Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants

Perioperative Management in Patients with Atrial Fibrillation Treated with Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Minor Bleeding Risk Procedure: Rationale and Protocol for the PERIXa Study

Background

While treatment interruption of non-vitamin K antagonist oral anticoagulants (NOACs) for elective surgery or procedures among patients with atrial fibrillation (AF) is becoming more prevalent, there remains insufficient evidence regarding the optimal perioperative management of NOACs, particularly procedures with minor bleeding risks.

Objective

This study aims to evaluate the safety and effectiveness of a simplified, standardized protocol for perioperative management of direct factor Xa inhibitors in patients, with AF undergoing procedures associated with minor bleeding risk.

Methods

This multicenter, prospective single-arm registry study plans to enroll patients undergoing procedures with minor bleeding risk who were prescribed direct factor Xa inhibitors for AF. The procedures with minor bleeding risk will include gastrointestinal endoscopy for diagnostic purposes, selected dental procedures, and ocular surgery for cataracts or glaucoma. For apixaban, patients will withhold the last evening dose and resume either from the evening dose of the procedure day or the following morning, depending on the bleeding risk of the patient. For edoxaban or rivaroxaban, patients will withhold only a single dose on the procedure day. The primary outcome is the occurrence of major bleeding events within 30 days. Secondary outcomes include systemic thromboembolism, all-cause mortality, and a composite of major and clinically relevant non-major bleeding events.

Conclusion

This study has the potential to generate evidence regarding the safety of perioperative management for patients, with AF undergoing procedures associated with minor bleeding risk.

Trial Registration

Clinicaltrials.gov: NCT05801068.

Efficacy of hemostatic gel for perioperative bleeding and prevention of delayed bleeding of cold snare polypectomy under anticoagulant

Background and Aim

A hemostatic gel, PuraStat (3-D Matrix, Tokyo, Japan), is used for various gastrointestinal hemostasis. In this study, we analyzed the efficacy of PuraStat for perioperative bleeding (POB) and prevention of delayed bleeding (DB) to colorectal cold snare polypectomy (CSP) with continuous anticoagulant.

Methods

This was a single-center, retrospective study. Subjects were lesions of 2-9 mm under continuous anticoagulant from 2021 to 2023 and treated with PuraStat for POB. The definition of POB was bleeding which did not stop spontaneously by 1.0-1.5 min after resection and needed hemostasis. Successful hemostasis was defined as cessation of bleeding within 1.0-1.5 min after spraying PuraStat and the rate of it and risk factors of POB were analyzed. For comparison, cases receiving previous CSP without PuraStat were extracted from all cases with CSP (2018-2021), and POB and DB rate (DBR) were analyzed after propensity score matching.

Results

One hundred twenty-two lesions (91: direct oral anticoagulant (DOAC), 31: warfarin) with anticoagulant were analyzed and the rate of successful hemostasis with PuraStat was 92.6% (DOAC/warfarin: 93.4%/80.6%, P = 0.01). The rate of DB was 0.0%. Multivariate analysis showed that significant risk factors about unsuccessful hemostasis for POB with PuraStat were lesion size 8-9 mm (P < 0.01), warfarin (P = 0.01), and combination of antiplatelet (P = 0.01). Regarding the comparison about CSP with/without PuraStat, the clipping rate and DBR were 8.5%/94.9% (P < 0.01) and 0%/1.7% (P = 1.0).

Conclusion

The effects of PuraStat for POB and DB in colorectal CSP with continuous anticoagulant were acceptable.

Risk Factors of Delayed Bleeding After Cold Snare Polypectomy for Colorectal Polyps: A Multicenter Study

BACKGROUND

Delayed bleeding (DB) rarely occurs after cold snare polypectomy (CSP) for colorectal polyps, but no large-scale studies have investigated this. The present study evaluated the rate, characteristics, and risk factors of DB of CSP.

METHODS

We conducted a multicenter retrospective study at 10 Japanese institutions. A total of 18,007 patients underwent CSP for colorectal polyps ≤ 10 mm in size from March 2015 to September 2019, and cases of DB (DB group) were analyzed for the rate, antithrombotic drugs, polyp size, morphology, location, and risk factors. As a control, 269 non-bleeding cases (non-DB group) with 606 polyps who underwent CSP at the same 10 facilities in the 2-week study period were extracted.

