding successfully controlled by one additional colonoscopy. No colonoscopy-related adverse events occurred. Multivariate analysis showed that management with at least two clips was the only independent prognostic factor for initial hemostatic success (odds ratio, 0.17; 95% confidence interval, 0.03–0.91; P = 0.04). All the patients who had at least two clips placed at the initial hemostatic colonoscopy required no further hemostatic intervention.

Conclusions

Colonoscopy is a safe, effective, and not too time-consuming approach for the management of patients with DPPB of small colorectal polyps and management with the placement of at least two hemoclips may be beneficial.

Prophylactic clipping to prevent delayed colonic post-polypectomy bleeding: meta-analysis of randomized and observational studies

BACKGROUND AND AIMS

Delayed post-polypectomy bleeding (DPPB) is a commonly described adverse event following polypectomy. Prophylactic clipping may prevent DPPB in some patient subgroups. We performed a meta-analysis to assess both the efficacy and real-world effectiveness of prophylactic clipping.

METHODS

We performed a database search through March 2020 for clinical trials or observational studies assessing prophylactic clipping and DPPB. Pooled risk ratios (RR) were calculated using random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to elucidate clinical or methodological factors associated with effects on outcomes.

RESULTS

A total of 2771 citations were screened, with 11 randomized controlled trials (RCTs) and 9 observational studies included, representing 24,670 colonoscopies. DPPB occurred in 2.0% of patients overall. The pooled RR of DPPB was 0.47 (95% CI 0.29-0.77) from RCTs enrolling only patients with polyps ≥ 20 mm. Remaining pooled RCT data did not demonstrate a benefit for clipping. The pooled RR of DPPB was 0.96 (95% CI 0.61-1.51) from observational studies including all polyp sizes. For patients with proximal polyps of any size, the RR was 0.73 (95% CI 0.33-1.62) from RCTs. Meta-regression confirmed that polyp size ≥ 20 mm significantly influenced the effect of clipping on DPPB.

CONCLUSION

Pooled evidence demonstrates a benefit when clipping polyps measuring ≥ 20 mm, especially in the proximal colon. In lower-risk subgroups, prophylactic clipping likely results in little to no difference in DPPB.

Analysis of 234 cases of colorectal polyps treated by endoscopic mucosal resection

BACKGROUND

Colorectal polyps refer to all neoplasms that protrude into the intestinal cavity. Researchers believe that 50%-70% of colorectal cancers originate from adenomatous polyps.

AIM

To investigate the endoscopic morphologic features, pathologic types, and clinical situation; evaluate the efficacy and safety of endoscopic mucosal resection (EMR); and guide clinicians in their daily practice.

METHODS

Two hundred thirty-four patients who underwent EMR in our hospital from January 1, 2018 to December 31, 2019 were recruited. Data including sex, age, endoscopic morphology of the polyps, and pathological characteristics were analyzed among groups.

RESULTS

A total of 295 polyps were resected from the 234 subjects enrolled in the study, of which 4 (1.36%) were Yamada type I. There were 75 (25.42%) type II, 101 (34.24%) type III, and 115 (38.98%) type IV adenomas. Among them, 41 were non-adenomas, 110 were low-risk adenomas, 139 were high-risk adenomas, and 5 were carcinomas. The differences in distribution were not statistically significant, with P values greater than 0.05. The risk of cancer significantly increased for polyps ≥ 1 cm in diameter (c2 = 199.825, P = 0.00). Regarding the endoscopic morphological features, congestion, erosion, and lobulation were more common on the surface morphology of high-risk adenomas and cancerous polyps (c2 = 75.257, P = 0.00), and most of them were Yamada types III and IV. In all, 6 of the 295 polyps could not be removed completely, with a one-time resection rate of 97.97%. There were two cases of postoperative bleeding and no cases of perforation, with an overall complication rate of 0.09%.

CONCLUSION

Colorectal polyps ranging from non-adenomatous polyps, low-risk adenomas, and high-risk adenomas to adenocarcinomas each has their own endoscopic features, while EMR, as a mature intervention, has good safety and operability and should be promoted clinically, especially at the primary care level.

