User login
, according to recent research published in the Annals of Internal Medicine.
“Guidelines on peripolypectomy management of anticoagulants vary greatly, and the current updated guidelines do not recommend heparin bridging (HB) for all patients; however, direct comparison of HB with continuous administration of oral anticoagulants (CA) has provided little evidence,” Yoji Takeuchi, MD, from the Department of Gastrointestinal Oncology at Osaka International Cancer Institute in Osaka, Japan, and colleagues wrote.
While cold snare polypectomy (CSP) has been recommended by the European Society of Gastrointestinal Endoscopy for subcentimeter polyps, anticoagulant delivery method has not been studied between these two poly removal methods. “Cold snare polypectomy with CA may be performed safely, without the complications of HB, while theoretically maintaining an anticoagulant effect,” the researchers said.
Dr. Takeuchi and colleagues performed a randomized controlled trial of 182 patients with subcentimeter colorectal polyps who underwent either CA with CSP (CA+CSP; 92 patients) or hot snare polypectomy (HSP) with HB (HB+HSP; 90 patients) at one of 30 different Japanese centers. Patients were between 20 and 80 years old and had preserved organ function, an Eastern Cooperative Oncology Group Performance Status score of 1 or less, and were taking warfarin or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. Researchers assessed the level of bleeding at 28-day follow-up, and also measured procedure time per polyp and length of hospital stay for each group.
Overall, there were 611 polyps removed in 168 patients. The rate of major bleeding in the CA+CSP group was 4.7% (95% confidence interval [CI], 0.2%-9.2%) compared with 12.0% (95% CI, 5.0%-19.1%) in the HB+HSP group with an intergroup difference of 7.3% (95% CI, 1.0%-15.7%).
“[T]he Japanese guidelines consider all patients receiving anticoagulants to be at high risk for thromboembolism associated with antithrombotic withdrawal,” Dr. Takeuchi and colleagues said. “Our results suggest that discontinuing anticoagulant therapy before polypectomy for subcentimeter polyps may be unnecessary and support the Japanese guidelines, which recommend not withholding anticoagulants for procedures with low bleeding risk.”
The researchers declared CA+CSP to be non-inferior with a 0.4% lower limit of 2-sided 90% CI. “[W]e noted a higher number of total and right-sided polyps in the CA+CSP group, both of which may result in more frequent bleeding episodes, which suggests that CA+CSP may be a relatively safe approach,” the researchers said. “Therefore, we think that CSP may be the least risky polypectomy procedure.”
The mean procedure time per polyp was 59.6 seconds in the CA+CSP group (54.0-65.2 seconds) compared with 94.4 seconds in the HB+HSP group (87.1-101.7 seconds; P less than .001). Mean hospital stay for patients in the CA+CSP group was shorter at 2.9 days (1.8-4.0 days) compared with 5.1 days in the HB+HSP group (4.2-6.1 days; P equals .003).
The study examined patients receiving two different anticoagulant delivery methods and polyp removal procedures, which made it difficult to determine which intervention contributed to the results, the researchers said. In addition, the study was not blinded and polyp type was limited to only subcentimeter polyps.
“Although CA+CSP is considered standard treatment for subcentimeter colorectal polyps in patients receiving anticoagulants, a larger trial is needed to identify a better management strategy for patients receiving DOACs,” the researchers said.
This study was supported by a grant from the Japanese Gastroenterological Association. The authors report no relevant conflicts of interest.
SOURCE: Takeuchi Y et al. Ann Intern Med. 2019;doi: 10.7326/M19-0026 .
It is still an open question what the safest method to remove colon polyps is in patients taking continuous anticoagulants (CA), but the study by Takeuchi et al. shows cold snare polypectomy (CSP) has promise, Jeffrey L. Tokar, MD; and Michael J. Bartel, MD, wrote in a related editorial.
“[T]his study adds to emerging evidence that small colorectal polyps may be resected safely with CSP while oral anticoagulation continues and provides the first comparative evidence that this strategy may be safer than [heparin bridging with hot snare polypectomy] HB+HSP,” they said.
