Introduction

Bleeding after colorectal endoscopic mucosal resection (EMR) is a relatively frequent complication. Some patients require hemostasis, and some patients can be monitored. Appropriate judgment of which cases are amenable to follow-up is beneficial in avoiding unnecessary invasion, especially in the elderly who are highly complicated. In this study, we aimed to clarify the characteristics of these cases while focusing on age-related factors.

Aims & Methods

Of 2099 colorectal EMR patients with 5744 lesions performed at our hospital between January 2007 and December 2019, 59 patients (M:F=43:16) and 154 lesions in the suspected delayed bleeding (DB) group with hematochezia (including small amounts of blood) or a decrease in Hb of 2 g/dL or more the day after EMR were included in the analysis. The DB group was divided into hemostasis group (H group; endoscopic hemostasis was performed) and no hemostasis group (no-H group; no endoscopy or endoscopy without hemostasis was performed), and the characteristics of patients who could be without hemostasis were identified by comparing patient and lesion’s backgrounds. Elderly defined as 75 years and older.

Results

17 patients (28.8%) in the suspected DB group were elderly, and the mean age of the elderly/nonelderly was 78 (75-92)/ 63 (40-74). Of these, (7 of 17 and 5 of 42 were on antiplatelet drugs, significantly more in the elderly (82.3% vs. 33.3%, p < 0.05). The H/ no-H group was 39/20. The 20 patients in the no-H group consisted of 8 elderly and 12 non-elderly. The elderly were significantly more amenable to no hemostasis than the non-elderly (47.1% vs 28.5%. p < 0.05). Mean lesion diameter (mm) and polypoid (Is, Isp, Ip) were 10 (4-30) /6 (1-50), 36 (78.2%)/33 (82.5%), respectively, with no significant difference. In univariate analysis, the factors that tended to contribute to no-hemostasis were antiplatelet medication (Odds Ratio (OR) 3.66, 95% Confidence Interval (CI) 0.98-13.62, p=0.053) and 75 years and older (OR 3.17, CI 0.979-10.264, p=0.054).

Conclusion

​Many cases of suspected DB in the elderly are amenable to follow-up. It was suggested that antiplatelet drug use leads to small amount of hematochezia that no hemostasis was required. This characteristic should be taken into account when making decisions regarding appropriate endoscopic hemostasis after suspected DB in the elderly.

Introduction

The majority of non-pedunculated colorectal lesions can be curatively resected by standard polypectomy or endoscopic mucosal resection (EMR). However, EMR carries a higher risk of bleeding, which remains one of the most common complications of the procedure¹.

Aims & Methods

We aimed to assess the incidence of intra-procedural bleeding (IPB) and post-polypectomy bleeding (PPB) following EMR of non-pedunculated colorectal lesions and to identify potential risk factors.
A retrospective single-center cohort study was conducted, including all consecutive patients who underwent EMR at a non-tertiary hospital between January 2020 and September 2023. Demographic data, clinical characteristics, lesion features, and procedural variables were collected. Risk factors for IPB and PPB were evaluated using logistic regression analysis.

Results

302 patients (61% male; mean age: 68.9 ± 9.3 years) with a total of 410 colorectal lesions underwent EMR. The mean lesion size was 20.9 ± 10.5mm, with over half (51%) exceeding 20mm, and the majority (57%) were located in the right colon. En bloc resection was achieved in 47% of cases. Regarding morphology, 58% (n=238) were classified as Paris 0-IIa and 30% (n=122) as lateral spread tumors.
IPB and PPB occurred in 8.3% and 3.9% of procedures, respectively, with none being clinically significant. Of these, 38% required endoscopic therapy with snare tip soft coagulation or clip placement. Although right colon location showed a higher incidence of IBP and PPB, these differences were not statistically significant (p=0.356 and p=0.569, respectively).
Larger lesions were associated with a higher incidence of IBP (p<0.05), with size >20mm harboring the highest rate (p=0.039. OR 2.159. IC 1.023-4.554). Higher SMSA (p=0.001) and SERT (p<0.005) scores were also associated with an increased incidence of IPB. Multivariate logistic regression analysis identified size as an independent risk factor for IPB (p=0.015).
Patients medicated with antiplatelet (p<0.05. OR: 7.924. IC 2.415-25.996) and anticoagulant (p<0.05. OR 10.697. IC 3.366-33.994) drugs exhibited higher rates of PPB, accounting for 69% of cases. Larger lesions were also associated with a higher incidence of PPB, though not statistically significant (p=0.337). Prophylactic soft coagulation of visible scar vessels was associated with a reduced risk of PPB (p=0.013. OR 2.420. IC 1.233-9.484). Mechanical prophylaxis with clip placement, performed in 19% of cases (71% in the right colon), did not reduce the risk of PPB (p=0.992). Multivariate logistic regression analysis confirmed anticoagulation as an independent risk factor for IPB (p=0.028).

