Safety of cold snare polypectomy with periprocedural antithrombotic agents for colorectal polyps: a systematic review and meta-analysis

Abstract

Background: We aimed to study the safety of cold snare polypectomy (CSP) for colorectal polyps in patients administered periprocedural antithrombotic agents. Methods: We searched the PubMed, Embase, and Cochrane Library databases through June 2021. The primary outcomes were the rates of delayed and immediate bleeding (requiring endoscopic hemostasis). Secondary outcomes included thromboembolic events. Meta-analysis using odds ratios (ORs) and corresponding 95% confidence intervals (CIs) was performed to compare the outcomes. Results: Seventeen studies, including five randomized trials, were included. Over 96% of polyps were ⩽1 cm. The pooled rates of delayed and immediate bleeding for patients receiving CSP and periprocedural antithrombotic agents were 1.6% and 10.5%, respectively. Both the delayed (OR = 4.02, 95% CI = 1.98–8.17) and immediate bleeding (OR = 5.85, 95% CI = 3.84–8.89) rates were significantly higher in patients using periprocedural antithrombotic agents than in non-users. Although both antiplatelet agents and anticoagulants increased the risk of delayed bleeding, the risks associated with the use of direct oral anticoagulants (DOACs; 2.5%) or multiple agents (3.9%) were particularly high. Compared to their counterparts, diminutive polyps and uncomplicated lesions not requiring hemoclipping were associated with lower risks of delayed bleeding (pooled estimates of 0.4% and 0.18%, respectively). Thromboembolic risk was similar among patients using and not using periprocedural antithrombotic agents. Conclusions: CSP with periprocedural antiplatelet agents and warfarin may be feasible, especially for diminutive polyps. However, drug discontinuation should be considered with the use of DOACs or multiple agents which entail higher bleeding risk even with hemoclipping.

Colorectal cold snare polypectomy: Current standard technique and future perspectives

“…A meta-analysis integrating a total of 17 prospective studies, including the aforementioned ones, showed that the pooled rate of delayed bleeding after CSP was 1.6% and the use of antithrombotic drugs was a risk factor for delayed bleeding after CSP (OR 4.02; 95% CI 1.98-8.17). 49 This study also revealed that the pooled rate of delayed bleeding after CSP was 2.5% for DOACs alone, and 3.9% for combination drugs, concluding that the delayed bleeding rate is acceptable for antiplatelet agents or warfarin alone. Considering the risk of thrombus formation due to the discontinuation of antithrombotic agents, CSP may be useful for resecting lesions safely without discontinuing antiplatelet agents or warfarin alone.…”

“…showed predominantly less delayed bleeding after CSP in the group that discontinued DOACs on the day of treatment. A meta‐analysis integrating a total of 17 prospective studies, including the aforementioned ones, showed that the pooled rate of delayed bleeding after CSP was 1.6% and the use of antithrombotic drugs was a risk factor for delayed bleeding after CSP (OR 4.02; 95% CI 1.98–8.17) 49 . This study also revealed that the pooled rate of delayed bleeding after CSP was 2.5% for DOACs alone, and 3.9% for combination drugs, concluding that the delayed bleeding rate is acceptable for antiplatelet agents or warfarin alone.…”

Impact of Submucosal Saline Injection During Cold Snare Polypectomy for Colorectal Polyps Sized 3–9 mm: A Multicenter Randomized Controlled Trial

“…Notably, we did not include patients taking antithrombotics within 5 days, who are regarded as having a high risk of bleeding in clinical practice. Although increasing evidence has demonstrated the safety of CSP in patients with periprocedural antiplatelet agents and warfarin (15), the impact of submucosal injection during CSP in such high-risk patients requires further evaluation.…”

Safety of Cold Snare Polypectomy during Continuous Use of Antithrombotic Drugs for Delayed Post-Polypectomy Bleeding: A Pilot Study

“…CSP has fewer adverse events than other polypectomy techniques [7,8], and it is now widely practiced. Increased delayed postpolypectomy bleeding (DPPB) rate in CSP has been reported in patients using antithrombotic drugs [9][10][11], and in such cases, CSP may not always be safe. As the number of patients taking antithrombotic drugs is increasing owing to the aging population [12,13], CSP is also being increasingly performed on those on antithrombotic medications.…”