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Clinical outcome of endoscopic management in delayed postpolypectomy bleeding

Clinical outcome of endoscopic management in delayed postpolypectomy bleeding ORIGINAL ARTICLE pISSN • eISSN 1598-9100 2288-1956 https://doi.org/10.5217/ir.2017.15.2.221 Intest Res 2017;15(2):221-227 Clinical outcome of endoscopic management in delayed postpolypectomy bleeding Jeong-Mi Lee, Wan Soo Kim, Min Seob Kwak, Sung-Wook Hwang, Dong-Hoon Yang, Seung-Jae Myung, Suk-Kyun Yang, Jeong-Sik Byeon Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background/Aims: The clinical course after endoscopic management of delayed postpolypectomy bleeding (DPPB) has not been clearly determined. This study aimed to assess clinical outcomes after endoscopic hemostasis of DPPB and evaluate risk factors for rebleeding after initial hemostasis. Methods: We reviewed medical records of 198 patients who developed DPPB and underwent endoscopic hemostasis between January 2010 and February 2015. The performance of endoscopic hemostasis was assessed. Rebleeding negative and positive patients were compared. Results: DPPB developed 1.4±1.6 days after colono- scopic polypectomy. All patients achieved initial hemostasis. Clipping was the most commonly used technique. Of 198 DPPB patients, 15 (7.6%) had rebleeding 3.3±2.5 days after initial hemostasis. The number of clips required for hemostasis was higher in the rebleeding positive group (3.2±1.6 vs. 4.2±1.9, P =0.047). Combinations of clipping with other modalities such as injection methods were more common in the rebleeding positive group (67/291, 23.0% vs. 12/17, 70.6%; P <0.001). Multivariate analysis showed a large number of clips and combination therapy were independent risk factors for rebleeding. All the rebleeding cases were successfully managed by repeat endoscopic hemostasis. Conclusions: Endoscopic hemostasis is effective for the man- agement of DPPB because of its high initial hemostasis rate and low rebleeding rate. Endoscopists should carefully observe patients in whom a large number of clips and/or combination therapy have been used to manage DPPB because these may be related to the severity of DPPB and a higher risk of rebleeding. (Intest Res 2017;15:221-227) Key Words: Colonoscopy; Postpolypectomy bleeding; Clip; Rebleeding 5-10 noscopic polypectomy cases. Postpolypectomy bleeding INTRODUCTION is generally classified as either immediate/early postpolypec- Most colorectal cancers develop from adenomatous pol- tomy bleeding (IPPB) or delayed postpolypectomy bleeding yps. Colonoscopic polypectomy can remove most colorectal (DPPB). IPPB is usually defined as bleeding that develops 1-3 polyps effectively, and reduce the risk of colorectal cancer. immediately after resection of polyps during the colonos- Despite its effectiveness in the prevention of colorectal can- copy procedure. Because endoscopists can directly detect cer, polypectomy is not completely safe because it is associ- IPPB, most cases can be managed endoscopically during the 4 6 ated with complications such as bleeding and perforation. colonoscopic procedure. DPPB is defined as bleeding that Postpolypectomy bleeding occurs in 0.3% to 6.1% of colo- develops after the end of colonoscopic polypectomy. Most DPPB is detected when patients complain of hematochezia several hours to several days after colonoscopic polypectomy. Received April 14, 2016. Revised May 19, 2016. 6-8,11,12 The incidence of DPPB is reported to be 0.2% to 2.2%. Accepted May 25, 2016. Published online March 21, 2017 Correspondence to Jeong-Sik Byeon, Department of Gastroenterology, Although most endoscopists apply endoscopic hemostasis Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro to manage DPPB, clinical outcomes of endoscopic man- 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3905, Fax: +82-2- agement have not been thoroughly investigated. Thus, the 476-0824, E-mail: [email protected] aim of our study was to assess the clinical outcomes after Financial support: None. Conflict of interest: None. © Copyright 2017. Korean Association for the Study of Intestinal Diseases. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Jeong-Mi Lee, et al. • Endoscopic management in delayed PPB endoscopic hemostasis for DPPB. We also evaluated the fre- gender, laboratory findings, comorbidities, and use of medi- quency of DPPB and risk factors for recurrence of bleeding cations including antiplatelet agents (aspirin, clopidogrel) after initial endoscopic hemostasis. and anticoagulants (warfarin, heparin) were investigated. Colonoscopic features of each resected polyp such as the size, location, endoscopic morphology, histological diagno- METHODS sis, and colonoscopic polypectomy methods were analyzed. 1. Patients Information on endoscopic hemostasis such as the endos- copist’s experience (staff vs. fellow) and the endoscopic All patients who underwent colonoscopic and/or sigmoid- hemostasis methods were also reviewed. Clinical outcomes oscopic bleeding control for DPPB at Asan Medical Center after endoscopic hemostasis, including success or failure between January 2010 and February 2015 were included in of endoscopic hemostasis, complications, recurrent bleed- this study. DPPB was defined as hematochezia and/or me- ing, and performance of repeat interventions, were further lena occurring within 14 days of colonoscopic polypectomy. investigated. Success of endoscopic hemostasis was defined Techniques included cold snare polypectomy, injection as- as the cessation of bleeding after endoscopic interventions sisted polypectomy (endoscopic mucosal