Conclusion

Lesion size, SMSA and SERT scores were associated with a higher risk of IPB. Patients on antiplatelet and anticoagulant drugs are at higher risk of PPB. Prophylactic endoscopic coagulation of nonbleeding visible vessels within the mucosal defect reduced the risk of PPB and may be a viable strategy to decrease PPB in patients taking anticoagulants.

References

1 – Ferlitsch M et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy. 2024 Jul;56(7):516-545. doi: 10.1055/a-2304-3219.

Introduction

Delayed bleeding (DB) is a major complication of colorectal endoscopic submucosal dissection (ESD). There are several definitions of DB, and one of the main ones is "cases requiring hemostasis with hematochezia or hemoglobin (Hb) decrease ≥2 g/dL as compared to the last preoperative level" [1]. However, it is not clear whether or not cases with Hb decrease actually requires endoscopic hemostasis, and this is sometimes difficult to determine in actual clinical practice.

Aims & Methods

We defined DB as a case requiring hemostasis with hematochezia or a Hb decrease ≥2 g/dL after colorectal ESD. The purpose of this study was to clarify the significance of Hb decrease in DB after colorectal ESD. Of the 595 patients (615 tumors) who underwent ESD or hybrid ESD for colorectal tumors at our hospital between June 2009 and April 2022, 145 patients (145 tumors) with suspected DB (suspected DB; with hematochezia or a Hb decrease ≥2 g/dL) were analyzed. We compared the hemostasis group (H group; hemostasis performed) and the no-hemostasis group (no-H group; no endoscopy performed or endoscopy performed but no hemostasis performed after hematochezia or Hb decrease) in a retrospective study.

Results

Thirty-two patients with 32 tumors were categorized into the H group, while 113 patients with 113 tumors were in the no-H group. Hematochezia was significantly higher in the H group than in the no-H group (100% vs 83.2%, p = 0.008, Fisher's exact test). On the other hand, the incidence of Hb decrease on postoperative day (POD) 1 was significantly higher in the no-H group than in the H group (26.5% vs 0%, p <0.001, Fisher's exact test). There were 7 cases in the 145 cases who had both hematochezia and a Hb decrease on POD 1, and every 7 cases were in the no-H group. Among the H group, only 8 cases (25%) had a Hb decrease ≥2 g/dL on the day of hemostasis compared to the preoperative level. On multivariate logistic regression analysis, date from ESD to first hematochezia ≤Day3 (OR 3.57, 95%CI 1.46–8.74; p = 0.005) was identified as the significant factor contributing to the no-H group, followed by bleeding duration ≤1 day (OR 4.58, 95%CI 1.45–14.43; p = 0.009).

Conclusion

The duration and the first date of hematochezia seemed to be important in determining whether to perform hemostasis when DB was suspected. On the other hand, there were no cases in which a Hb decrease ≥2 g/dL on POD 1 required hemostasis. This suggests that a Hb decrease may be a low priority factor in DB after colorectal ESD.
​

References

1. Tajiri H, Kitano S. Complications associated with endoscopic mucosal resection: Definition of bleeding that can be viewed as accidental. Dig Endosc 2004; 16: S134– S136.

Introduction

Delayed bleeding remains a significant complication after endoscopic resection procedures in the gastrointestinal tract. Effective strategies to prevent post-procedural bleeding and promote optimal healing are critical for improving patient’s outcomes. Self-assembling peptide (SAP) is a new hemostatic agent that forms protective nanofibers scaffold after contact with body fluids. Its application may reduce delayed bleeding and support tissue healing after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Early clinical data has shown promising results, but evidence is still limited.

