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Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in oral anticoagulant users: a propensity-score analysis

  • Louis H.S. Lau
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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  • Cosmos L.T. Guo
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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  • Joyce K.K. Lee
    Affiliations
    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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  • Clive S.T. Chan
    Affiliations
    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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  • Joyce W.Y. Mak
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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  • Sunny H. Wong
    Affiliations
    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong

    Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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  • Terry C.F. Yip
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong

    Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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  • Grace L.H. Wong
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong

    Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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  • Vincent W.S. Wong
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong

    Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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  • Francis K.L. Chan
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
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  • Raymond S.Y. Tang
    Correspondence
    Reprint requests: Raymond S. Y. Tang, MD, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 30-32, Ngan Shing St, Prince of Wales Hospital, Hong Kong SAR.
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong

    Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
    Search for articles by this author
Published:April 08, 2022DOI:https://doi.org/10.1016/j.gie.2022.04.001

      Background and Aims

      Evidence of prophylactic clipping is inconsistent except for proximal and large colonic lesions in the general population. Although warfarin and direct oral anticoagulants (DOACs) are significant risk factors of postpolypectomy bleeding (PPB), dedicated studies to examine the benefit of prophylactic clipping in these high-risk patients remain limited.

      Methods

      We performed a propensity score–weighted retrospective cohort study from 2012 to 2020. Patients who received an oral anticoagulant and underwent colonoscopic polypectomy were included. Data were collected on baseline demographics, medications (anticoagulant, antiplatelet, and heparin bridging), and endoscopies (polyp number, location, size, morphology, histopathology, resection method and prophylactic clipping). Propensity-score models with inverse probability of treatment weighting were developed between prophylactic clipping and no clipping groups. Unbalanced variables were included in a doubly robust model with multivariate analysis. The primary outcome was clinically significant delayed PPB, defined as a composite endpoint of hemoglobin drop ≥2 g/dL, blood transfusion, or repeat colonoscopy for hemostasis within 30 days.

      Results

      Five hundred forty-seven patients with 1485 polyps were included. Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio [OR], 1.19; 95% confidence interval [CI], .73-1.95; P = .497). The hot resection method was associated with a significantly higher risk of PPB (OR, 9.76; 95% CI, 3.94-32.60; P < .001) compared with cold biopsy or snare polypectomy. In a subgroup analysis, prophylactic clipping was associated with a lower PPB risk in patients on DOACs (OR, .36; 95% CI, .16-.82; P = .015).

      Conclusions

      Prophylactic clipping was not associated with an overall reduced risk of PPB in patients on oral anticoagulants. The use of cold snare polypectomy should be maximized in anticoagulated patients.

      Abbreviations:

      ASMD (absolute standardized mean difference), CI (confidence interval), DOAC (direct oral anticoagulant), HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs), ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), IPTW (inverse probability of treatment weighting), OR (odds ratio), PPB (postpolypectomy bleeding)
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