resection, EMR), such as clipping. The Institutional Review Board of our cen- endoscopic piecemeal mucosal resection (EPMR), endo- ter approved the protocol of this study. scopic submucosal resection (ESD), and ESD with snaring (hybrid ESD). Patients were categorized into two groups 3. Statistical Analysis based on the occurrence of rebleeding. The rebleeding posi- tive group was defined as those who presented with hemato- Statistical analyses were performed by using SPSS ver- chezia and/or melena after the initial successful endoscopic sion 21.0 (IBM Corp., Armonk, NY, USA). Continuous vari- hemostasis and required repeat hemostatic interventions. ables are reported as means with SDs and compared using The rebleeding negative group was defined as those who did Student t -test. Categorical data were analyzed using Fisher not show further hematochezia and/or melena after the ini- exact test. Multivariate logistic regression analyses were per- tial successful endoscopic hemostasis. formed to investigate the risk factors for recurrent bleeding after initial endoscopic hemostasis. A P -value <0.05 was con- 2. Review of Clinical Data sidered statistically significant. We retrospectively reviewed medical records and endos- copy reports with pictures. Demographic data such as age, 21,780 Patients underwent colonoscopic polypectomy 198 Patients (0.9%) developed DPPB and underwent endoscopic hemostasis Initial hemostasis was achieved by endoscopic interventions in all 198 patients (100%) 183 Patients (92.4%) were no 15 Patients (7.6%) were rebleeding rebleeding Fig. 1. Flow diagram of patients with de- Successful hemostasis by repeat layed postpolypectomy bleeding (DPPB). All endoscopic interventions in all DPPB patients were eventually managed by 15 patients (100%) endoscopic hemostasis. 222 www.irjournal.org https://doi.org/10.5217/ir.<년>.<년>.<년>.<년년년년년> • Intest Res <년>;<년>(<년>):<년년년년년>-<년년년년> https://doi.org/10.5217/ir.2017.15.2.221 • Intest Res 2017;15(2):221-227 79.5%). DPPB developed 1.4±1.6 days (median, 0.8 days; RESULTS range, 0.2−11.0 days) after colonoscopic polypectomy. Endo- 1. Baseline Characteristics and Clinical Course scopic hemostasis was attempted on the 308 polyps. A clip with or without other intervention was the most commonly A total of 21,780 patients underwent colonoscopic polyp- used hemostatic method (263/308, 85.4%). Endoscopic ectomy at our institution between January 2010 and Febru- hemostasis was successful for all 308 polyps in 198 patients ary 2015. Of these, 198 patients (0.9%) developed DPPB, (100%). There were no adverse events and no patient re- which was associated with 308 polyps (Fig. 1). The mean age quired a blood transfusion. Of the 198 patients, 17 polyps of the 198 patients was 60.1±11.2 years and 150 were male. (5.5%) in 15 cases (7.6%) presented with rebleeding 3.3±2.5 EMR was the most common polypectomy method (245/308, days (median, 2.1 days; range, 0.8−10.0 days) after initial Fig. 2. Rebleeding after initial endoscopic hemostasis in delayed postpolypectomy bleeding (DPPB). (A) Active blood oozing is noted at a large postpolypectomy ulcer where five clips were applied during a previous endoscopy to control DPPB. All five clips were attached at the periphery of the ulcer. (B) Hemostasis was achieved by the application of additional argon plasma A B coagulation. Table 1. Per-Patient Comparisons of Demographic Characteristics in the Rebleeding Positive and Negative Groups Rebleeding Total Characteristics P -value (n=198) Negative group (n=183) Positive group (n=15) Age (yr) 60.10±11.20 60.20±10.98 58.80±13.98 0.637 Male sex 150 (75.8) 141 (77.0) 9 (60.0) 0.205 Laboratory finding Hb before polypectomy (g/dL) 14.10±1.93 14.10±1.83 13.50±2.89 0.254 Hb after DPPB (g/dL) 13.10±2.36 13.10±2.32 12.70±2.80 0.572 PT (sec) 11.80±2.48 11.80±2.54 12.10±1.65 0.652 Current medication Aspirin 19 (9.6) 18 (9.5) 1 (6.7) 0.598 Clopidogrel 8 (4.0) 7 (3.8) 1 (6.7) 0.509 Aspirin+clopidogrel 7 (3.5) 6 (3.3) 1 (6.7) Warfarin 28 (14.1) 25 (13.7) 3 (20.0) 0.471 Comorbidity Hypertension 71 (35.9) 66 (36.1) 5 (33.3) 0.832 Cerebrovascular disease 14 (7.1) 13 (7.1) 1 (6.7) 0.713 Coronary artery disease 13 (6.6) 11 (6.0) 2 (13.3) 0.257 Liver cirrhosis 7 (3.6) 5 (2.7) 2 (13.3) 0.090 Values are presented mean±SD or number (%). Hb, hemoglobin; DPPB, delayed postpolypectomy bleeding . www.irjournal.org 223 Jeong-Mi Lee, et al. • Endoscopic management in delayed PPB endoscopic hemostasis (Fig. 2). Only one additional repeat 2. Comparison between Rebleeding Positive and endoscopic hemostasis session was necessary to control Negative Groups rebleeding in 11 of the 15 patients (73.3%). Two additional sessions were required in one patient because of repeated Demographic characteristics were compared in the bleeding. Three repeat endoscopic interventions were nec- rebleeding positive and negative groups, and showed no essary in one patient. Four repeat endoscopic hemostatic significant differences regarding age, gender, laboratory find- procedures were performed in the remaining two patients. ings, medications, and comorbidities (Table 1). Endoscopic All 15 patients with recurrent bleeding were managed suc- features at the time of colonoscopic polypectomy were com- cessfully without adverse events by repeat endoscopic inter- pared in the two groups (Table 2). The mean size of polyps vention and none of the patients with rebleeding required tended to be larger in the rebleeding positive group, but this further angiography or surgery to control recurrent bleeding. was not statistically significant (12.2±13.3 mm vs. 18.0±18.5 No blood transfusions were necessary in