Aims & Methods

This study evaluates the impact of SAP use on delayed bleeding rates and healing process after advanced endoscopic therapies. The findings may support the integration of SAP into standard post-endoscopic care protocols.
A retrospective analysis was conducted on patients after EMR or ESD at a single tertiary endoscopy center. Two primary outcomes were assessed: delayed bleeding and post-resection defect healing. Delayed bleeding was defined as clinically evident bleeding occurring within 30 days following the index endoscopy. Healing was evaluated endoscopically using the Sakita-Fukutomi classification at 4, 8, and 24 weeks. The size of the resection defect was measured during the procedure using endoscopic forceps or a polypectomy snare for reference. Data were collected from medical reports.​​​​​​​​

Results

A total of 141 patients (55 women, 86 men) were included in the analysis. The majority underwent ESD (n=96; 68 %), followed by piece-meal EMR (n=36; 26 %), hybrid procedure EMR+ESD (n=7; 5 %), and en-bloc EMR (n=2; 1 %). 35 lesions (25 %) were located in upper GI tract, 106 lesions (75 %) in colon and rectum with an average lesion size of 48 mm. R0 resection was achieved in 71 (78 %) of all 91 en-bloc resections. Delayed bleeding occurred in 6 patients (4.3%), with an average onset of 4 days after the procedure. All these patients had subsequent endoscopy with various hemostatic approaches, including SAP alone (n=3), SAP with coagulation (n=1), coagulation with hemoclips (n=1), and coagulation with hemospray (n=1). In all cases hemostasis was achieved. 2 patients required transfusion. The post-resection defect averaged 51 mm after index endoscopy. At 4, 8, and 24 weeks post-procedure, its size decreased to 20 mm, 14.5 mm, and 10 mm, marking reductions of 61%, 72%, and 80%, respectively.

Conclusion

SAP is effective in preventing delayed bleeding and healing post-resection defects. Its use can increase overall safety of advanced endoscopic procedures. Further studies are needed to establish optimal indications and integration into standard post-procedure protocol.
Supported by program projects of the Ministry of Health of the Czech Republic with reg. no. NU22-08-00424, MO1012 and Cooperatio.

Introduction

Colorectal endoscopic mucosal resection (EMR) is associated with high recurrence rates, which requires a regular surveillance program by colonoscopy. Our aim was to study the 5-year follow-up of a population undergoing EMR and the risk factors associated with recurrence.

Aims & Methods

Prospective cohort study, single centre, including patients who underwent colorectal EMR of lesions ≥20mm with a minimum follow-up of 5 years, between 2009 and 2019. We analysed the lesions’ characteristics, as well as the recurrence rate, and logistic regression conducted for risk factors associated with recurrence.

Results

Included 407 EMR and patients were 58% male, with a mean age of 68.5±9.8 years. From our analysis: 65.8% of the lesions were 20-40mm, 21.4% 40-60mm and 12.8% were ≥60mm; 49.4% were sessile and 50,6% flat; 34.1% were localized in the right colon, 21.6% in the transverse colon, 15.5% in the left colon, and 28.7% in the rectum; 85.7% were granular and 14.3% non-granular. The mean SMSA score was 12.5±1.8. The overall recurrence rate was 19,9%, with rates and respective time of follow-up as follows: 15,8%, 7,4%, 3,6% and 0% at 3, 12, 36 and 60 months.
Evaluating the risk factors for recurrence, anal location (32.6% vs. 18.4%; p=0.02) and size of lesion: ≥60mm vs. 40-60mm vs. ≤40mm (34.7% vs. 33.7% vs. 12.8%; p<0.001) were statistically significant, but not with argon plasma therapy (23.3% vs. 18.1%; p=0.21) and non-granular morphology (19.0% vs. 20.3%; p=0.82). Logistic regression analysis revealed that only an escalation in size in multiples of 20mm had a significant risk of recurrence (OR 1.98; p<0.001). The global complication rate was 6.1%, including early complications (perforations, n=3) and late complications (bleeding, n=17 and post-polypectomy syndrome, n=3).

Conclusion

Despite the high overall recurrence rate, a 5-year surveillance has demonstrated to be an adequate time interval to evaluate the EMR’s efficacy and safety.

Introduction

Colorectal endoscopic mucosal resection (EMR) is the treatment of choice for large colorectal lesions, but it has an important recurrence risk, requiring endoscopic surveillance. This study aims to identify factors associated with relapse and complications, by analysing the 5-year follow-up.

Aims & Methods

Prospective cohort study conducted in a single centre, including all patients submitted to colorectal pEMR between 2009 and 2021 with follow-up ≥3 months. We analysed lesion characteristics, calculated Sydney EMR recurrence tool (SERT) and SMSA (size, morphology, site, access) scores and compared complication and recurrence rates and respective risk factors.

