Safe and effective colon polypectomy in patients receiving uninterrupted anticoagulation: Can we do it?

摘要

As the need for colonoscopy screening in the prevention of colon cancer grows, we see more cases of colonos-copy being performed in patients taking anticoagulants. Overall, an increasing number of patients at high risk for bleeding adverse events are undergoing colon polypec-tomy in routine clinical practice. Colon polypectomy has been classified as a high-risk bleeding procedure, with bleeding adverse events seen in more than 196 of cases.1'2 However, the range of adverse events reported is wide (0.696-8.696), likely because of the definition of bleeding, the polypectomy technique, and the clinical setting. A recent, large-scale, multicenter study reported the postpo-lypectomy bleeding rate to be 1.296; however, the issue is that this rate can spike in special circumstances, such as in patients taking anticoagulants.Anticoagulation is a well-known risk factor for postpoly-pectomy bleeding. Several previous studies have reported risk factors for bleeding adverse events after colon polypectomy, including cardiovascular disease, age older than 65 years, hypertension, polyp size larger than 1 cm, and anticoagulation.4'6'9 Anticoagulation in particular increases the risk of procedure-related bleeding 3-fold to 5-fold. Interestingly, even though we are already aware of the issue of bleeding adverse events, and interest has been shown in their management and prevention, previous studies of anticoagulation and postpolypectomy bleeding are very limited. The American Society for Gastrointestinal Endoscopy guidelines for colonoscopy in patients requiring long-term anticoagulation therapy recommend temporary discontinuation of anticoagulants.1 However, although most patients recover from postpolypectomy bleeding, thrombotic adverse events such as stroke from interruption of anticoagulation can be catastrophic. Anticoagulation therapy management, including adjustment of dose, the decision whether to interrupt its administration, and the use of low-moiecular-weight heparin bridging before the procedure, can be complex, and the course chosen can depend on the patient's indication for anticoagulation and comorbid disease status. The logistics of performing randomized studies in this patient population are challenging.