Risk factors for post-polypectomy bleeding; a retrospective case-control study of a high-volume colonoscopy center

Abstract

Background and aim Post-polypectomy bleeding (PPB) remains an uncommon although serious complication of colonoscopy. The aim of this study is to determine the PPB-prevalence in a secondary care hospital and its associated risk factors.

Patients and methods We collected data from 581 patients, with the removal of 1593 polyps between August 2017 and August 2019. A univariate binary logistic regression analysis was conducted retrospectively.

Results PPB occurred in only 10 cases, representing 1.7% of patients: immediate in 1.2% and delayed in 0.5%. The number of removed polyps per patient [4.5 (SD 2.59) for hemorrhagic vs. 2.74 (SD 1.98) for non-hemorrhagic group] and the propofol dose [232 mg (SD 93.07) for hemorrhagic vs. 133 mg (SD 57.28) for non-hemorrhagic group] were relevant patient-related risk factors. The polyp-based analysis showed the polyp size [18.4 mm (SD 10.44) for hemorrhagic vs. 4.42 mm (SD 4.29) for non-hemorrhagic group], the morphology [wide-based: OR 24.83 (95 % CI 2.76 – 223.44), pedunculated: OR 56.67 (95 % CI 5.03 – 638.29)], the location at ileocecal valve [OR 20.48, 95 % CI 1.81 – 231.97)], and the polypectomy method [hot snare piecemeal with epinephrine injection: OR 75.38 (95 % CI 7.67 – 741.21)] as significant risk factors for PPB, too.

Conclusions The low rate of PPB confirms the safety of the procedure in non-tertiary, high-volume colonoscopy centers. The number of polyps removed per patient, the polyp size, morphology and location, as well as the sedation dose and the method of polypectomy were shown as relevant risk factors.

Zusammenfassung

Hintergrund und Ziele Blutungen nach Polypektomie (PPB) bleiben eine seltene, wenn auch schwerwiegende Komplikation der Koloskopie. Ziel dieser Studie ist es, die PPB-Prävalenz in einem Sekundärkrankenhaus und die damit verbundenen Risikofaktoren zu bestimmen.

Patienten und Methoden Wir sammelten Data von 581 Patienten, wobei zwischen August 2017 und August 2019 1.593 Polypen entfernt wurden. Eine univariate binäre logistische Regressionsanalyse wurde retrospektiv durchgeführt.

Ergebnisse PPB trat nur in 10 Fällen auf, welches 1,7 % der Patienten entspricht: sofort in 1,2 % und verzögert in 0,5 %. Die Anzahl der entfernten Polypen pro Patient (4,5 [SD 2,59] für hämorrhagische vs. 2,74 [SD 1,98] für nicht hämorrhagische Gruppe) und die Propofol-Dosis (232 mg [SD 93,07] für hämorrhagische vs. 133 mg [SD 57,28] für nicht hämorrhagische Gruppe) waren relevante patientenbezogene Risikofaktoren. Die polypenbasierte Analyse zeigte die Polypengröße (18,4 mm [SD 10,44] für die hämorrhagische vs. 4,42 mm [SD 4,29] für die nicht hämorrhagische Gruppe), die Morphologie (breitbasig: OR 24,83 [95 % CI 2,76 – 223,44], gestielt: OR 56,67 [95 % CI 5,03 – 638,29]), die Position an der Ileozökalklappe [OR 20,48, 95 % CI 1,81 – 231,97]) und die Polypektomiemethode (Elektroschlinge piecemeal mit Adrenalininjektion: OR 75,38 [95 % CI 7,67 – 741,21]) als signifikante Risikofaktoren auch für PPB.

Schlussfolgerungen Die niedrige PPB-Rate bestätigt die Sicherheit dieses Verfahrens in nicht tertiären Koloskopiezentren mit hohem Volumen. Die Anzahl der pro Patient entfernten Polypen, die Polypengröße, Morphologie und Lokalisation sowie die Sedierungsdosis und die Methode der Polypektomie wurden als relevante Risikofaktoren angegeben.

Schlüsselwörter

Adenom - Polypektomie - Blutung - Risikofaktor - submukosale Unterspritzung - Adrenalin - Schlinge - Piecemeal-Resektion - Blutstillung - Clip

Keywords

adenoma - polypectomy - bleeding - risk factor - submucosal injection - epinephrine - snare - piecemeal resection - hemostasis - clip

