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

Abstract

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.

International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy

“…One multicenter, parallel, non-inferiority RCT 79 and 26 retrospective or prospective cohort studies 59,62,65,74, procedures, such as colorectal EMR, 59,62,74,[79][80][81][82][83][84][85][86]88,89,91,[93][94][95][96]100 ESD, 74,79,90,96 gastric ESD, 65,74,79,96,98 EST, 74,79,92 esophageal ESD, 74,79 duodenal EMR, 79 PEG, 74,99 endoscopic ultrasound-guided fine needle aspiration, 74,87 and endoscopic ultrasound-guided biliary drainage 97 were evaluated. Most studies focused on the risks and benefits of heparin bridging therapy before the procedure.…”

“…Most studies focused on the risks and benefits of heparin bridging therapy before the procedure. 65,74,[79][80][81]84,85,88,93,94,96,100 Heparin bridging therapy is performed to reduce the risk of thromboembolism associated with the temporary cessation of warfarin therapy. However, procedure-related hemorrhage is significant when warfarin is continued or when heparin bridging therapy is performed during high-risk endoscopic procedures.…”

“…Several studies commonly recommend not using heparin bridging therapy because of its associated PPB risk. 65,74,[79][80][81]84,85,88,93,94,96,100 Some studies have advocated for continuing warfarin therapy before and after therapeutic procedures. 59,62,82,83,86,87,89,90,92,95,[97][98][99] However, most of these studies were conducted in Japan, and their retrospective nature hampered changes in previous statements.…”