Anticoagulation can be continued with "cold" polypectomy

    

    

Doctors newspaper online, 27.09.2019

    

        
        
        

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Japanese study

When small intestinal polyps are ablated with the cold snare, it does not seem necessary to discontinue anticoagulation. The risk of bleeding is rather lower than with heparin bridging and the use of cutting current.

By Beate Schumacher

Polypectomy: The authors of a Japanese study considered cold-loop erosion with continued anticoagulation as the standard procedure for removing polyps 1 cm.

© Albertinen KH / endoscopy images

OSAKA. In order to reduce the risk of bleeding in a colonoscopy with polypectomy, the German guideline recommends temporarily suspending an existing anticoagulation (discontinuation: Phenprocoumon 7 days, NMH and NOAK 1 day before the procedure, reuptake: NMH 6-12, phenprocoumon , NOAK 12-24 hours afterwards). In patients with oral anticoagulation, who have a high risk of thromboembolic risk, this time should be bridged with heparin.

What are exceptions?

An exception to this is the guideline polyps with a diameter of up to 5 mm: They can be removed under anticoagulation with vitamin K antagonists and with endoscopic bleeding prophylaxis if the INR does not exceed the therapeutic range.

A study from Japan suggests that this strategy can be extended to colon polyps that are less than 1 cm in diameter unless current is used for polypectomy ( Ann Intern Med 2019, online August 20 ). In the randomized controlled trial, the combination of continuous anticoagulation (CA) and cold snare (CSP) for bleeding was at least as safe as heparin bridging (HB) in combination with the hot snare (HSP).

Greater bleeding associated with the intervention occurred in 4.7 percent of CA / CSP patients and 12.0 percent of HB / HSP patients. In all cases these were post-polypectomy bleedings, which had to be breastfed in another endoscopic procedure. With the difference of 7.3 percent, the predefined minimum difference of 5 percent was proven to demonstrate the non-inferiority of the CA / CSP strategy.

Study participants were 168 patients who received oral anticoagulants mostly for atrial fibrillation and had at least one (non-pedunculated) colon polyp <1 cm removed. In total, around 600 lesions were treated. Haemostasis clips were used prophylactically more frequently in the HB / HSP group. For the CA / CSP patients, doctors needed less time per lesion and the hospital stay was shorter.

    

        4.7% of patients with polyps under anticoagulation with a cold
        Sling were eroded, suffered major bleeding. In patients under
        Heparin bridging and erosion with a hot snare accounted for 12 percent.

Based on the results, the study authors consider cold-loop erosion with continued anticoagulation as the standard procedure for removing polyps <1 cm, especially for those patients in whom discontinuation of anticoagulation is associated with a high thromboembolic risk.

A disadvantage of the study besides the lack of blinding is the simultaneous testing of two influencing factors. The effects of suspending oral anticoagulation without heparin bridging in patients with low thromboembolic risk have not been studied.

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