The effect of prophylactic hemoclip placement and risk factors of delayed post-polypectomy bleeding in polyps sized 6 to 20 millimeters: a propensity score matching analysis

BACKGROUND

Delayed post-polypectomy bleeding (PPB) is a major complication of polypectomy. The effect of prophylactic hemoclipping on delayed PPB is uncertain. The aim of this study was to evaluate the effectiveness of prophylactic hemoclipping and identify the risk factors of delayed PPB.

METHODS

Patients with polyps sized 6 to 20 mm underwent snare polypectomy from 2015 to 2017 were retrospectively reviewed. The patients with prophylactic hemoclipping for delayed PPB prevention were included in the clipping group, and those without prophylactic hemoclipping were included in the non-clipping group. The incidence of delayed PPB and time to bleeding were compared between the groups. Multivariate analysis was used to identify the risk factors of delayed PPB. Propensity score matching was used to minimize potential bias.

RESULTS

After propensity score matching, 612 patients with 806 polyps were in the clipping group, and 576 patients with 806 polyps were in the non-clipping group. There were no significant differences in the incidence of delayed PPB and days to bleeding between two groups (0.8% vs 1.3%, p = 0.4; 3.4 ± 1.94 days vs 4.13 ± 3.39 days, p = 0.94). In the multivariate analysis, the polyp size [Odds ratio (OR):1.16, 95% confidence interval (CI):1.01-1.16, p = 0.03), multiple polypectomies (OR: 4.64, 95% CI:1.24-17.44, p = 0.02) and a history of anticoagulant use (OR:37.52, 95% CI:6.49-216.8, p < 0.001) were associated with delayed PPB.

CONCLUSIONS

In polyps sized 6 to 20 mm, prophylactic hemoclip placement did not decrease the risk of delayed PPB. Patients without risk factors including multiple polypectomies and anticoagulant use are no need to performing prophylactic hemoclipping.

Development of a definition and rules for causal attribution of post-colonoscopy bleeding

Background

Post-colonoscopy bleeding (PCB) is an important colonoscopy quality indicator that is recommended to be routinely collected by colorectal cancer screening programs and endoscopy quality improvement programs. We created a standardized and reliable definition of PCB and set of rules for attributing the relatedness of PCB to a colonoscopy.

Methods

PCB events were identified from colonoscopies performed at the Forzani & MacPhail Colon Cancer Screening Centre. Existing definitions and relatedness rules for PCB were reviewed by the authors and a draft definition and set of rules was created. The definition and rules were revised after initial testing was performed using a set of 15 bleeding events. Information available for each event included the original endoscopy report and data abstracted from the emergency or inpatient record by a trained research assistant. A validation set of 32 bleeding events were then reviewed to assess their interrater reliability by having three endoscopists and one research assistant complete independent reviews and three endoscopists complete a consensus review. The Kappa statistic was used to measure interrater reliability.

Results

The panel classified 28 of 32 events as meeting the definition of PCB and rated 7, 8 and 6 events as definitely, probably and possibly related to the colonoscopy, respectively. The Kappa for the definition of PCB for the three independent reviews was 0.82 (substantial agreement). The Kappa for the attribution of the PCB to the colonoscopy by the three endosocopists was 0.74 (substantial agreement). The research assistant had a high agreement with the panel for both the definition (100% agreement) and application of the causal criteria (kappa 0.95).

Conclusions

A standardized definition of PCB and attribution rules achieved high interrater reliability by endoscopists and a non-endoscopist and provides a template of required data for event adjudication by screening and quality improvement programs.

Risk of Delayed Bleeding after a Colorectal Endoscopic Mucosal Resection without Prophylactic Clipping: Single Center, Observational Study

BACKGROUND/AIMS

Bleeding is one of the major complications of a colorectal polypectomy. The aim of this study was to identify the risk of delayed bleeding, particularly after a colorectal endoscopic mucosal resection (EMR) without prophylactic clipping.

METHODS

Between April 2014 and August 2014, patients who underwent colorectal EMR (≥6 mm and <2 cm) without prophylactic clipping were included. This study evaluated the incidence of delayed bleeding and the associated factors after colorectal EMR without prophylactic clipping.