Another consideration of CA+CSP is the risk of intraprocedural postpolypectomy bleeding, but there were no cases of this kind of bleeding in the results by Takeuchi et al., which may give some clinicians reassurance about the method. However, the study did not take into account the risk in patients taking warfarin or direct oral anticoagulants who had incomplete polyp resection, and the difference in CA therapy between CSP and HSP, or the effect of not using heparin bridging in CSP or HSP was not studied.
“The results warrant confirmatory studies, preferably with blinding to the use of anticoagulation and assessment of several additional factors: incomplete polyp resection, the effect of prophylactic hemostatic actions (such as clipping), and the applicability of CA+CSP to the removal of larger polyps and to the use of other classes of antithrombotic medications (such as thienopyridines),” Dr. Tokar and Dr. Bartel concluded.
Dr. Tokar and Dr. Bartel are from the Fox Chase Cancer Center in Philadelphia. They report no relevant conflicts of interest.
It is still an open question what the safest method to remove colon polyps is in patients taking continuous anticoagulants (CA), but the study by Takeuchi et al. shows cold snare polypectomy (CSP) has promise, Jeffrey L. Tokar, MD; and Michael J. Bartel, MD, wrote in a related editorial.
“[T]his study adds to emerging evidence that small colorectal polyps may be resected safely with CSP while oral anticoagulation continues and provides the first comparative evidence that this strategy may be safer than [heparin bridging with hot snare polypectomy] HB+HSP,” they said.
Another consideration of CA+CSP is the risk of intraprocedural postpolypectomy bleeding, but there were no cases of this kind of bleeding in the results by Takeuchi et al., which may give some clinicians reassurance about the method. However, the study did not take into account the risk in patients taking warfarin or direct oral anticoagulants who had incomplete polyp resection, and the difference in CA therapy between CSP and HSP, or the effect of not using heparin bridging in CSP or HSP was not studied.
“The results warrant confirmatory studies, preferably with blinding to the use of anticoagulation and assessment of several additional factors: incomplete polyp resection, the effect of prophylactic hemostatic actions (such as clipping), and the applicability of CA+CSP to the removal of larger polyps and to the use of other classes of antithrombotic medications (such as thienopyridines),” Dr. Tokar and Dr. Bartel concluded.
Dr. Tokar and Dr. Bartel are from the Fox Chase Cancer Center in Philadelphia. They report no relevant conflicts of interest.
It is still an open question what the safest method to remove colon polyps is in patients taking continuous anticoagulants (CA), but the study by Takeuchi et al. shows cold snare polypectomy (CSP) has promise, Jeffrey L. Tokar, MD; and Michael J. Bartel, MD, wrote in a related editorial.
“[T]his study adds to emerging evidence that small colorectal polyps may be resected safely with CSP while oral anticoagulation continues and provides the first comparative evidence that this strategy may be safer than [heparin bridging with hot snare polypectomy] HB+HSP,” they said.
Another consideration of CA+CSP is the risk of intraprocedural postpolypectomy bleeding, but there were no cases of this kind of bleeding in the results by Takeuchi et al., which may give some clinicians reassurance about the method. However, the study did not take into account the risk in patients taking warfarin or direct oral anticoagulants who had incomplete polyp resection, and the difference in CA therapy between CSP and HSP, or the effect of not using heparin bridging in CSP or HSP was not studied.
“The results warrant confirmatory studies, preferably with blinding to the use of anticoagulation and assessment of several additional factors: incomplete polyp resection, the effect of prophylactic hemostatic actions (such as clipping), and the applicability of CA+CSP to the removal of larger polyps and to the use of other classes of antithrombotic medications (such as thienopyridines),” Dr. Tokar and Dr. Bartel concluded.
Dr. Tokar and Dr. Bartel are from the Fox Chase Cancer Center in Philadelphia. They report no relevant conflicts of interest.