any of the rebleed- mm, P =0.217). There was no significant difference between ing patients. the groups with respect to polyp distribution or morphology. Table 2. Per-Polyp Comparisons of Endoscopic and Histological Features in the Rebleeding Positive and Negative Groups Rebleeding Total Endoscopic feature P -value (n=308) Negative group (n=291) Positive group (n=17) Polyp size (mm) 12.5±13.7 12.2±13.3 18.0±18.5 0.217 Polyp location 0.329 Cecum 15 (4.9) 13 (4.5) 2 (11.8) Ascending colon 95 (30.8) 92 (31.6) 3 (17.6) Transverse colon 39 (12.7) 37 (12.7) 2 (11.8) Descending colon 27 (8.8) 27 (9.3) 0 Sigmoid colon 76 (24.7) 71 (24.4) 5 (29.4) Rectum 56 (18.2) 51 (17.5) 5 (29.4) Polyp morphology 0.775 Is 198 (64.3) 188 (64.6) 10 (58.8) Ip 41 (13.3) 39 (13.4) 2 (11.8) IIa 69 (22.4) 64 (22.0) 5 (29.4) Method of resection 0.034 EMR 245 (79.5) 235 (80.8) 10 (58.8) EPMR 21 (6.8) 17 (5.8) 4 (23.5) ESD 11 (3.6) 10 (3.4) 1 (5.9) Hybrid ESD 7 (2.3) 6 (2.1) 1 (5.9) CSP 24 (7.8) 23 (7.9) 1 (5.9) Histologic finding 0.002 Tubular adenoma 205 (66.6) 200 (68.7) 5 (29.4) Villotubular adenoma 26 (8.4) 24 (8.2) 2 (11.8) Hyperplastic polyp 17 (5.5) 15 (5.2) 2 (11.8) Serrated adenoma 13 (4.2) 12 (4.1) 1 (5.9) Adenocarcinoma 21 (6.8) 17 (5.8) 4 (23.5) Unknown 26 (8.4) 23 (7.9) 3 (17.6) Values are presented mean±SD or number (%). EMR, endoscopic mucosal dissection; EPMR, endoscopic piecemeal mucosal resection; ESD, endoscopic submucosal dissection; CSP, cold snare polypectomy. 224 www.irjournal.org https://doi.org/10.5217/ir.<년>.<년>.<년>.<년년년년년> • Intest Res <년>;<년>(<년>):<년년년년년>-<년년년년> https://doi.org/10.5217/ir.2017.15.2.221 • Intest Res 2017;15(2):221-227 Table 3. Per-Polyp Comparisons of Performance of Endoscopic Hemostasis in the Rebleeding Positive and Negative Groups Rebleeding Endoscopic hemostasis Total (n=308) P -value Negative group (n=291) Positive group (n=17) Hemostatic method Clip 263 (85.4) 249 (85.6) 14 (82.4) 0.723 No. of clips 3.3±1.7 3.2±1.6 4.2±1.9 0.047 Clip alone 185 (60.1) 183 (62.9) 2 (11.8) <0.001 Clip with others 79 (25.6) 67 (23.0) 12 (70.6) <0.001 APC 67 (21.8) 57 (19.6) 10 (58.8) <0.001 Epinephrine injection 36 (11.7) 31 (10.7) 5 (29.4) 0.019 Fibrin glue injection 34 (11.0) 27 (9.3) 7 (41.2) <0.001 Coagulation forcep 12 (3.9) 9 (3.1) 3 (17.6) 0.023 Operator Staff 123 (39.9) 115 (39.5) 8 (47.1) 0.537 Fellow 185 (60.1) 176 (60.5) 9 (52.9) 0.747 Values are presented number (%) or mean±SD. APC, argon plasma coagulation. EPMR was more frequently used in the rebleeding positive Table 4. Risk Factors for Recurrent Postpolypectomy Bleeding (Multivariate Analysis) group than the rebleeding negative group (17/291, 5.8% vs. 4/17, 23.5%). Adenocarcinoma was more common in Adjusted OR Risk factor P -value (95% CI) the rebleeding positive group than the rebleeding negative group (Table 2). The performance of endoscopic hemosta- No. of clips 1.405 (1.006–1.962) 0.046 sis was compared in the rebleeding positive and negative Clip combined with other 16.541 (3.465–78.952) <0.001 interventions groups (Table 3). Clipping with or without other intervention was the most commonly used hemostatic method in both groups. The number of clips required for successful hemo- stasis was higher in the rebleeding positive group (3.2±1.6 DISCUSSION vs. 4.2±1.9, P =0.047). Clipping alone was more common (183/291, 62.9% vs. 2/17, 11.8%; P <0.001) in the rebleeding Our study showed that endoscopic interventions achieved negative group, whereas a combination of a clip and other 100% hemostasis for DPPB without any adverse events. Only modalities such as injection methods were more commonly 7.6% of patients who initially achieved endoscopic hemosta- used in the rebleeding positive group (67/291, 23.0% vs. sis developed rebleeding, and all of these patients were man- 12/17, 70.6%; P <0.001). The experience of the endoscopists aged successfully by repeat endoscopic hemostasis without (staff vs. fellow) did not differ between the two groups. the additional need for other interventions such as surgery or angiographic embolization. Therefore, endoscopic hemo- 3. Risk Factors for Rebleeding after Endoscopic stasis is effective and safe for the management of DPPB. Hemostasis of DPPB In our study, clinically significant DPPB requiring endo- scopic interventions developed in 0.9% of patients who Multivariate analysis was performed to investigate inde- underwent colonoscopic polypectomy. This frequency cor- pendent risk factors for recurrent bleeding after successful responds to the DPPB rate of up to 2.2% reported in previous 6,9 endoscopic hemostasis of DPPB. A large number of clips studies. Initial endoscopic hemostasis was achieved in all and a combination of a clip with other hemostatic methods of these DPPB patients by using several hemostatic meth- increased the risk of rebleeding after endoscopic hemostasis ods, with the clip method most commonly used. A previous of DPPB (Table 4). retrospective study assessed the effectiveness of clipping in 45 cases of IPPB, 18 cases of DPPB, and nine cases of post- www.irjournal.org 225 Jeong-Mi Lee, et al. • Endoscopic management in delayed PPB biopsy bleeding. All cases of IPPB and postbiopsy bleeding number of clips required. A previous study revealed that op- and all but one DPPB case were successfully managed by erator familiarity with clipping had a bearing on successful clipping. Bleeding was controlled by using a clip in combina- hemostasis. Furthermore, the number of clips used was re- tion with the placement of a detachable snare in a patient in lated to the appearance and severity of DPPB. Spurting arte- whom clipping alone failed to achieve