Publication History

Received: 22 January 2021

Accepted after revision: 01 November 2021

Article published online:
14 December 2021

• References

• 1 Xirasagar S, Wu Y, Tsai MH. et al. Colorectal cancer prevention by a CLEAR principles-based colonoscopy protocol: an observational study. Gastrointest Endosc 2020; 91: 905-916 DOI: 10.1016/j.gie.2019.11.043. (PMID: 31816316)
• 2 Click B, Pinsky PF, Hickey T. et al. Association of Colonoscopy Adenoma Findings With Long-term Colorectal Cancer Incidence. JAMA 2018; 319: 2021-2031 DOI: 10.1001/jama.2018.5809. (PMID: 29800214)
• 3 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981 DOI: 10.1056/NEJM199312303292701. (PMID: 8247072)
• 4 Zhang Q, An SL, Chen ZY. et al. Assessment of Risk Factors for Delayed Colonic PostPolypectomy Hemorrhage: A Study of 15553 Polypectomies from 2005 to 2013. PLoS ONE 2014; 9: e108290 DOI: 10.1371/journal.pone.0108290. (PMID: 25271734)
• 5 Liu C, Wu R, Sun X. et al. Risk factors for delayed hemorrhage after colonoscopic postpolypectomy: Polyp size and operative modality. JGH Open 2019; 3: 61-64 DOI: 10.1002/jgh3.12106. (PMID: 30834342)
• 6 Jaruvongvanich V, Prasitlumkum N, Assavapongpaiboon B. et al. Risk Factors for Delayed Colonic Post-Polypectomy Bleeding: A Systematic Review and Meta-Analysis. Int J Colorectal Dis 2017; 32: 1399-1406 DOI: 10.1007/s00384-017-2870-0. (PMID: 28779355)
• 7 Amato A, Radaelli F, Correale L. et al. Intra-procedural and delayed bleeding after resection of large colorectal lesions: The SCALP study. United European Gastroenterology Journal 2019; 7: 1361-1372 DOI: 10.1177/2050640619874176. (PMID: 31839962)
• 8 Choung BS, Kim SH, Ahn DS. et al. Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study. J Clin Gastroenterol 2014; 48: 784-789 DOI: 10.1097/MCG.0000000000000027. (PMID: 24231934)
• 9 Wu XR, Church JM, Jarrar A. et al. Risk factors for delayed postpolypectomy bleeding: how to minimize your patients’ risk. Int J Colorectal Dis 2013; 28: 1127-1134 DOI: 10.1007/s00384-013-1661-5. (PMID: 23440363)
• 10 Pigò F, Bertani H, Grande G. et al. Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis. Dig Liver Dis 2018; 50: 20-26 DOI: 10.1016/j.dld.2017.10.005. (PMID: 29089272)
• 11 Kubo K, Kato M, Mabe K. et al. Risk Factors for Delayed Bleeding after Therapeutic Gastrointestinal Endoscopy in Patients Receiving Oral Anticoagulants: A Multicenter Retrospective Study. Digestion 2019; 10: 1-9 DOI: 10.1159/000502952. (PMID: 31505493)
• 12 Tullavardhana T, Akranurakkul P, Ungkitphaiboon W. et al. Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies. Annals of Medicine and Surgery 2017; 19: 65-73
• 13 Aizawa M, Utano K, Tsunoda T. et al. Delayed hemorrhage after cold and hot snare resection of colorectal polyps: a multicenter randomized trial (interim analysis). Endosc Int Open 2019; 7: E1123-E1129 DOI: 10.1055/a-0854-3561. (PMID: 31475229)
• 14 Luigiano C, Ferrara F, Ghersi S. et al. Endoclipassisted resection of large pedunculated colorectal polyps: technical aspects and outcome. Dig Dis Sci 2010; 55: 1726-1731 DOI: 10.1007/s10620-009-0905-2. (PMID: 19657735)
• 15 Shinozaki S, Kobayashi Y, Hayashi Y. et al. Efficacy and Safety of Cold Versus Hot Snare Polypectomy for Resecting Small Colorectal Polyps: Systematic Review and Meta-Analysis. Dig Endosc 2018; 30: 592-599 DOI: 10.1111/den.13173. (PMID: 29675857)
• 16 Qu J, Jian H, Li L. et al. Effectiveness and safety of cold versus hot snare polypectomy: A meta-analysis. Journal of Gastroenterology and Hepatology 2019; 34: 49-58 DOI: 10.1111/jgh.14464. (PMID: 30176072)
• 17 Faul F, Erdfelder E, Buchner A. et al. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods 2009; 41: 1149-1160 DOI: 10.3758/BRM.41.4.1149. (PMID: 19897823)
• 18 Consolo P, Luigiano C, Strangio G. et al. Efficacy, risk factors and complications of endoscopic polypectomy: ten year experience at a single center. World J Gastroenterol 2008; 14: 2364-2369 DOI: 10.3748/wjg.14.2364. (PMID: 18416463)
• 19 Buddingh T, Herngreen T, Haringsma J. et al. Location in the Right Hemi-Colon Is an Independent Risk Factor for Delayed Post-Polypectomy Hemorrhage: A Multi-Center Case-Control Study. Am J Gastroenterol 2011; 106: 1119-1124 DOI: 10.1038/ajg.2010.507. (PMID: 21266961)