RESULTS

A total of 717 colorectal polyps (≥6 mm and <2 cm) of 243 patients resected by colorectal EMR in the study period were evaluated. The mean age of the patients was 63 years; 165 patients were men and 78 patients were women. The mean polyp size removed by colorectal EMR was 9.0 mm (range 6.0-19.0), and the number of polyps larger than 1 cm was 212 (29.6%). Delayed bleeding after colorectal EMR occurred in 12 polyps (1.7%) in eight patients (3.3%), and there were no significant risk factors affecting delayed bleeding.

CONCLUSIONS

This study identified that the incidence of delayed bleeding on colorectal polyps (≥6 mm and <2 cm) after EMR without prophylactic clipping was 3.3%, but no significant risk factors affecting delayed bleeding were found.

Practice patterns and predictors of prophylactic endoscopic clip usage during polypectomy

Background and study aims  Prophylactic endoscopic clips are commonly placed during polypectomy to reduce risk of delayed bleeding, although evidence to support this practice is unclear. Our study aimed to: (1) identify variables associated with prophylactic clip use; (2) explore variability between endoscopists' clipping practices and (3) study temporal trends in prophylactic clip use. Patients and methods  This was a retrospective cohort study in a high-volume unit dedicated to screening-related colonoscopies. Colonoscopies involving polypectomy from 2008 to 2014 were reviewed. The primary outcome was prophylactic clipping status, both at the patient level and per polyp. Hierarchical regression models yielded adjusted odds ratios (AORs) to determine predictors of prophylactic clipping. Results  A total of 8,366 colonoscopies involving 19,129 polypectomies were included. Polyp size ≥ 20 mm was associated with higher clip usage (AOR 2.94; 95 % CI: 2.43, 3.54) compared to polyps < 10 mm. Right-sided polyps were more likely to be clipped (AOR 2.78; 95 % CI: 2.34, 3.30) relative to the rectum. Surgeons clipped less than gastroenterologists (OR 0.52; 95 % CI: 0.44, 0.63). From 2008 to 2014, the crude proportion of prophylactically clipped cases increased by 7.4 % (95 % CI: 7.1, 7.6) from 1.9 % to 9.3 %. Significant inter-endoscopist variability in clipping practices was observed, notably, for polyps < 10 mm. Conclusions  Prophylactic clip usage was correlated with established risk factors for delayed bleeding. Significantly increased clip usage over time was shown. Given that evidence does not clearly support prophylactic clipping, there is a need to educate practitioners and limit healthcare resource utilization.

Risk factors for delayed hemorrhage after colonoscopic postpolypectomy: Polyp size and operative modality

Background and Aim

Delayed postpolypectomy hemorrhage is relatively common, with occasional extensive blood loss, endangering life. This study aimed to determine the factors associated with postoperative hemorrhage.

Methods

The study was a retrospective cohort study of patients hospitalized for colonoscopic polypectomy at the Department of Gastroenterology and Hepatology, Tenth People's Hospital of Tongji University, China, between January and December 2015. Data on gender, age, bowel preparation, location, size, number of polyps, operative modality, pathology, and operation practitioner were collected. Patients were divided into two groups based on the presence or absence of postoperative hemorrhage.

Results

A total of 1962 polyps were detected in patients and they underwent polypectomy; hemorrhage occurred in 41 cases. A correlation was demonstrated between postpolypectomy hemorrhage and each of the following factors: polyp size and operative modality. The odds ratio (OR) was 4.535 (95% confidence interval [CI], 2.331–8.823) for 1–2‐cm polyps, 4.008 (95% CI, 0.904–17.776) for 2–3‐cm polyps, and 22.407 (95% CI, 5.783–86.812) for ≥3‐cm polyps. Compared with argon plasma coagulation, OR was 9.128 (95% CI, 3.548–23.486) for endoscopic mucosal resection and 31.257 (95% CI, 7.009–139.395) for endoscopic submucosal dissection.

Conclusions

The independent risk factors for delayed postpolypectomy hemorrhage include polyp size and operative modality.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis

BACKGROUND AND AIM

The aim of this systematic review and meta-analysis was to assess the risk of post-polypectomy bleeding (PPB) in patients that underwent colorectal polypectomy and exposed to ASA/NSAIDs.

METHODS

Relevant publications were identified in MEDLINE/EMBASE for the period 1950-2016. Studies with specified ASA/NSAIDs exposure and bleeding rate were included. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was based on fixed or random effect models in relation to the heterogeneity.