RESULTS

We analyzed 26 DB cases with 28 lesions, and the total DB rate was 0.14% (26/18,007). The DB group had significantly higher rates of using antiplatelets (42.3% vs. 13.0%, p < 0.001) and anticoagulants (19.2% vs. 2.6%, p = 0.002), and significantly higher rates of polyp size ≥ 5 mm (67.9% vs. 45.2%, p = 0.015), rectal lesion (25.0% vs. 6.6%, p = 0.003), and polypoid lesion (89.3% vs. 55.3%, p < 0.001) than the non-DB group. A multivariate analysis (odds ratio; 95% confidence interval) for patient characteristics showed antiplatelet use (4.521; 1.817-11.249, p = 0.001) and anticoagulant use (7.866; 20.63-29.988, p = 0.003) as independent risk factors for DB. Polyp size ≥ 5 mm (3.251; 1.417-7.463, p = 0.005), rectal lesion (3.674; 1.426-9.465, p = 0.007), and polypoid lesion (7.087; 20.81-24.132, p = 0.002) were also risk factors for lesion characteristics.

CONCLUSIONS

The rate of DB was 0.14% and antithrombotic drug use, polyp size, location, and morphology were related to it.

Bleeding After Gastric Endoscopic Submucosal Dissection Focused on Management of Xa Inhibitors

Purpose

The use of direct oral Xa inhibitors (DXaIs) to prevent venothrombotic events is increasing. However, gastrointestinal bleeding, including that related to endoscopic resection, is a concern. In this study, we evaluated bleeding and coagulation times during the perioperative period of gastric endoscopic submucosal dissection (ESD).

Materials and Methods

Patients who consecutively underwent gastric ESD from August 2016 to December 2018 were analyzed. Bleeding rates were compared among the 3 groups (antiplatelet, DXaIs, and control). DXaI administration was discontinued on the day of the procedure. Prothrombin time (PT), activated partial thromboplastin time, and the ratio of inhibited thrombin generation (RITG), which was based on dilute PT, were determined before and after ESD.

Results

During the study period, 265 gastric ESDs were performed in 239 patients, where 23 and 50 patients received DXaIs and antiplatelets, respectively. Delayed bleeding occurred in 17 patients (7.4%) and 21 lesions (7.1%). The bleeding rate in the DXaI group was significantly higher than that in the other groups (30.4%, P<0.01), and the adjusted odds ratio of bleeding was 5.7 (95% confidence interval, 1.4–23.7; P=0.016). In patients using DXaIs, there was a significant (P=0.046) difference in the median RITG between bleeding cases (18.6%) and non-bleeding cases (3.8%).

Conclusions

A one-day cessation of DXaIs was related to a high incidence of bleeding after gastric ESD, and monitoring of residual coagulation activity at trough levels might enable the predicted risk of delayed bleeding in patients using DXaIs.

Risk of Bleeding after Colorectal Endoscopic Resection in Patients with Continued Warfarin Use Compared to Heparin Replacement: A Propensity Score Matching Analysis

The Japan Gastroenterological Endoscopy Society (JGES) guidelines recommend continued warfarin treatment during gastroenterological endoscopic procedures with a high risk of bleeding as an alternative to heparin replacement in patients on warfarin therapy. However, there is insufficient evidence to support the use of warfarin in colorectal endoscopic resection (ER). The present study is aimed at verifying the risk of bleeding after ER for colorectal neoplasia (CRN) in patients with continued warfarin use. This was a single-center retrospective cohort study using clinical records. We assessed 126 consecutive patients with 159 CRNs who underwent ER (endoscopic mucosal resection, 146 cases; endoscopic submucosal dissection, 13 cases) at Hiroshima University Hospital between January 2014 and December 2019. Patients were divided into two groups: the heparin replacement group (79 patients with 79 CRNs) and the continued warfarin group (47 patients with 80 CRNs). One-to-one propensity score matching was performed to compare the bleeding rate after ER between the groups. The rate of bleeding after ER was significantly higher in the heparin replacement group than in the continued warfarin group for both before (10.1% vs. 1.3%, respectively; P = 0.0178) and after (11.9% vs. 0%, respectively; P = 0.0211) propensity score matching. None of the patients experienced thromboembolic events during the perioperative period. The risk of bleeding after colorectal ER was significantly lower in patients with continued warfarin use than in those with heparin replacement. Our data supports the recommendations of the latest JGES guidelines for patients receiving warfarin therapy.

Complications of colonoscopy in Japan: An analysis using large-scale health insurance claims data

BACKGROUND AND AIM

In Japan, screening colonoscopy for colorectal cancer is expected to reduce colorectal cancer mortality, although its complication rate has not been sufficiently examined. The aim of this study is to analyze severe complications due to colonoscopy.

METHODS

As a study population, we retrospectively used commercially anonymized health insurance claims data covering 5.71 million patients from January 2005 to August 2018. We extracted patients who received colonoscopy with lesions resection or without treatment. Main outcomes were rates of hemorrhage, perforation, fatal events, and their risk factors.

