RESUMEN
BACKGROUND AND AIMS: Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy. METHODS: We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding. RESULTS: There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001). CONCLUSION: We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.
Asunto(s)
Pólipos del Colon/cirugía , Neoplasias Colorrectales/cirugía , Hemorragia Gastrointestinal/epidemiología , Inhibidores de Agregación Plaquetaria/uso terapéutico , Hemorragia Posoperatoria/epidemiología , Anciano , Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Estudios de Casos y Controles , Clopidogrel , Pólipos del Colon/patología , Colonoscopía , Neoplasias Colorrectales/patología , Femenino , Hemorragia Gastrointestinal/etiología , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/etiología , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia/prevención & control , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico , Factores de Tiempo , Warfarina/uso terapéuticoRESUMEN
BACKGROUND: Colorectal adenocarcinoma with depth of invasion ≤1,000 µm from the muscularis mucosa and favorable histology is now considered for local resection. We aimed to examine the strength of evidence for this emerging practice. METHODS: We searched Medline, Scopus, and Cochrane (1950-2011), then performed a meta-analysis on the risk of lymph node metastasis in nonpedunculated (sessile and nonpolypoid) T1 colorectal cancers. We included studies with nonpedunculated lesions, actual invasion depth, and pathologic factors of interest. Synchronous, polyposis or secondary cancers, and chemoradiation studies were excluded. Our primary outcome was the risk of LNM. We analyzed using Review Manager; we estimated heterogeneity using Cochran Q χ(2) test and I (2). We generated summary risk ratios using a random effects model, performed sensitivity analyses, and evaluated the quality of evidence using GRADEPro. RESULTS: We identified 209 articles; 5 studies (n = 1213 patients) met the inclusion criteria. The risk of LNM in nonpedunculated ≤1,000 µm is 1.9 % (95 % confidence interval 0.5-4.8 %). The risk for all T1 is 13 % (95 % confidence interval 11.5-15.4 %). Characteristics protective against LNM were ≤1,000 µm invasion, well differentiation, absence of lymphatic and vascular invasion, and absence of tumor budding. We did not detect significant study heterogeneity. The quality of evidence was poor. CONCLUSIONS: Well-differentiated nonpedunculated T1 colorectal cancer invasive into the submucosa ≤1,000 µm, without lymphovascular involvement or tumor budding, has the lowest risk of nodal metastasis. Importantly, the risk was not zero (1.9 %), and the qualitative formal analysis of data was not strong. As such, endoscopic resection alone may be adequate in select patients with submucosal invasive colorectal cancers, but more studies are needed. Overall, the quality of evidence was poor; data were from small retrospective studies from limited geographic regions.
Asunto(s)
Neoplasias Colorrectales/secundario , Mucosa Intestinal/patología , Metástasis Linfática , Estadificación de Neoplasias , Neoplasias Colorrectales/diagnóstico , Humanos , Invasividad NeoplásicaAsunto(s)
Anastomosis en-Y de Roux/métodos , Colangiopancreatografia Retrógrada Endoscópica/instrumentación , Quiste del Colédoco/cirugía , Conducto Hepático Común/cirugía , Aumento de la Imagen/instrumentación , Yeyunostomía/métodos , Quiste del Colédoco/diagnóstico , Diagnóstico Diferencial , Diseño de Equipo , Femenino , Estudios de Seguimiento , Conducto Hepático Común/patología , Humanos , Persona de Mediana Edad , Reproducibilidad de los Resultados , Grabación en VideoRESUMEN
BACKGROUND: Sexually transmitted infections (STIs) are of growing concern in China. Understanding the relationship between socioeconomic status (SES) and healthcare-seeking (HCS) behavior will help design effective policies to contain the epidemic of STIs across SES. METHODS: We used the Chinese Health and Family Life Survey, a nationally representative survey of 3813 adults from 48 Chinese cities and counties during 1999-2000. We studied the 730 women with at least one genitourinary (GU) symptom. HCS was measured by whether respondents visited a hospital or an unrecognized clinic, self-treatment, or doing nothing. Formal treatment was defined as visiting a hospital. SES was measured by income (tertile group) and education (< or =primary school, junior high school, senior high school, college or above). Bivariate tests and logistic regressions were applied. RESULTS: There was a significantly positive relationship among income, education, and treatment. Odds ratios (ORs) of medium and high income were 2.01 (p = 0.04) and 1.39 (p = 0.46), respectively, after controlling demographics. ORs of middle school, high school, and college or above were 1.81 (p = 0.05), 2.27 (p = 0.03), and 1.27 (p = 0.64), respectively. The relationship between income and formal treatment was also positive, and the relationship between education and formal treatment was negative. Additional adjustment for STI knowledge and experience reduced the HCS disparity across education. CONCLUSIONS: Income and education have different effects on HCS behavior among Chinese women with GU symptoms. Income may affect HCS via affordability, and education is a complicated proxy for sex education, STI knowledge, and experience that will affect the socioeconomic disparity in HCS.