Results

Included 568 mucosal resections, median age 69.5 years (IQR 62.3-76.0), male sex 58.1%. From the lesions included: 32.6% ≥40mm; 51.6% plane and 48.4% sessile; 35.9% in the right colon, 27.6% in the rectum, 23.2% in the transverse colon and 13.2% in the left colon. The median SMSA score was 4 (IQR 3-4) and median SERT score 1 (IQR 0-2), complication rate of 7.0% (bleeding, n=33; perforation, n=4; post-polypectomy syndrome, n=3) and overall recurrence rate of 20.3%: 15.1% in 3 months, 6.3% in 12 months, 2.5% in 36 months and 0% in 60 months.
The variables associated with recurrence were size ≥40mm (35.0% vs. 14.6%, p<0.001), anal location (35.1% vs. 19.7%, p<0.01), SERT score>0 (27.5% vs. 11.8%, p<0.001) and SMSA score=4 (30.6% vs. 11.5%, p<0.001), but not argon plasma therapy (22.8% vs. 18.7%, p=0.26). By logistic regression, size ≥40mm was associated with higher recurrence, but not statistically significant (OR 3.19, CI95% 0.69-1.63).
Use of anticoagulant/antiplatelet drugs was associated with higher risk of complications (12.7% vs. 4.7%, p<0.001), particularly bleeding (11.4% vs. 4.2%, p<0.01), with no difference for size ≥40mm (9.2% vs. 6.0%, p=0.17) or SMSA score=4 (7.6% vs. 6.5%, p=0.61).

Conclusion

The 5-year surveillance proved colorectal EMR’s efficacy. Recurrence is higher in lesions ≥40mm, with anal location, SERT score>0 and SMSA score=4, whereas bleeding is more frequent with the use of anticoagulant/antiplatelet drugs.

Introduction

Reported rates of delayed bleeding (DB) after endoscopic resection with each direct oral anticoagulant (DOAC) are high and heterogeneous. This large-scale multicenter study analyzed lesions resected by colorectal endoscopic submucosal dissection (ESD) under DOACs to compare the DB of each DOAC with warfarin.

Aims & Methods

We retrospectively reviewed 1,019 lesions with DOAC and 459 lesions with warfarin among 34,455 cases of ESD in 47 Japanese institutions from 2012 to 2021. The rate of DB in each DOAC was compared with warfarin. Risk factors of DB for DOAC and warfarin were also investigated.

Results

In the DOAC and warfarin groups, the mean age was 75.1±13.7 and 73.6±10.4 years, and the male rate was 70.2% and 71.4%, respectively. The mean tumor sizes (mm) were 29.5±14.0 and 30.3±16. The en bloc resection rates were 97.5% and 96.5%, respectively. Among 31,968 ESD cases from 46 institutions, the rate of DB was significantly higher in cases with anticoagulation (10.08%, 149/1478) than in cases without anticoagulation (2.21%, 677/30526) (p<0.001). Among the total 34,455 ESD cases, the rates of DOAC and warfarin were 9.32% (95/1019) and 11.76% (54/459), respectively (p=0.149).
The rate of DB with dabigatran (18.26%, 21/115) was significantly higher than with apixaban (10.08%, 25/248, p=0.029), edoxaban (7.73%, 25/323, p=0.001), and rivaroxaban (7.21%, 24/333, p=0.001). The rate of dabigatran was slightly higher than that of warfarin (11.76%, 54/459, p=0.055) and only the rate of rivaroxaban was significantly lower than that of warfarin (p=0.033).
Multivariate analysis showed that the significant risk factors of DB for DOAC were heparin exchange (odds ratio (OR), 95% confidence interval (CI), 2.185, 1.277-3.739, p=0.005), rectal site (2.013, 1.282-3.161, p=0.002), and longer procedure time ≥55 min (2.434, 1.498-3.956, p<0.001). The significant risk factors of DB for warfarin were antiplatelet combination (2.286, 1.274-4.100, p=0.006), rectal location (2.261, 1.248-4.095, p=0.007), and tumor size ≥35mm (2.019, 1.163-3.652, p=0.008).
The number of significant risk factors and the risk of DB (OR, 95%CI) for DOAC were 2.136 (1.301-3.507) and 4.53 (2.525-8.155) for one and two risk factors, respectively. Those for warfarin were 1.646 (0.742-3.650), 3.624 (1.593-8.243), and 13.037 (3.929-43.266) for one, two, and three risk factors, respectively.

Conclusion

The DB rate of dabigatran was higher than that of other DOACs, and only rivaroxaban was significantly lower than that of warfarin. The risk factors for DB with DOACs have been elucidated.