hemostasis. Another rial bleeding required more clips to achieve hemostasis than case series of 42 patients with postpolypectomy bleeding oozing bleeding, and active bleeding required more clips evaluated the usefulness of the clip method and found that than non-bleeding visible vessels. These considerations initial hemostasis was successful in all patients with active suggest that in severe, active DPPB cases, in which there is a bleeding. The average number of clips used was 2.9 in this high degree of difficulty in obtaining endoscopic hemostasis, study. Sorbi et al. also found that clipping was effective for more clips may be required and combination therapy may the management of DPPB and that an average of 4.6 clips be needed more frequently, which can be associated with a was required in patients with severe DPPB who required high risk of rebleeding. Therefore, these patients should be hospitalization. In our study, the average number of clips more closely monitored, even when initial hemostasis for needed for initial hemostasis of DPPB was 3.3, which is in DPPB has been achieved. agreement with previous studies. Besides clipping, other Several factors reportedly associated with a higher risk of methods were used for hemostasis in our study, including DPPB, such as anticoagulation, comorbidities, large polyp 9,17-19 injection of epinephrine and/or fibrin glue, argon plasma size, and inexperience of the endoscopists, were not as- coagulation, and coagulation forceps. Methods other than sociated with the risk of rebleeding after initial hemostasis clipping were more frequently used in the rebleeding posi- of DPPB in our study. We suggest that the quality of initial tive group. The choice of hemostatic method apparently hemostasis may be the most important factor affecting the 12,15 depends on an individual endoscopist’s preference. A recurrence of bleeding. combination of several methods was required in some cases. Our study has several limitations. First, it was retrospec- Because this was not a prospective study, we could not com- tive. Therefore, we could not analyze in detail the factors pare the hemostatic methods. Nonetheless, we suggest that involved in DPPB. For example, we could not assess the clipping may be a better hemostatic method for most DPPB nature of DPPB in some cases, i.e., whether the bleeding was because it can ensure mechanical closure of the bleeding arterial or venous. Second, we did not include patients with vessels regardless of whether they are arteries or veins. In minimal DPPB who were managed conservatively, or un- contrast, other methods such as injection and/or thermal co- stable patients who were initially managed by angiographic agulation may be effective for venous oozing but not for arte- embolization because of severe DPPB. Therefore, we could rial spurting, and may cause perforation of thin walled post- not completely determine the usefulness of endoscopic polypectomy ulcers. This might be the reason why clipping hemostasis in all DPPB patients. Third, other than rebleed- was the most commonly used hemostatic technique in our ing after endoscopic hemostasis, our study did not evaluate study of DPPB cases. other aspects of DPPB management. We did not evaluate Only 5.5% of polyps associated with DPPB showed re- bowel preparation methods for DPPB patients and timing bleeding after initial endoscopic hemostasis. In per-patient of diet resumption after endoscopic hemostasis. In addition, analysis, only 7.6% of DPPB patients showed rebleeding. Pre- we did not determine whether admission was necessary in 9,13 vious studies reported a rebleeding rate of 4.2% to 9.5%, the management of DPPB. If DPPB management is not ef- which is comparable to the rate reported in this study. Al- fective, a variety of issues such as medicolegal problems and though this rebleeding rate is not negligible, it is not signifi- high cost may develop. Therefore, further studies address- cantly high. Therefore, endoscopic hemostasis is effective for ing all these aspects are necessary to provide more useful the management of DPPB because it achieves a 100% initial information on the management of DPPB. Fourth, we did hemostasis rate, and also results in a low rebleeding rate. not analyze the initial DPPB rates according to endoscopic A large number of clips and a combination of clipping resection method in all 21,780 patients. Thus, we could not with other interventions were independent risk factors for assess the DPPB rate after cold snare polypectomy, EMR, rebleeding after initial hemostasis in DPPB. We believe that EPMR, ESD, and hybrid ESD in this study. Finally, this was a large numbers of clips and combination therapy may indi- single, tertiary center experience, and caution should be ex- cate technical difficulties during the hemostatic procedure. ercised when generalizing the findings of our study to other In addition, unfamiliarity with clipping may increase the situations. 226 www.irjournal.org https://doi.org/10.5217/ir.<년>.<년>.<년>.<년년년년년> • Intest Res <년>;<년>(<년>):<년년년년년>-<년년년년> https://doi.org/10.5217/ir.2017.15.2.221 • Intest Res 2017;15(2):221-227 9. Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. In conclusion, endoscopic hemostasis was very effective for the management of DPPB because it achieved 100% Postpolypectomy lower GI bleeding: descriptive analysis. Gas- trointest Endosc 2000;51:690-696. initial hemostasis and had a low rebleeding rate. Because a large number of clips and clipping combined with other 10. Levin TR, Zhao W, Conell C, et al. 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Clinical outcome of endoscopic management in delayed postpolypectomy bleeding

