Cold snare polypectomy under continuous anticoagulation appears safe

Last Updated: 2019-07-15

By Will Boggs MD

NEW YORK (Reuters Health) - Cold snare polypectomy (CSP) under continuous anticoagulation is noninferior to hot snare polypectomy (HSP) with heparin bridging in patients on anticoagulation therapy, researchers from Japan report.

"Theoretically, continuous anticoagulation can be risky for bleeding events, but CSP did not increase (and actually decreased by more than half) severe bleeding for patients on continuous anticoagulation," Dr. Yoji Takeuchi from Osaka International Cancer Institute, Osaka, Japan told Reuters Health by email. "So, I think this study is indicating not only the safety of CSP for patients taking anticoagulants, but also indicating the safety of CSP itself."

Dr. Takeuchi and colleagues in the Madowazu Study Group compared outcomes of CSP under continuous anticoagulation (CA) versus HSP with heparin bridging (HB) in their noninferiority trial of 168 patients with subcentimeter colorectal polyps.

The incidence of polypectomy-related major bleeding (the primary endpoint) was 4.7% in the CA+CSP group, compared with 12.0% in the HB+HSP group, a difference that satisfied the noninferiority criterion.

Results were similar in the per-protocol analysis (after excluding protocol deviation cases), with major bleeding rates of 4.7% in the CA+CSP group and 12.7% in the HB+HSP group.

Noninferiority was also confirmed in the subgroup analyses of patients receiving warfarin and patients receiving direct oral anticoagulants (DOACs), according to the July 15th online report in Annals of Internal Medicine.

Poorly controlled intraprocedural bleeding did not occur in either treatment group.

Mean procedure time per lesion and mean hospitalization duration were significantly shorter in the CA+CSP group than in the HB+HSP group.

"Our results are consistent with current guidelines, which recommend CSP for subcentimeter polyps and do not recommend HB," the researchers conclude.

"CSP should be applied only for benign adenoma," Dr. Takeuchi said. "HSP should be considered for lesions with suspicious findings for invasive cancer, although it is rare among small polyps. Careful observation before polypectomy should be performed even for small polyps."

In a related editorial, Dr. Jeffrey L. Tokar and Dr. Michael J. Bartel from Fox Chase Cancer Center, Philadelphia, mention several limitations of the trial. "The lack of blinding introduced opportunities for bias. Furthermore, the study was not powered to fully characterize either class-specific risks for postpolypectomy bleeding in patients using warfarin versus those receiving direct oral anticoagulants or the rate of residual adenoma (incomplete polyp resection), which are important considerations in clinical practice."

"It also did not compare outcomes of CA with either CSP or HSP with those of simply holding anticoagulation without HB, a strategy commonly used for persons perceived to have a low thromboembolic risk," they note.

"In summary, this study adds to emerging evidence that small colorectal polyps may be resected safely with CSP while oral anticoagulation continues and provides the first comparative evidence that this strategy may be safer than HB+HSP," they conclude. "The results warrant confirmatory studies, preferably with blinding to the use of anticoagulation and assessment of several additional factors: incomplete polyp resection, the effect of prophylactic hemostatic actions (such as clipping), and the applicability of CA+CSP to the removal of larger polyps and to the use of other classes of antithrombotic medications (such as thienopyridines)."

SOURCE: http://bit.ly/2YVwkY7 and http://bit.ly/2Z2STdH

Ann Intern Med 2019.