Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants

Abstract

Backgrounds and Aims. Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors. Materials and Methods. This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients’ clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups. Results. The rates of POH were 7.9%∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6%∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively (∗ vs. ∗∗, p<0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2±8.3 vs. 7.2±4.9, p<0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment. Conclusions. Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics.

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

“…Detailed information about the excluded studies is presented in the supporting information. Eventually, 30 articles were included 24–53 …”

“…Only two studies mentioned the usage of epinephrine as injection solution 50,53 . As for the types of DOACs, 14 (46.67%) studies included dabigatran, rivaroxaban, apixaban, and edoxaban 24–28,32–38,41,43 . And five studies reported that the duration of withdrawal of antithrombotic agents was determined according to the guidelines published by the JGES 24,25,28,31,44 .…”

“…And five studies reported that the duration of withdrawal of antithrombotic agents was determined according to the guidelines published by the JGES 24,25,28,31,44 . For DOACs, HB was applied in 17 studies 24,25,27,29,31–34,36,37,39,42,45,46,48,50,52 . Six studies just discontinued DOACs before the endoscopic procedures without the usage of HB 26,28,35,40,41,49 .…”

Management of anticoagulants in delayed bleeding after endoscopic resection: A systematic review and meta-analysis

“…After reviewing the full-text of the remaining 27 articles, a total of 19 studies were found to be ineligible for the inclusion criteria, and were excluded. Finally, eight studies 11 12 13 14 15 16 17 18 were included for the meta-analysis. Results of the study flow diagram are shown in Fig.…”

“…All articles demonstrated the outcome, and five of these [11][12][13][14][15] reported no thrombotic events. Therefore, the meta-analysis was conducted using three studies [16][17][18] with a total of 1,085 patients (601 patients with warfarin and 484 patients with DOACs).…”