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Abstract

ORIGINAL ARTICLE pISSN • eISSN 1598-9100 2288-1956 https://doi.org/10.5217/ir.2017.15.2.221 Intest Res 2017;15(2):221-227 Clinical outcome of endoscopic management in delayed postpolypectomy bleeding Jeong-Mi Lee, Wan Soo Kim, Min Seob Kwak, Sung-Wook Hwang, Dong-Hoon Yang, Seung-Jae Myung, Suk-Kyun Yang, Jeong-Sik Byeon Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background/Aims: The clinical course after endoscopic management of delayed postpolypectomy bleeding (DPPB) has not been clearly determined. This study aimed to assess clinical outcomes after endoscopic hemostasis of DPPB and evaluate risk factors for rebleeding after initial hemostasis. Methods: We reviewed medical records of 198 patients who developed DPPB and underwent endoscopic hemostasis between January 2010 and February 2015. The performance of endoscopic hemostasis was assessed. Rebleeding negative and positive patients were compared. Results: DPPB developed 1.4±1.6 days after colono- scopic polypectomy. All patients achieved initial hemostasis. Clipping was the most commonly used technique. Of 198 DPPB patients, 15 (7.6%) had rebleeding 3.3±2.5 days after initial hemostasis. The number of clips required for hemostasis was higher in the rebleeding positive group (3.2±1.6 vs. 4.2±1.9, P =0.047). Combinations of clipping with other modalities such as injection methods were more common in the rebleeding positive group (67/291, 23.0% vs. 12/17, 70.6%; P <0.001). Multivariate analysis showed a large number of clips and combination therapy were independent risk factors for rebleeding. All the rebleeding cases were successfully managed by repeat endoscopic hemostasis. Conclusions: Endoscopic hemostasis is effective for the man- agement of DPPB because of its high initial hemostasis rate and low rebleeding rate. Endoscopists should carefully observe patients in whom a large number of clips and/or combination therapy have been used to manage DPPB because these may be related to the severity of DPPB and a higher risk of rebleeding. (Intest Res 2017;15:221-227) Key Words: Colonoscopy; Postpolypectomy bleeding; Clip; Rebleeding 5-10 noscopic polypectomy cases. Postpolypectomy bleeding INTRODUCTION is generally classified as either immediate/early postpolypec- Most colorectal cancers develop from adenomatous pol- tomy bleeding (IPPB) or delayed postpolypectomy bleeding yps. Colonoscopic polypectomy can remove most colorectal (DPPB). IPPB is usually defined as bleeding that develops 1-3 polyps effectively, and reduce the risk of colorectal cancer. immediately after resection of polyps during the colonos- Despite its effectiveness in the prevention of colorectal can- copy procedure. Because endoscopists can directly detect cer, polypectomy is not completely safe because it is associ- IPPB, most cases can be managed endoscopically during the 4 6 ated with complications such as bleeding and perforation. colonoscopic procedure. DPPB is defined as bleeding that Postpolypectomy bleeding occurs in 0.3% to 6.1% of colo- develops after the end of colonoscopic polypectomy. Most DPPB is detected when patients complain of hematochezia several hours to several days after colonoscopic polypectomy. Received April 14, 2016. Revised May 19, 2016. 6-8,11,12 The incidence of DPPB is reported to be 0.2% to 2.2%. Accepted May 25, 2016. Published online March 21, 2017 Correspondence to Jeong-Sik Byeon, Department of Gastroenterology, Although most endoscopists apply endoscopic hemostasis Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro to manage DPPB, clinical outcomes of endoscopic man- 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3905, Fax: +82-2- agement have not been thoroughly investigated. Thus, the 476-0824, E-mail: [email protected] aim of our study was to assess the clinical outcomes after Financial support: None. Conflict of interest: None. © Copyright 2017. Korean Association for the Study of Intestinal Diseases. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Jeong-Mi Lee, et al. • Endoscopic management in delayed PPB endoscopic hemostasis for DPPB. We also evaluated the fre- gender, laboratory findings, comorbidities, and use of medi- quency of DPPB and risk factors for recurrence of bleeding cations including antiplatelet agents (aspirin, clopidogrel) after initial endoscopic hemostasis. and anticoagulants (warfarin, heparin) were investigated. Colonoscopic features of each resected polyp such as the size, location, endoscopic morphology, histological diagno- METHODS sis, and colonoscopic polypectomy methods were analyzed. 1. Patients Information on endoscopic hemostasis such as the endos- copist’s experience (staff vs. fellow) and the endoscopic All patients who underwent colonoscopic and/or sigmoid- hemostasis methods were also reviewed. Clinical outcomes oscopic bleeding control for DPPB at Asan Medical Center after endoscopic hemostasis, including success or failure between January 2010 and February 2015 were included in of endoscopic hemostasis, complications, recurrent bleed- this study. DPPB was defined as hematochezia and/or me- ing, and performance of repeat interventions, were further lena occurring within 14 days of colonoscopic polypectomy. investigated. Success of endoscopic hemostasis was defined Techniques included cold snare polypectomy, injection as- as the cessation of bleeding after endoscopic interventions sisted polypectomy (endoscopic mucosal resection, EMR), such as clipping. The Institutional Review Board of our cen- endoscopic piecemeal