RESULTS

11 studies (4 prospective and 7 retrospective) including 9307 patients were included in the analyses. Overall, 344 patients (OR 1.8; 95% CI 1.2-2.7; p-value 0.001, I² 52%) experienced rectal bleeding after procedure. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR 1.1; CI 95% 0.6-2.1; d.f.=1, p=0.64, I² 0%), the risk of delayed PPB was augmented (OR 1.7; 95% CI 1.2-2.2; d.f.=8, p=0.127, I² 36%).

CONCLUSIONS

ASA/NSAIDs are not a risk factor for immediate PPB but the chance of delayed is increased.

Risk factors for delayed colonic post-polypectomy bleeding: a systematic review and meta-analysis

PURPOSE

Delayed post-polypectomy bleeding (PPB) is an infrequent but serious adverse event after colonoscopic polypectomy. Several studies have tried to identify risk factors for delayed PPB, with inconsistent results. This meta-analysis aims to identify significant risk factors for delayed PPB.

METHODS

MEDLINE and EMBASE databases were searched through January 2016 for studies that investigated the risk factors for delayed PPB. Pooled odds ratio (OR) for categorical variables and mean differences (MD) for continuous variables and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity of effect size was quantified using the Q statistic and I ².

RESULTS

Twelve articles involving 14,313 patients were included. The pooled delayed PPB rate was 1.5% (95%CI, 0.7-3.4%), I ² = 96%. Cardiovascular disease (OR = 1.55), hypertension (OR = 1.53), polyp size > 10 mm (OR = 3.41), and polyps located in the right colon (OR = 1.60) were identified as significant risk factors for delayed PPB, whereas age, sex, alcohol use, smoking, diabetes, cerebrovascular disease, pedunculated morphology, and carcinoma histology were not.

CONCLUSIONS

Cardiovascular disease, hypertension, polyp size, and polyp location were associated with delayed PPB. More caution is needed when removing polyps in patients with these risk factors. Future studies are warranted to determine appropriate preventive hemostatic measures in these patients.

Endoscopic resection of colorectal polyps in patients on antiplatelet therapy: an evidence-based guidance for clinicians

Due to the rising prevalence of coronary heart disease, endoscopists are more frequently performing a polypectomy in patients on antiplatelet therapy (APT) and dual antiplatelet therapy (DATP). Despite the availability of several guidelines with regard to the management of antiplatelet drugs during the periprocedure period, there is still variability in the current clinical practice. This may be influenced by the low quality of the evidence supporting recommendations, because most of the studies dealing with APT and polypectomy are observational and retrospective, and include mainly small (< 10 mm) polyps. However, some recommendations can still be made. An estimation of the bleeding and thrombotic risk of the patient should be made in advance. In the case of DAPT the procedure should be postponed, at least until clopidogrel can be safely withheld. If possible, non-aspirin antiplatelet drugs should be withheld 5-7 days before the procedure. Polyp size is the main factor related with post-polypectomy bleeding and it is the factor that should drive clinical decisions regarding the resection method and the use of endoscopic prophylactic measures. Non-aspirin antiplatelet agents can be reintroduced 24-48 hours after the procedure. In conclusion, there is little data with regard to the management of DAPT in patients with a scheduled polypectomy. Large randomized controlled trials are needed to support clinical recommendations.

Heparin bridge therapy and post-polypectomy bleeding

AIM

To identify risk factors for post-polypectomy bleeding (PPB), focusing on antithrombotic agents.

METHODS

This was a case-control study based on medical records at a single center. PPB was defined as bleeding that occurred 6 h to 10 d after colonoscopic polypectomy and required endoscopic hemostasis. As risk factors for PPB, patient-related factors including anticoagulants, antiplatelets and heparin bridge therapy as well as polyp- and procedure-related factors were evaluated. All colonoscopic hot polypectomies, endoscopic mucosal resections and endoscopic submucosal dissections performed between January 2011 and December 2014 were reviewed.