, according to recent research published in the Annals of Internal Medicine.
“Guidelines on peripolypectomy management of anticoagulants vary greatly, and the current updated guidelines do not recommend heparin bridging (HB) for all patients; however, direct comparison of HB with continuous administration of oral anticoagulants (CA) has provided little evidence,” Yoji Takeuchi, MD, from the Department of Gastrointestinal Oncology at Osaka International Cancer Institute in Osaka, Japan, and colleagues wrote.
While cold snare polypectomy (CSP) has been recommended by the European Society of Gastrointestinal Endoscopy for subcentimeter polyps, anticoagulant delivery method has not been studied between these two poly removal methods. “Cold snare polypectomy with CA may be performed safely, without the complications of HB, while theoretically maintaining an anticoagulant effect,” the researchers said.
Dr. Takeuchi and colleagues performed a randomized controlled trial of 182 patients with subcentimeter colorectal polyps who underwent either CA with CSP (CA+CSP; 92 patients) or hot snare polypectomy (HSP) with HB (HB+HSP; 90 patients) at one of 30 different Japanese centers. Patients were between 20 and 80 years old and had preserved organ function, an Eastern Cooperative Oncology Group Performance Status score of 1 or less, and were taking warfarin or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. Researchers assessed the level of bleeding at 28-day follow-up, and also measured procedure time per polyp and length of hospital stay for each group.
Overall, there were 611 polyps removed in 168 patients. The rate of major bleeding in the CA+CSP group was 4.7% (95% confidence interval [CI], 0.2%-9.2%) compared with 12.0% (95% CI, 5.0%-19.1%) in the HB+HSP group with an intergroup difference of 7.3% (95% CI, 1.0%-15.7%).
“[T]he Japanese guidelines consider all patients receiving anticoagulants to be at high risk for thromboembolism associated with antithrombotic withdrawal,” Dr. Takeuchi and colleagues said. “Our results suggest that discontinuing anticoagulant therapy before polypectomy for subcentimeter polyps may be unnecessary and support the Japanese guidelines, which recommend not withholding anticoagulants for procedures with low bleeding risk.”
The researchers declared CA+CSP to be non-inferior with a 0.4% lower limit of 2-sided 90% CI. “[W]e noted a higher number of total and right-sided polyps in the CA+CSP group, both of which may result in more frequent bleeding episodes, which suggests that CA+CSP may be a relatively safe approach,” the researchers said. “Therefore, we think that CSP may be the least risky polypectomy procedure.”
The mean procedure time per polyp was 59.6 seconds in the CA+CSP group (54.0-65.2 seconds) compared with 94.4 seconds in the HB+HSP group (87.1-101.7 seconds; P less than .001). Mean hospital stay for patients in the CA+CSP group was shorter at 2.9 days (1.8-4.0 days) compared with 5.1 days in the HB+HSP group (4.2-6.1 days; P equals .003).
The study examined patients receiving two different anticoagulant delivery methods and polyp removal procedures, which made it difficult to determine which intervention contributed to the results, the researchers said. In addition, the study was not blinded and polyp type was limited to only subcentimeter polyps.
“Although CA+CSP is considered standard treatment for subcentimeter colorectal polyps in patients receiving anticoagulants, a larger trial is needed to identify a better management strategy for patients receiving DOACs,” the researchers said.
This study was supported by a grant from the Japanese Gastroenterological Association. The authors report no relevant conflicts of interest.
SOURCE: Takeuchi Y et al. Ann Intern Med. 2019;doi: 10.7326/M19-0026 .
, according to recent research published in the Annals of Internal Medicine.
“Guidelines on peripolypectomy management of anticoagulants vary greatly, and the current updated guidelines do not recommend heparin bridging (HB) for all patients; however, direct comparison of HB with continuous administration of oral anticoagulants (CA) has provided little evidence,” Yoji Takeuchi, MD, from the Department of Gastrointestinal Oncology at Osaka International Cancer Institute in Osaka, Japan, and colleagues wrote.