mucosal resection (EPMR), endo- ter approved the protocol of this study. scopic submucosal resection (ESD), and ESD with snaring (hybrid ESD). Patients were categorized into two groups 3. Statistical Analysis based on the occurrence of rebleeding. The rebleeding posi- tive group was defined as those who presented with hemato- Statistical analyses were performed by using SPSS ver- chezia and/or melena after the initial successful endoscopic sion 21.0 (IBM Corp., Armonk, NY, USA). Continuous vari- hemostasis and required repeat hemostatic interventions. ables are reported as means with SDs and compared using The rebleeding negative group was defined as those who did Student t -test. Categorical data were analyzed using Fisher not show further hematochezia and/or melena after the ini- exact test. Multivariate logistic regression analyses were per- tial successful endoscopic hemostasis. formed to investigate the risk factors for recurrent bleeding after initial endoscopic hemostasis. A P -value <0.05 was con- 2. Review of Clinical Data sidered statistically significant. We retrospectively reviewed medical records and endos- copy reports with pictures. Demographic data such as age, 21,780 Patients underwent colonoscopic polypectomy 198 Patients (0.9%) developed DPPB and underwent endoscopic hemostasis Initial hemostasis was achieved by endoscopic interventions in all 198 patients (100%) 183 Patients (92.4%) were no 15 Patients (7.6%) were rebleeding rebleeding Fig. 1. Flow diagram of patients with de- Successful hemostasis by repeat layed postpolypectomy bleeding (DPPB). All endoscopic interventions in all DPPB patients were eventually managed by 15 patients (100%) endoscopic hemostasis. 222 www.irjournal.org https://doi.org/10.5217/ir.<년>.<년>.<년>.<년년년년년> • Intest Res <년>;<년>(<년>):<년년년년년>-<년년년년> https://doi.org/10.5217/ir.2017.15.2.221 • Intest Res 2017;15(2):221-227 79.5%). DPPB developed 1.4±1.6 days (median, 0.8 days; RESULTS range, 0.2−11.0 days) after colonoscopic polypectomy. Endo- 1. Baseline Characteristics and Clinical Course scopic hemostasis was attempted on the 308 polyps. A clip with or without other intervention was the most commonly A total of 21,780 patients underwent colonoscopic polyp- used hemostatic method (263/308, 85.4%). Endoscopic ectomy at our institution between January 2010 and Febru- hemostasis was successful for all 308 polyps in 198 patients ary 2015. Of these, 198 patients (0.9%) developed DPPB, (100%). There were no adverse events and no patient re- which was associated with 308 polyps (Fig. 1). The mean age quired a blood transfusion. Of the 198 patients, 17 polyps of the 198 patients was 60.1±11.2 years and 150 were male. (5.5%) in 15 cases (7.6%) presented with rebleeding 3.3±2.5 EMR was the most common polypectomy method (245/308, days (median, 2.1 days; range, 0.8−10.0 days) after initial Fig. 2. Rebleeding after initial endoscopic hemostasis in delayed postpolypectomy bleeding (DPPB). (A) Active blood oozing is noted at a large postpolypectomy ulcer where five clips were applied during a previous endoscopy to control DPPB. All five clips were attached at the periphery of the ulcer. (B) Hemostasis was achieved by the application of additional argon plasma A B coagulation. Table 1. Per-Patient Comparisons of Demographic Characteristics in the Rebleeding Positive and Negative Groups Rebleeding Total Characteristics P -value (n=198) Negative group (n=183) Positive group (n=15) Age (yr) 60.10±11.20 60.20±10.98 58.80±13.98 0.637 Male sex 150 (75.8) 141 (77.0) 9 (60.0) 0.205 Laboratory finding Hb before polypectomy (g/dL) 14.10±1.93 14.10±1.83 13.50±2.89 0.254 Hb after DPPB (g/dL) 13.10±2.36 13.10±2.32 12.70±2.80 0.572 PT (sec) 11.80±2.48 11.80±2.54 12.10±1.65 0.652 Current medication Aspirin 19 (9.6) 18 (9.5) 1 (6.7) 0.598 Clopidogrel 8 (4.0) 7 (3.8) 1 (6.7) 0.509 Aspirin+clopidogrel 7 (3.5) 6 (3.3) 1 (6.7) Warfarin 28 (14.1) 25 (13.7) 3 (20.0) 0.471 Comorbidity Hypertension 71 (35.9) 66 (36.1) 5 (33.3) 0.832 Cerebrovascular disease 14 (7.1) 13 (7.1) 1 (6.7) 0.713 Coronary artery disease 13 (6.6) 11 (6.0) 2 (13.3) 0.257 Liver cirrhosis 7 (3.6) 5 (2.7) 2 (13.3) 0.090 Values are presented mean±SD or number (%). Hb, hemoglobin; DPPB, delayed postpolypectomy bleeding . www.irjournal.org 223 Jeong-Mi Lee, et al. • Endoscopic management in delayed PPB endoscopic hemostasis (Fig. 2). Only one additional repeat 2. Comparison between Rebleeding Positive and endoscopic hemostasis session was necessary to control Negative Groups rebleeding in 11 of the 15 patients (73.3%). Two additional sessions were required in one patient because of repeated Demographic characteristics were compared in the bleeding. Three repeat endoscopic interventions were nec- rebleeding positive and negative groups, and showed no essary in one patient. Four repeat endoscopic hemostatic significant differences regarding age, gender, laboratory find- procedures were performed in the remaining two patients. ings, medications, and comorbidities (Table 1). Endoscopic All 15 patients with recurrent bleeding were managed suc- features at the time of colonoscopic polypectomy were com- cessfully without adverse events by repeat endoscopic inter- pared in the two groups (Table 2). The mean size of polyps vention and none of the patients with rebleeding required tended to be larger in the rebleeding positive group, but this further angiography or surgery to control recurrent bleeding. was not statistically significant (12.2±13.3 mm vs. 18.0±18.5 No blood transfusions were necessary in any of the rebleed- mm, P =0.217). There was no significant difference between ing