RESULTS

PPB occurred in 29 (3.7%) of 788 polypectomies performed during the study period. Antiplatelet or anticoagulant agents were prescribed for 210 (26.6%) patients and were ceased before polypectomy except for aspirin and cilostazol in 19 cases. Bridging therapy using intravenous unfractionated heparin was adopted for 73 patients. The univariate analysis revealed that anticoagulants, heparin bridge, and anticoagulants plus heparin bridge were significantly associated with PPB (P < 0.0001) whereas antiplatelets and antiplatelets plus heparin were not. None of the other factors including age, gender, location, size, shape, number of resected polyps, prophylactic clipping and resection method were correlated with PPB. The multivariate analysis demonstrated that anticoagulants and anticoagulants plus heparin bridge therapy were significant risk factors for PPB (P < 0.0001). Of the 29 PPB cases, 4 required transfusions and none required surgery. A thromboembolic event occurred in a patient who took anticoagulant.

CONCLUSION

Patients taking anticoagulants have an increased risk of PPB, even if the anticoagulants are interrupted before polypectomy. Heparin-bridge therapy might be responsible for the increased PPB in patients taking anticoagulants.

A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions

BACKGROUND & AIMS

After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk.

METHODS

We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding.

RESULTS

Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively.

CONCLUSIONS

The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.

Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review

BACKGROUND

Bleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding.

METHODS

Multiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip.

RESULTS

Five hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56-4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42-1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69-2.24; P=0.47) were analyzed.

CONCLUSIONS

The use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.

Complication and local recurrence rate after endoscopic resection of large high-risk colorectal adenomas of ≥3 cm in size

PURPOSE

Endoscopic resection is a widely used technique for treatment of large colorectal adenomas, but few data are available including only lesions larger than ≥2 cm. The aim of this study is to evaluate the complication and recurrence rate after endoscopic resection of high-risk colorectal adenomas ≥3 cm in size.

METHODS

Retrospective analysis of a prospectively maintained database of patients undergoing polypectomy of large colorectal polyps of ≥3 cm.

RESULTS

In 341 patients, 360 colorectal adenomas with a mean size of 3.9 cm were resected endoscopically. In 25 patients, a complication including 22 delayed bleedings (6.5%) and three perforations (0.9%) occurred. Single-variate analysis showed an increasing risk of complications for larger adenomas (3.9 vs. 4.6 cm; p ≤ 0.05). Two hundred twelve patients with 224 adenomas had undergone at least one documented follow-up endoscopy with a medium follow-up period of 16 months. In 95 resected lesions (42.4%), a residual adenoma occurred in the first follow-up colonoscopy (n = 88, 92.6%) or a recurrent adenoma occurred after at least one negative follow-up colonoscopy (n = 7, 7.4%). In multivariate analysis, risk factors were lesion size, sessile growth pattern, and the performing endoscopist. The complication and recurrence rate correlated inversely between endoscopists.

CONCLUSIONS

The present study is the largest study showing complication and recurrence rates after colorectal polypectomy of advanced colorectal adenomas of ≥3 cm in size. Polyp size was identified as the most important risk factor for complications. For the first time, this study shows that the complication rate after colorectal polypectomy of large adenomas is correlated inversely with the residual and/or recurrence rate.

Risk factors for delayed post-polypectomy bleeding

Background/Aims

Among the many complications that can occur following therapeutic endoscopy, bleeding is the most serious, which occurs in 1.0-6.1% of all colonoscopic polypectomies. The aim of this study was to identify risk factors of delayed post-polypectomy bleeding (PPB).

Methods

We retrospectively reviewed the data of patients who underwent colonoscopic polypectomy between January 2003 and December 2012. We compared patients who experienced delayed PPB with those who did not. The control-to-patient ratio was 3:1. The clinical data analyzed included polyp size, number, location, and shape, patient' body mass index (BMI), preventive hemostasis, and endoscopist experience.

Results

Of 1,745 patients undergoing colonoscopic polypectomy, 21 (1.2%) experienced significant delayed PPB. We selected 63 age- and sex-matched controls. Multivariate logistic regression analysis showed that polyps >10 mm (odds ratio [OR], 2.605; 95% confidence interval [CI], 1.035-4.528; P=0.049), a pedunculated polyp (OR, 3.517; 95% CI, 1.428-7.176; P=0.045), a polyp located in the right hemicolon (OR, 3.10; 95% CI, 1.291-5.761; P=0.013), and a high BMI (OR, 3.681; 95% CI, 1.876-8.613; P=0.013) were significantly associated with delayed PPB.

