Post mucosectomy bleeding – a common complication – where are we and what have we learned? – Retrospective analysis of a non-tertiary hospital

Aims Endoscopic resection (ER) is associated with a reduction in the incidence of colorectal cancer by 76-90%. However, it is an invasive procedure and is not free from complications. Bleeding is the most common complication and has a variable incidence (1.5-2.8% intraprocedural bledding [IPB]; 0.3-6.1% post-polypectomy bleeding [PPB]). Anticoagulation (AC), location in the right colon, dimension>30mm and use of prophylactic hemoclip (HC) in the right colon are risk factors (RF) for PPB. The risk of PIB appears to be higher in lateral spreading tumor (LST) and polyps (Pps)>40mm. We aimed to analyse the rate of haemorrhage associated with colorectal ER (PIB and PPB) and relate it to patient characteristics, Pps and the technique used.

Methods Retrospective cohort study, based on a prospectively collected database, covering a period of 6 years (January 2014 to December 2019). Patients undergoing mucosectomy (EMR) of large non-pedunculate Pps (>20mm) were included. Demographic data, Pps and EMR characteristics were analysed. IPB was defined as bleeding detected during the procedure and submitted to endoscopic therapy and PPB was defined as bleeding within 30 days after the procedure and which led to a visit to the hospital. Statistical analysis performed with SPSS (X2 test, Fishers exact test, odds ratio).

Results In the sample of 361 patients (64% male; mean age 56 years), the overall bleeding rate was 19.3% (IPB 16.9% and PPB 3%). Around 22% were antiaggregated (AAG)/AC, which was associated with an increased risk of PPB (p-value>0.05). Most PPB didn’t require transfusion support and colonoscopy was performed without endoscopic therapy. The majority of Pps were LST (n=282) and had an SMSA score 3-4 (n=260), which was associated with a higher incidence of IPB (p-value 0.047). The right colon was the most common location (65.7%) and there was no difference in the incidence of PPB compared to the left colon. Approximately 25% of Pps were>30 mm in size, which was associated with a higher incidence of PIB (p-value 0.001). Half of the Pps underwent en bloc EMR with a diathermic loop (53%), which was associated with a lower incidence of IPB (p-value 0.016). HC were applied to 51% of Pps (intent: 68% (n=123) prophylactic; 32% (n=57) therapeutic [IPB]). The rate of prophylactic HC was 36% in the right colon and 30% in the left colon, associated with a reduced risk of PPB (OR 0.159; 95% CI [0.006; 3.835]). [1] [2] [3] [4] [5] [6]

Conclusions The incidence of PPB was similar to values reported internationally, however the incidence of IPB was higher (no data from national portuguese series available). EMR proved to be safe in patients undergoing AAG/AC, despite the increased risk of PPB. The complexity of the Pps defined by the SMSA score appeared to signal an increased risk of PPB. The application of prophylactic HC was associated with a reduction in the risk of PPB.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

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• 2 Bendall O, James J, Pawlak KM. et al. Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients. Clin Exp Gastroenterol 2021; 14: 477-492
• 3 Anderloni A, Jovani M, Hassan C, Repici A.. Advances, problems, and complications of polypectomy. Clin Exp Gastroenterol 2014; 7: 285-296
• 4 Hong SP.. How do I manage post-polypectomy bleeding?. Clin Endosc 2012; 45 (03) 282-284
• 5 Choo WK, Subhani J.. Complication Rates of Endoscopic Polypectomy in Relation to Polyp Characteristics and Techniques. Gut 2011; 60: A126-A127
• 6 Ferlitsh M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024