• Yoji Takeuchi, Katsuhiro Mabe, Yuichi Shimodate, Shinji Yoshii, Shinya Yamada, Mineo Iwatate, Takuji Kawamura, Kinichi Hotta, Koji Nagaike, Nobuaki Ikezawa, Tomoaki Yamasaki, Yoriaki Komeda, Satoshi Asai, Yasuhiro Abe, Takuji Akamatsu, Yuko Sakakibara, Hisatomo Ikehara, Yuzuru Kinjo, Takashi Ohta, Yoko Kitamura, Takashi Shono, Takuya Inoue, Yoshio Ohda, Nozomu Kobayashi, Tokuma Tanuma, Ryu Sato, Taku Sakamoto, Naohiko Harada, Akiko Chino, Hideki Ishikawa, Masanori Nojima, Toshio Uraoka, and Madowazu Study Group.
• Osaka International Cancer Institute, Osaka, Japan (Y.T.).
• Ann. Intern. Med. 2019 Aug 20; 171 (4): 229-237.

BackgroundManagement of anticoagulants for patients undergoing polypectomy is still controversial. Cold snare polypectomy (CSP) is reported to cause less bleeding than hot snare polypectomy (HSP).ObjectiveTo compare outcomes between continuous administration of anticoagulants (CA) with CSP (CA+CSP) and periprocedural heparin bridging (HB) with HSP (HB+HSP) for subcentimeter colorectal polyps.DesignMulticenter, parallel, noninferiority randomized controlled trial. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000019355).Setting30 Japanese institutions.PatientsPatients receiving anticoagulant therapy (warfarin or direct oral anticoagulants) who had at least 1 nonpedunculated subcentimeter colorectal polyp.InterventionPatients were randomly assigned to undergo HB+HSP or CA+CSP and followed up 28 days after polypectomy.MeasurementsThe primary end point was incidence of polypectomy-related major bleeding (based on the incidence of poorly controlled intraprocedural bleeding or postpolypectomy bleeding requiring endoscopic hemostasis). The prespecified inferiority margin was -5% (CA+CSP vs. HB+HSP).ResultsA total of 184 patients were enrolled: 90 in the HB+HSP group, 92 in the CA+CSP group, and 2 who declined to participate after enrollment. The incidence of polypectomy-related major bleeding in the HB+HSP and CA+CSP groups was 12.0% (95% CI, 5.0% to 19.1%) and 4.7% (CI, 0.2% to 9.2%), respectively. The intergroup difference for the primary end point was +7.3% (CI, -1.0% to 15.7%), with a 0.4% lower limit of 2-sided 90% CI, demonstrating the noninferiority of CA+CSP. The mean procedure time for each polyp and the hospitalization period were longer in the HB+HSP than in the CA+CSP group.LimitationAn open-label trial assessing 2 factors (anticoagulation approach and polypectomy procedure type) simultaneously.ConclusionPatients having CA+CSP for subcentimeter colorectal polyps who were receiving oral anticoagulants did not have an increased incidence of polypectomy-related major bleeding, and procedure time and hospitalization were shorter than in those having HB+HSP.Primary Funding SourceJapanese Gastroenterological Association.

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