patients. the groups with respect to polyp distribution or morphology. Table 2. Per-Polyp Comparisons of Endoscopic and Histological Features in the Rebleeding Positive and Negative Groups Rebleeding Total Endoscopic feature P -value (n=308) Negative group (n=291) Positive group (n=17) Polyp size (mm) 12.5±13.7 12.2±13.3 18.0±18.5 0.217 Polyp location 0.329 Cecum 15 (4.9) 13 (4.5) 2 (11.8) Ascending colon 95 (30.8) 92 (31.6) 3 (17.6) Transverse colon 39 (12.7) 37 (12.7) 2 (11.8) Descending colon 27 (8.8) 27 (9.3) 0 Sigmoid colon 76 (24.7) 71 (24.4) 5 (29.4) Rectum 56 (18.2) 51 (17.5) 5 (29.4) Polyp morphology 0.775 Is 198 (64.3) 188 (64.6) 10 (58.8) Ip 41 (13.3) 39 (13.4) 2 (11.8) IIa 69 (22.4) 64 (22.0) 5 (29.4) Method of resection 0.034 EMR 245 (79.5) 235 (80.8) 10 (58.8) EPMR 21 (6.8) 17 (5.8) 4 (23.5) ESD 11 (3.6) 10 (3.4) 1 (5.9) Hybrid ESD 7 (2.3) 6 (2.1) 1 (5.9) CSP 24 (7.8) 23 (7.9) 1 (5.9) Histologic finding 0.002 Tubular adenoma 205 (66.6) 200 (68.7) 5 (29.4) Villotubular adenoma 26 (8.4) 24 (8.2) 2 (11.8) Hyperplastic polyp 17 (5.5) 15 (5.2) 2 (11.8) Serrated adenoma 13 (4.2) 12 (4.1) 1 (5.9) Adenocarcinoma 21 (6.8) 17 (5.8) 4 (23.5) Unknown 26 (8.4) 23 (7.9) 3 (17.6) Values are presented mean±SD or number (%). EMR, endoscopic mucosal dissection; EPMR, endoscopic piecemeal mucosal resection; ESD, endoscopic submucosal dissection; CSP, cold snare polypectomy. 224 www.irjournal.org https://doi.org/10.5217/ir.<년>.<년>.<년>.<년년년년년> • Intest Res <년>;<년>(<년>):<년년년년년>-<년년년년> https://doi.org/10.5217/ir.2017.15.2.221 • Intest Res 2017;15(2):221-227 Table 3. Per-Polyp Comparisons of Performance of Endoscopic Hemostasis in the Rebleeding Positive and Negative Groups Rebleeding Endoscopic hemostasis Total (n=308) P -value Negative group (n=291) Positive group (n=17) Hemostatic method Clip 263 (85.4) 249 (85.6) 14 (82.4) 0.723 No. of clips 3.3±1.7 3.2±1.6 4.2±1.9 0.047 Clip alone 185 (60.1) 183 (62.9) 2 (11.8) <0.001 Clip with others 79 (25.6) 67 (23.0) 12 (70.6) <0.001 APC 67 (21.8) 57 (19.6) 10 (58.8) <0.001 Epinephrine injection 36 (11.7) 31 (10.7) 5 (29.4) 0.019 Fibrin glue injection 34 (11.0) 27 (9.3) 7 (41.2) <0.001 Coagulation forcep 12 (3.9) 9 (3.1) 3 (17.6) 0.023 Operator Staff 123 (39.9) 115 (39.5) 8 (47.1) 0.537 Fellow 185 (60.1) 176 (60.5) 9 (52.9) 0.747 Values are presented number (%) or mean±SD. APC, argon plasma coagulation. EPMR was more frequently used in the rebleeding positive Table 4. Risk Factors for Recurrent Postpolypectomy Bleeding (Multivariate Analysis) group than the rebleeding negative group (17/291, 5.8% vs. 4/17, 23.5%). Adenocarcinoma was more common in Adjusted OR Risk factor P -value (95% CI) the rebleeding positive group than the rebleeding negative group (Table 2). The performance of endoscopic hemosta- No. of clips 1.405 (1.006–1.962) 0.046 sis was compared in the rebleeding positive and negative Clip combined with other 16.541 (3.465–78.952) <0.001 interventions groups (Table 3). Clipping with or without other intervention was the most commonly used hemostatic method in both groups. The number of clips required for successful hemo- stasis was higher in the rebleeding positive group (3.2±1.6 DISCUSSION vs. 4.2±1.9, P =0.047). Clipping alone was more common (183/291, 62.9% vs. 2/17, 11.8%; P <0.001) in the rebleeding Our study showed that endoscopic interventions achieved negative group, whereas a combination of a clip and other 100% hemostasis for DPPB without any adverse events. Only modalities such as injection methods were more commonly 7.6% of patients who initially achieved endoscopic hemosta- used in the rebleeding positive group (67/291, 23.0% vs. sis developed rebleeding, and all of these patients were man- 12/17, 70.6%; P <0.001). The experience of the endoscopists aged successfully by repeat endoscopic hemostasis without (staff vs. fellow) did not differ between the two groups. the additional need for other interventions such as surgery or angiographic embolization. Therefore, endoscopic hemo- 3. Risk Factors for Rebleeding after Endoscopic stasis is effective and safe for the management of DPPB. Hemostasis of DPPB In our study, clinically significant DPPB requiring endo- scopic interventions developed in 0.9% of patients who Multivariate analysis was performed to investigate inde- underwent colonoscopic polypectomy. This frequency cor- pendent risk factors for recurrent bleeding after successful responds to the DPPB rate of up to 2.2% reported in previous 6,9 endoscopic hemostasis of DPPB. A large number of clips studies. Initial endoscopic hemostasis was achieved in all and a combination of a clip with other hemostatic methods of these DPPB patients by using several hemostatic meth- increased the risk of rebleeding after endoscopic hemostasis ods, with the clip method most commonly used. A previous of DPPB (Table 4). retrospective study assessed the effectiveness of clipping in 45 cases of IPPB, 18 cases of DPPB, and nine cases of post- www.irjournal.org 225 Jeong-Mi Lee, et al. • Endoscopic management in delayed PPB biopsy bleeding. All cases of IPPB and postbiopsy bleeding number of clips required. A previous study revealed that op- and all but one DPPB case were successfully managed by erator familiarity with clipping had a bearing on successful clipping. Bleeding was controlled by using a clip in combina- hemostasis. Furthermore, the number of clips used was re- tion with the placement of a detachable snare in a patient in lated to the appearance and severity of DPPB. Spurting arte- whom clipping alone failed to achieve hemostasis. Another rial bleeding required more clips to achieve hemostasis than case series