Prophylactic clip closure in preventing delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulants: a multicenter retrospective cohort study in Japan

Abstract

Background The effectiveness of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) is uncertain among patients on anticoagulants. We therefore aimed to assess this effectiveness using data from a large multicenter study.

Methods We used the ABCD-J study database to analyze delayed bleeding among 34 455 colorectal ESD cases from 47 Japanese institutions. Delayed bleeding rates among the no/partial and complete closure groups were compared in patients on direct oral anticoagulants (DOACs) or warfarin. Propensity score matching was used for baseline characteristics to reduce the effects of selection bias.

Results Overall, data from 1478 patients on anticoagulants who underwent colorectal ESD were examined. After propensity score matching, the complete and no/partial closure groups were compared in 212 patients on DOACs and 82 on warfarin. The complete closure group showed a significantly lower delayed bleeding rate in patients receiving DOACs (10.8 % vs. 5.2 %, absolute risk reduction [ARR] 5.7 %, P = 0.048) and warfarin (17.1 % vs. 6.1 %, ARR 11.0 %, P = 0.049). Additionally, complete closure significantly reduced the risk of delayed bleeding among patients taking DOACs for right-sided lesions (ARR 6.7 %, P = 0.04), whereas no risk reduction was observed for left-sided (P > 0.99) or rectal (P = 0.50) lesions. A similar trend was observed among patients on warfarin.

Conclusions Prophylactic complete clip closure after colorectal ESD significantly reduced the delayed bleeding rate in patients receiving DOACs or warfarin. It should be performed after ESD, particularly for right-sided lesions.