RESULTS

Among 341 852 colonoscopy without treatment in 260 128 patients (mean age: 49.6 ± 11.7 years), the rates of hemorrhage, perforation, and fatal events were 0.0059% (95% confidence interval [CI] 0.0031-0.0085), 0.0032% (95% CI 0.0011-0.0052), and 0.00029% (95% CI 0-0.0012), respectively. Regarding hemorrhage, compared with the rate for patients <50 years old (0.0050%), the rates for those 50-59, 60-69, and ≥70 years old were 0.0095% (P = 0.17), 0.0031% (P = 0.17), and 0%, respectively. Regarding perforation, compared with patients <50 years old (0.0056%), the rates for those 50-59, 60-69, and ≥70 years old were 0%, 0.0015% (P = 0.99), and 0.0102% (P = 0.99), respectively. A multivariate analysis for risk factors showed no significant findings for hemorrhage and perforation without treatment. Among 123 087 colonoscopy with lesions resection in 102 058 patients (mean age: 53.7 ± 9.3 years), the rates of hemorrhage, perforation, and fatal events were 0.136% (95% CI 0.1157-0.1572), 0.033% (95% CI 0.0228-0.0437), and 0.00081% (95% CI 0-0.0035), respectively.

CONCLUSIONS

The analysis using health insurance claims data demonstrated the safety of colonoscopy.

Bleeding after endoscopic resection between direct oral anticoagulants or warfarin: Systematic review and meta-analysis

BACKGROUND AND AIM

Oral anticoagulants are risk factors for post-endoscopic resection bleeding. We aimed to conduct a systematic review and meta-analysis for the risks of post-procedural bleeding (PPB) for direct oral anticoagulants (DOACs) and warfarin following endoscopic resection.

METHODS

Two independent reviewers searched PubMed, Web of Science, Embase, and Cochrane Library. The Newcastle-Ottawa Scale score was used to assess the quality of the studies, the pooled odds ratio (OR) to present PPB results, and the funnel plots to assess publication bias. The Higgins I² statistic was employed to determine the variation across studies due to heterogeneity.

RESULTS

We reviewed 30 articles. PPB occurred in 586 patients on DOACs and 1782 on warfarin. The patients on DOACs had a significantly lower overall risk of PPB compared with those on warfarin (OR, 0.867, 95% confidence interval, 0.771-0.975; P = 0.017, I²  = 1.6%). Cumulative meta-analysis showed that the PPB rate of DOACs has the trend to be lower than that of warfarin with publication year and sample size. For the subgroup of endoscopic submucosal dissection, the PPB of DOACs was significantly lower than that of warfarin (OR, 0.786; 95% confidence interval, 0.633-0.976; P = 0.029, I²  = 0%). No significant difference was observed between DOACs and warfarin for anticoagulant strategies, endoscopic procedures, and lesion location.

CONCLUSIONS

Compared with warfarin, DOACs have the possibility to significantly decrease the risk of PPB following endoscopic resection, especially for endoscopic submucosal dissection.

Management of anticoagulants in delayed bleeding after endoscopic resection: A systematic review and meta-analysis

Background and study aims  Delayed bleeding and thrombotic events are uncontrolled adverse events that are hard to balance in patients receiving anticoagulants after endoscopic resection. The present study aims to assess the clinical effect of warfarin, when compared to direct oral anticoagulants (DOACs), in terms of delayed bleeding and thrombotic events. Methods  A comprehensive electronic literature search was conducted for eligible literature. Pairwise meta-analyses were performed on outcomes of delayed bleeding and thrombotic events. Two networks within the Bayesian framework were established based on the management of anticoagulants and type of DOAC. Results  Eight cohort studies with 2,046 patients were eligible for inclusion, including 1,176 patients treated with warfarin and 870 with DOACs. There was no significant difference between warfarin and DOACs, in terms of delayed bleeding (OR = 1.29, 95 % CI [0.99-1.69]) and thromboembolism (OR = 2.0, 95 % CI [0.32-12.39]). In the network meta-analyses for delayed bleeding, the rank probabilities revealed that the safest management was discontinuous warfarin without heparin bridge therapy (HBT). Rank probabilities for the types of DOACs demonstrated that the safest drug was dabigatran. Conclusions  There was no significant difference in delayed bleeding and thromboembolism between warfarin and DOACs in patients receiving endoscopic treatment. In terms of delayed bleeding, discontinuous warfarin without HBT was suggested as the best management, and dabigatran was recommended as the best type of DOAC.