Continuous Anticoagulation and Cold Snare Polypectomy Versus Heparin Bridging and Hot Snare Polypectomy in Patients on Anticoagulants With Subcentimeter Polyps A Randomized Controlled Trial

Background: Management of anticoagulants for patients undergoing polypectomy is still controversial. Cold snare polypectomy ( CSP) is reported to cause less bleeding than hot snare polypectomy ( HSP). Objective: To 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. Design: Multicenter, parallel, noninferiority randomized controlled trial. ( University Hospital Medical Information Network Clinical Trials Registry: UMIN000019355) Setting: 30 Japanese institutions. Patients: Patients receiving anticoagulant therapy ( warfarin or direct oral anticoagulants) who had at least 1 nonpedunculated subcentimeter colorectal polyp. Intervention: Patients were randomly assigned to undergo HB+HSP or CA+CSP and followed up 28 days after polypectomy. Measurements: The 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). Results: A 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. Limitation: An open-label trial assessing 2 factors ( anticoagulation approach and polypectomy procedure type) simultaneously. Conclusion: Patients 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.