Conclusions

Although delayed PPB is a rare event, more caution is needed during colonoscopic polypectomies performed in patients with high BMI or large polyps, pedunculated polyps, or polyps located in the right hemicolon.

Risk factors for delayed postpolypectomy bleeding

AIM: To identify risk factors for delayed postpolypectomy bleeding (DPPB) and analyze the correlations of these risk factors with DPPB.

METHODS: A total of 2292 polpyectomies performed in 1426 cases between November 2008 and April 2014 were retrospectively reviewed. Polyp-related and procedure-related factors were evaluated as potential risk factors for DPPB.

RESULTS: Delayed bleeding occurred in 20 (1.4%) cases. Multivariate analysis revealed that polyp size > 10 mm [odds ratio (OR) = 1.222, 95% confidence interval (CI): 1.205-1.239, (P = 0.003], location in the right hemicolon (OR = 1.152, 95%CI: 1.137-1.167, (P = 0.049), and inadequate endoscopic experience of endoscopist (OR = 1.307, 95%CI: 1.288-1.326, (P = 0.046) were significant risk factors for DPPB. Right-sided polypectomy by an inexperienced endoscopist (OR = 1.992, 95%CI: 1.975-2.009, (P = 0.000) significantly increased the risk for DPPB.

CONCLUSION: Polyp size, right hemicolon location andinadequate endoscopic experience of endoscopist were identified as potential risk factors for DPPB.

Optimized sedation improves colonoscopy quality long-term

Background. Quality monitoring and improvement is prerequisite for efficient colonoscopy. Aim. To assess the effects of increased sedation administration on colonoscopy performance. Materials and Methods. During Era 1 we prospectively measured four colonoscopy quality indicators: sedation administration, colonoscopy completion rate, adenoma detection rate, and early complications rate in three cohorts: cohort A: intention for total colonoscopy cases; cohort B: cohort A excluding bowel obstruction cases; cohort C: CRC screening-surveillance cases within cohort B. We identified deficiencies and implemented our plan to optimize sedation. We prospectively evaluated its effects in both short- (Era 2) and long-term period (Era 3). Results. We identified that sedation administration and colonoscopy completion rates were below recommended standards. After sedation optimization its use rate increased significantly (38.1% to 55.8% to 69.5%) and colonoscopy completion rate increased from 88.3% to 90.6% to 96.4% in cohort B and from 93.2% to 95.3% to 98.3% in cohort C, in Eras 1, 2, and 3, respectively. Adenoma detection rate increased in cohort C (25.9% to 30.6% to 35%) and early complications rate decreased from 3.4% to 1.9% to 0.3%. Most endoscopists increased significantly their completion rate and this was preserved long-term. Conclusion. Increased sedation administration results in long-lasting improvement of colonoscopy quality indicators.

Only the size of resected polyps is an independent risk factor for delayed postpolypectomy hemorrhage: a 10-year single-center case-control study

Purpose

A colonoscopic polypectomy is an important procedure for preventing colorectal cancer, but it is not free from complications. Delayed hemorrhage after a colonoscopic polypectomy is one infrequent, but serious, complication. The aim of this study was to identify the risk factors for delayed hemorrhage after a colonoscopic polypectomy.

Methods

This was a retrospective case-control study based on medical records from a single gastroenterology center. The records of 7,217 patients who underwent a colonoscopic polypectomy between March 2002 and March 2012 were reviewed, and 92 patients and 276 controls were selected. Data collected included comorbidity, use of antiplatelet agents, size and number of resected polyps, histology and gross morphology of resected polyps, resection method, and use of prophylactic hemostasis.

Results

The average time between the procedure and bleeding was 2.71 ± 1.55 days. Univariate and multivariate analyses revealed that the size of the polyps was the only and most important predictor of delayed hemorrhage after a colonoscopic polypectomy (odds ratio, 2.06; 95% confidence interval, 1.12-1.27; P = 0.03).

Conclusion

The size of resected polyps was the only independent risk factor for delayed bleeding after a colonoscopic polypectomy. The size of a polyp, as revealed by the colonoscopic procedure, may aid in making decisions, such as the decision to conduct a prophylactic hemostatic procedure.