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

Abstract

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.

The Risk of Postpolypectomy Bleeding in Patients Receiving Direct Oral Anticoagulants compared to Warfarin or Nonanticoagulation: A Systematic Review with Meta-Analysis

“…Ethnic differences should also be taken into consideration. Our outcome is different from Zhu et al [25] work, which included 27 of 30 studies in their meta-analysis from Japan [25]. These different outcomes between our Japanese-study subgroup and their works are mainly due to the different internalized studies, especially Harada et al [12] work, which was published recently and with a high preponderance in our analysis.…”

“…No significant difference between DOACs and warfarin was detected regarding the risk of PPB (OR=0.826, 95%CI: 0.583-1.172). However, a recent meta-analysis comparing DOACs with warfarin reported a decrease in postprocedural bleeding risk using DOACs instead of warfarin, following endoscopic resection [25]. This opposite result may be due to the different endoscopic procedures incorporated.…”

“…This opposite result may be due to the different endoscopic procedures incorporated. Since Zhu et al [25] focused on endoscopic resection, including cold polypectomy, hot polypectomy, endoscopic submucosal dissection (ESD), and endoscopic mucosal resection (EMR), we only focused on polypectomy. Furthermore, 27 of 30 studies included in their meta-analysis came from Japan, suggesting a probable existence of geographical bias.…”