of 42 patients with postpolypectomy bleeding oozing bleeding, and active bleeding required more clips evaluated the usefulness of the clip method and found that than non-bleeding visible vessels. These considerations initial hemostasis was successful in all patients with active suggest that in severe, active DPPB cases, in which there is a bleeding. The average number of clips used was 2.9 in this high degree of difficulty in obtaining endoscopic hemostasis, study. Sorbi et al. also found that clipping was effective for more clips may be required and combination therapy may the management of DPPB and that an average of 4.6 clips be needed more frequently, which can be associated with a was required in patients with severe DPPB who required high risk of rebleeding. Therefore, these patients should be hospitalization. In our study, the average number of clips more closely monitored, even when initial hemostasis for needed for initial hemostasis of DPPB was 3.3, which is in DPPB has been achieved. agreement with previous studies. Besides clipping, other Several factors reportedly associated with a higher risk of methods were used for hemostasis in our study, including DPPB, such as anticoagulation, comorbidities, large polyp 9,17-19 injection of epinephrine and/or fibrin glue, argon plasma size, and inexperience of the endoscopists, were not as- coagulation, and coagulation forceps. Methods other than sociated with the risk of rebleeding after initial hemostasis clipping were more frequently used in the rebleeding posi- of DPPB in our study. We suggest that the quality of initial tive group. The choice of hemostatic method apparently hemostasis may be the most important factor affecting the 12,15 depends on an individual endoscopist’s preference. A recurrence of bleeding. combination of several methods was required in some cases. Our study has several limitations. First, it was retrospec- Because this was not a prospective study, we could not com- tive. Therefore, we could not analyze in detail the factors pare the hemostatic methods. Nonetheless, we suggest that involved in DPPB. For example, we could not assess the clipping may be a better hemostatic method for most DPPB nature of DPPB in some cases, i.e., whether the bleeding was because it can ensure mechanical closure of the bleeding arterial or venous. Second, we did not include patients with vessels regardless of whether they are arteries or veins. In minimal DPPB who were managed conservatively, or un- contrast, other methods such as injection and/or thermal co- stable patients who were initially managed by angiographic agulation may be effective for venous oozing but not for arte- embolization because of severe DPPB. Therefore, we could rial spurting, and may cause perforation of thin walled post- not completely determine the usefulness of endoscopic polypectomy ulcers. This might be the reason why clipping hemostasis in all DPPB patients. Third, other than rebleed- was the most commonly used hemostatic technique in our ing after endoscopic hemostasis, our study did not evaluate study of DPPB cases. other aspects of DPPB management. We did not evaluate Only 5.5% of polyps associated with DPPB showed re- bowel preparation methods for DPPB patients and timing bleeding after initial endoscopic hemostasis. In per-patient of diet resumption after endoscopic hemostasis. In addition, analysis, only 7.6% of DPPB patients showed rebleeding. Pre- we did not determine whether admission was necessary in 9,13 vious studies reported a rebleeding rate of 4.2% to 9.5%, the management of DPPB. If DPPB management is not ef- which is comparable to the rate reported in this study. Al- fective, a variety of issues such as medicolegal problems and though this rebleeding rate is not negligible, it is not signifi- high cost may develop. Therefore, further studies address- cantly high. Therefore, endoscopic hemostasis is effective for ing all these aspects are necessary to provide more useful the management of DPPB because it achieves a 100% initial information on the management of DPPB. Fourth, we did hemostasis rate, and also results in a low rebleeding rate. not analyze the initial DPPB rates according to endoscopic A large number of clips and a combination of clipping resection method in all 21,780 patients. Thus, we could not with other interventions were independent risk factors for assess the DPPB rate after cold snare polypectomy, EMR, rebleeding after initial hemostasis in DPPB. We believe that EPMR, ESD, and hybrid ESD in this study. Finally, this was a large numbers of clips and combination therapy may indi- single, tertiary center experience, and caution should be ex- cate technical difficulties during the hemostatic procedure. ercised when generalizing the findings of our study to other In addition, unfamiliarity with clipping may increase the situations. 226 www.irjournal.org https://doi.org/10.5217/ir.<년>.<년>.<년>.<년년년년년> • Intest Res <년>;<년>(<년>):<년년년년년>-<년년년년> https://doi.org/10.5217/ir.2017.15.2.221 • Intest Res 2017;15(2):221-227 9. Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. In conclusion, endoscopic hemostasis was very effective for the management of DPPB because it achieved 100% Postpolypectomy lower GI bleeding: descriptive analysis. Gas- trointest Endosc 2000;51:690-696. initial hemostasis and had a low rebleeding rate. Because a large number of clips and clipping combined with other 10. Levin TR, Zhao W, Conell C, et al. 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Intestinal ResearchPubmed Central

Published: Apr 27, 2017

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