Use of anticoagulants increases risk of bleeding after colorectal endoscopic submucosal dissection

Abstract

Background and study aims Japanese guidelines for gastroenterological endoscopy have recommended temporary withdrawal of anticoagulants (warfarin, direct oral anticoagulants [DOAC], or heparin) to prevent hemorrhagic complications during endoscopic submucosal dissection (ESD) for colorectal neoplasias (CRNs). However, serious thrombosis might occur during temporary withdrawal of anticoagulants. The current study aimed to evaluate outcomes with anticoagulants in patients undergoing ESD for CRNs. Patients and methods This study was a single-institution retrospective cohort study based on clinical records. We assessed 650 consecutive patients with 698 CRNs who underwent ESD at Hiroshima University Hospital between December 2010 and June 2016. The patients were divided into three groups: the warfarin group (19 patients with 19 CRNs), DOAC group (7 patients with 9 CRNs), and no-antithrombotics group (624 patients with 670 CRNs). We replaced warfarin with heparin 3 to 5 days before endoscopy. Although DOAC was suspended on the morning of endoscopy, we did not replace heparin. Results Bleeding after the procedure occurred in 26.3 % (5/19), 22.0 % (2/9), and 2.7 % (18/670) of patients in the warfarin, DOAC, and no-antithrombotics groups, respectively. In the warfarin group, four patients who bled after the procedure took not only warfarin but also other antiplatelets. En bloc resection rates were 94.7 % (18/19), 100 % (9/9), and 96.6 % (647/670) in the warfarin, DOAC, and no-antithrombotics groups, respectively. No patients experienced ischemic events in the perioperative period. Conclusions Among patients undergoing ESD for CRNs, risk of bleeding was higher among patients who took anticoagulants than among those who did not. In particular, careful attention to patients who took antiplatelets in addition to warfarin before ESD for CRNs is warranted.

Effect of anticoagulants on the risk of delayed bleeding after colorectal endoscopic submucosal dissection

“…In addition, the proportion of patients requiring blood transfusion due to severe bleeding was high at 3.4 %. Our data showing the high occurrence rate of delayed bleeding were similar to the rates reported in previous single-center, retrospective studies that included a small number of patients taking anticoagulants [8,14,15,22]. Our study is the first multicenter investigation to present detailed data on a high delayed bleeding rate in patients receiving anticoagulant therapy who underwent colorectal ESD.…”

“…Transfusion was required in three patients (3.4 %). Both hospitalization and fasting duration were longer in patients with delayed than those with non-delayed bleeding (median [IQR], 15 [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] vs. 10 [8][9][10][11][12][13][14] days, 4 [3][4][5][6][7] vs. 2 days, respectively).…”

“…Fourth, we could not collect a large patient sample taking anticoagulants even across many institutions. This was due to the small number of patients taking anticoagulants, as previous reports have acknowledged [14,15]. Fifth, the number of patients with continued warfarin therapy and those taking edoxaban was small.…”

“…In this study, the delayed bleeding rate was relatively low in the warfarin group with HBT (12.1 %) compared with the DOAC group (23.2 %). Yamashita et al reported that the delayed bleeding rate in patients taking warfarin with HBT was 26.3 % (5/19) [15], whereas Yoshida et al reported that the rate was 0 % (0/14) [14]. Therefore, it is unclear whether HBT in warfarin users is a risk factor for delayed bleeding.…”

“…Many reports have demonstrated that colonoscopic polypectomy in patients receiving anticoagulation therapy has a high risk of delayed bleeding [11][12][13]. Conversely, in colorectal ESD, few reports have demonstrated a high incidence of delayed bleeding in patients taking anticoagulants, but these studies were conducted at a single institution and involved a small number of cases [8,14,15]. This multicenter study aimed to evaluate the rate of delayed bleeding in patients taking anticoagulants after colorectal ESD for colorectal neoplasms.…”