Publikationsverlauf

Eingereicht: 06. September 2024

Angenommen nach Revision: 18. Dezember 2024

Accepted Manuscript online:
18. Dezember 2024

Artikel online veröffentlicht:
31. Januar 2025

• References

• 1 Kobayashi N, Takeuchi Y, Ohata K. et al. Outcomes of endoscopic submucosal dissection for colorectal neoplasms: prospective, multicenter, cohort trial. Dig Endosc 2022; 34: 1042-1051
• 2 Draganov PV, Aihara H, Karasik MS. et al. Endoscopic submucosal dissection in North America: a large prospective multicenter study. Gastroenterology 2021; 160: 2317-2327.e2312
• 3 Ohata K, Kobayashi N, Sakai E. et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology 2022; 163: 1423-1434.e1422
• 4 Odagiri H, Yasunaga H, Matsui H. et al. Hospital volume and the occurrence of bleeding and perforation after colorectal endoscopic submucosal dissection: analysis of a national administrative database in Japan. Dis Colon Rectum 2015; 58: 597-603
• 5 Yoshida N, Naito Y, Murakami T. et al. High incidence of postoperative hemorrhage in colorectal endoscopic submucosal dissection during anticoagulant therapy. Int J Colorectal Dis 2016; 31: 1487-1488
• 6 Yamashita K, Oka S, Tanaka S. et al. Use of anticoagulants increases risk of bleeding after colorectal endoscopic submucosal dissection. Endosc Int Open 2018; 6: E857-E864
• 7 Ogiyama H, Inoue T, Maekawa A. et al. Effect of anticoagulants on the risk of delayed bleeding after colorectal endoscopic submucosal dissection. Endosc Int Open 2020; 8: E1654-E1663
• 8 Yoshida N, Hayashi Y, Togo D. et al. An analysis of delayed bleeding in cases of colorectal endoscopic submucosal dissection due to types of direct oral anticoagulants in Japan. Clin Gastroenterol Hepatol 2024; 22: 271-282.e273
• 9 Chen B, Du L, Luo L. et al. Prophylactic clips to reduce delayed polypectomy bleeding after resection of large colorectal polyps: a systematic review and meta-analysis of randomized trials. Gastrointest Endosc 2021; 93: 807-815
• 10 Gupta S, Sidhu M, Shahidi N. et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7: 152-160
• 11 Turan AS, Pohl H, Matsumoto M. et al. the role of clips in preventing delayed bleeding after colorectal polyp resection: an individual patient data meta-analysis. Clin Gastroenterol Hepatol 2022; 20: 362-371.e323
• 12 Ogiyama H, Tsutsui S, Murayama Y. et al. Prophylactic clip closure may reduce the risk of delayed bleeding after colorectal endoscopic submucosal dissection. Endosc Int Open 2018; 6: E582-E588
• 13 Miyakawa A, Kuwai T, Sakuma Y. et al. The efficacy of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection on delayed bleeding. Scand J Gastroenterol 2021; 56: 1236-1242
• 14 Kobara H, Tada N, Fujihara S. et al. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: literature review over one decade. Dig Endosc 2023; 35: 216-231
• 15 Liu M, Zhang Y, Wang Y. et al. Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: a meta-analysis. J Gastroenterol Hepatol 2020; 35: 1869-1877
• 16 Lee SP, Sung IK, Kim JH. et al. Effect of prophylactic endoscopic closure for an artificial ulceration after colorectal endoscopic submucosal dissection: a randomized controlled trial. Scand J Gastroenterol 2019; 54: 1291-1299
• 17 Nomura S, Shimura T, Katano T. et al. A multicenter, single-blind randomized controlled trial of endoscopic clipping closure for preventing coagulation syndrome after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2020; 91: 859-867.e851
• 18 Tanaka S, Kashida H, Saito Y. et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2020; 32: 219-239
• 19 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434
• 20 Takizawa K, Oda I, Gotoda T. et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection – an analysis of risk factors. Endoscopy 2008; 40: 179-183
• 21 Bahin FF, Naidoo M, Williams SJ. et al. Prophylactic endoscopic coagulation to prevent bleeding after wide-field endoscopic mucosal resection of large sessile colon polyps. Clin Gastroenterol Hepatol 2015; 13: 724-730.e721-722
• 22 Lee HS, Jeon SW, Kwon YH. et al. Prophylactic endoscopic coagulation to prevent delayed post-EMR bleeding in the colorectum: a prospective randomized controlled trial (with videos). Gastrointest Endosc 2019; 90: 813-822
• 23 Tsuji Y, Ohata K, Gunji T. et al. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to cover wounds after colorectal endoscopic submucosal dissection (with video). Gastrointest Endosc 2014; 79: 151-155
• 24 Fujimoto K, Fujishiro M, Kato M. et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc 2014; 26: 1-14
• 25 Kato M, Uedo N, Hokimoto S. et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants. Dig Endosc 2018; 30: 433-440
• 26 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
• 27 Seo M, Song EM, Cho JW. et al. A risk-scoring model for the prediction of delayed bleeding after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2019; 89: 990-998.e992
• 28 Ogiyama H, Kato M, Yamaguchi S. et al. Efficacy of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulant therapy: multicenter prospective study. Dig Endosc 2024; 36: 1021-1029
• 29 Albouys J, Montori Pina S, Boukechiche S. et al. Risk of delayed bleeding after colorectal endoscopic submucosal dissection: the Limoges Bleeding Score. Endoscopy 2024; 56: 110-118
• 30 Pohl H, Grimm IS, Moyer MT. et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; 157: 977-984.e973
• 31 Albeniz E, Alvarez MA, Espinos JC. et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 2019; 157: 1213-1221.e1214
• 32 Shah ED, Pohl H, Rex DK. et al. Routine prophylactic clip closure is cost saving after endoscopic resection of large colon polyps in a Medicare population. Gastroenterology 2020; 158: 1164-1166.e1163
• 33 Albeniz E, Enguita-German M, Gimeno-Garcia AZ. et al. The answer to “when to clip” after colorectal endoscopic mucosal resection based on a cost-effectiveness analysis. Am J Gastroenterol 2021; 116: 311-318
• 34 Nomura T, Sugimoto S, Temma T. et al. Suturing techniques with endoscopic clips and special devices after endoscopic resection. Dig Endosc 2023; 35: 287-301
• 35 Shiotsuki K, Takizawa K, Notsu A. et al. Endoloop closure following gastric endoscopic submucosal dissection to prevent delayed bleeding in patients receiving antithrombotic therapy. Scand J Gastroenterol 2021; 56: 1117-1125
• 36 Fujihara S, Mori H, Kobara H. et al. The efficacy and safety of prophylactic closure for a large mucosal defect after colorectal endoscopic submucosal dissection. Oncol Rep 2013; 30: 85-90
• 37 Han S, Wani S, Edmundowicz SA. et al. Feasibility of endoscopic suturing to prevent adverse events and hospitalization after endoscopic submucosal dissection. Endosc Int Open 2020; 8: E1212-E1217
• 38 Abe S, Saito Y, Tanaka Y. et al. A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study. Endoscopy 2020; 52: 780-785
• 39 Bi D, Zhang LY, Alqaisieh M. et al. Novel through-the-scope suture closure of colonic EMR defects (with video). Gastrointest Endosc 2023; 98: 122-129
• 40 Lee CK, Lee SH, Park JY. et al. Prophylactic argon plasma coagulation ablation does not decrease delayed postpolypectomy bleeding. Gastrointest Endosc 2009; 70: 353-361
• 41 Horiuchi A, Nakayama Y, Kajiyama M. et al. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014; 79: 417-423
• 42 Suzuki S, Gotoda T, Kusano C. et al. Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy. Gastrointest Endosc 2018; 87: 1095-1103
• 43 Veitch AM, Radaelli F, Alikhan R. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70: 1611-1628
• 44 Ichita C, Goto T, Fushimi K. et al. Timing of direct oral anticoagulants resumption following colorectal endoscopic submucosal dissection: a nationwide study in Japan. Am J Gastroenterol 2024;