While cold snare polypectomy (CSP) has been recommended by the European Society of Gastrointestinal Endoscopy for subcentimeter polyps, anticoagulant delivery method has not been studied between these two poly removal methods. “Cold snare polypectomy with CA may be performed safely, without the complications of HB, while theoretically maintaining an anticoagulant effect,” the researchers said.
Dr. Takeuchi and colleagues performed a randomized controlled trial of 182 patients with subcentimeter colorectal polyps who underwent either CA with CSP (CA+CSP; 92 patients) or hot snare polypectomy (HSP) with HB (HB+HSP; 90 patients) at one of 30 different Japanese centers. Patients were between 20 and 80 years old and had preserved organ function, an Eastern Cooperative Oncology Group Performance Status score of 1 or less, and were taking warfarin or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, apixaban, or edoxaban. Researchers assessed the level of bleeding at 28-day follow-up, and also measured procedure time per polyp and length of hospital stay for each group.
Overall, there were 611 polyps removed in 168 patients. The rate of major bleeding in the CA+CSP group was 4.7% (95% confidence interval [CI], 0.2%-9.2%) compared with 12.0% (95% CI, 5.0%-19.1%) in the HB+HSP group with an intergroup difference of 7.3% (95% CI, 1.0%-15.7%).
“[T]he Japanese guidelines consider all patients receiving anticoagulants to be at high risk for thromboembolism associated with antithrombotic withdrawal,” Dr. Takeuchi and colleagues said. “Our results suggest that discontinuing anticoagulant therapy before polypectomy for subcentimeter polyps may be unnecessary and support the Japanese guidelines, which recommend not withholding anticoagulants for procedures with low bleeding risk.”
The researchers declared CA+CSP to be non-inferior with a 0.4% lower limit of 2-sided 90% CI. “[W]e noted a higher number of total and right-sided polyps in the CA+CSP group, both of which may result in more frequent bleeding episodes, which suggests that CA+CSP may be a relatively safe approach,” the researchers said. “Therefore, we think that CSP may be the least risky polypectomy procedure.”
The mean procedure time per polyp was 59.6 seconds in the CA+CSP group (54.0-65.2 seconds) compared with 94.4 seconds in the HB+HSP group (87.1-101.7 seconds; P less than .001). Mean hospital stay for patients in the CA+CSP group was shorter at 2.9 days (1.8-4.0 days) compared with 5.1 days in the HB+HSP group (4.2-6.1 days; P equals .003).
The study examined patients receiving two different anticoagulant delivery methods and polyp removal procedures, which made it difficult to determine which intervention contributed to the results, the researchers said. In addition, the study was not blinded and polyp type was limited to only subcentimeter polyps.
“Although CA+CSP is considered standard treatment for subcentimeter colorectal polyps in patients receiving anticoagulants, a larger trial is needed to identify a better management strategy for patients receiving DOACs,” the researchers said.
This study was supported by a grant from the Japanese Gastroenterological Association. The authors report no relevant conflicts of interest.
SOURCE: Takeuchi Y et al. Ann Intern Med. 2019;doi: 10.7326/M19-0026 .
FROM THE ANNALS OF INTERNAL MEDICINE
Key clinical point: Cold snare polypectomy (CSP) with continuous administration of anticoagulants (CA) used to remove colon polyps appears to result in less bleeding, a lower procedure time and shorter hospital stay than heparin bridging (HB) with hot snare polypectomy (HSP).
Major finding: The rate of major bleeding in the CA+CSP group was 4.7% compared with 12.0% in the HB+HSP group.
Study details: A prospective, open-label, parallel, multicenter randomized controlled trial of 182 patients who underwent CA+CSP or HB+HSP at 30 Japanese institutions between June 2016 and April 2018.
Disclosures: This study was supported by a grant from the Japanese Gastroenterological Association. The authors report no relevant conflicts of interest.
Source: Takeuchi Y, et al. Ann Intern Med. 2019;doi:10.7326/M19-0026.