title: Endoscopic mucosal resection of early oesophageal neoplasia in patients requiring anticoagulation: is it safe?
abstract: Endoscopic mucosal resection (EMR) has become the standard treatment for early oesophageal neoplasia. The mucosal defect caused by EMR usually takes several weeks to heal. Despite guidelines on high-risk endoscopic procedures in patients on anticoagulation, evidence is lacking whether EMR is safe in such patients. We investigated the immediate and delayed bleeding risk in patients undergoing diagnostic or therapeutic oesophageal EMR comparing patients requiring warfarin anticoagulation with a control group.
  
  
  
  Warfarin was stopped 5 days before the planned EMR and restarted on the evening following the procedure. Patients with high-risk conditions, such as recent pulmonary thromboemboli, received bridging with low molecular weight heparin. All EMRs were performed when the INR was <1.5. Bleeding events on the day of the EMR and within 3 months post-procedure were documented.
  
  
  
  One hundred and seventeen consecutive patients with early oesophageal neoplasia were included. Sixty-eight EMRs were performed in 15 patients requiring anticoagulation. One patient on warfarin was readmitted 10 days after EMR with haematemesis and melaena. Out of 400 EMRs in 102 controls, 26 immediate bleeding events occurred requiring endoscopic intervention. One delayed bleeding event (melaena) occurred in the control group. The number of bleeding events did not differ between groups [p = 0.99; odds ratio 1.01 (0.30-3.44)], neither for acute (p = 0.76) nor delayed bleeding (p = 0.24).
  
  
  
  EMR of early oesophageal neoplasia can be safely performed in patients requiring anticoagulation when warfarin is discontinued 5 days before the endoscopic intervention and reinstituted on the evening of the procedure day.
authors: Translational Gastroenterology Unit, Oxford University Hospitals, OX3 9DU, Oxford, UK.
authors: Said
authors: S
authors: Al-Mammari
authors: Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK.
authors: Richard
authors: R
authors: Owen
authors: Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK.
authors: John
authors: J
authors: Findlay
authors: Translational Gastroenterology Unit, Oxford University Hospitals, OX3 9DU, Oxford, UK.
authors: Andreas
authors: A
authors: Koutsoumpas
authors: Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK.
authors: Richard
authors: R
authors: Gillies
authors: Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK.
authors: Robert
authors: R
authors: Marshall
authors: Translational Gastroenterology Unit, Oxford University Hospitals, OX3 9DU, Oxford, UK.
authors: Adam A
authors: AA
authors: Bailey
authors: Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK.
authors: Nick
authors: N
authors: Maynard
authors: Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK.
authors: Bruno
authors: B
authors: Sgromo
authors: Translational Gastroenterology Unit, Oxford University Hospitals, OX3 9DU, Oxford, UK. braden@em.uni-frankfurt.de.
authors: Barbara
authors: B
authors: Braden
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001471:Barrett Esophagus / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D016022:Case-Control Studies; D000069916:Endoscopic Mucosal Resection; D004938:Esophageal Neoplasms / Q000601:surgery*; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000601:surgery; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D008297:Male; D011446:Prospective Studies; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin
keywords: Anticoagulation; Barrett’s oesophagus; Endoscopic mucosal resection; Haemostasis; High-grade dysplasia; Intramucosal cancer