Introduction Endoscopic mucosal resection (EMR) has become an established treatment modality in the managment of patients with high grade dysplastic lesions and intramucosal cancer in Barrett oesophagus. The mucosal defect caused by the endoscopic resection usually takes several weeks to heal. There is no data whether this procedure is also safe for patients requiring anticoagulation. The aim of the study was to investigate the risk of acute and delayed bleeding in patients on anticoagulation undergoing EMR for treatment of early neoplasia in Barrett oesophagus. We compared the complication rate of EMR in patients taking warfarin as anticoagulants with that of a control group.
Methods Warfarin was stopped 5 days before the planned EMR and restarted on the evening of the procedure day. 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.
Results 34 EMRs were performed in nine patients requiring anticoagulation. 8 were on warfarin due to atrial fibrillation, one took warfarin after pulmonary embolism. One patient on warfarin was readmitted 10 days after EMR with haematemesis, melaena and an drop in haemoglobin >5 g/dl caused by bleeding from an EMR resection ulcer; the bleeding had settled spontaneously at the time of endoscopy. Out of 138 EMRs in 35 controls, five acute bleeding events occurred during EMR which required treatment by clipping, coagulation grasper or heater probe. No delayed bleeding event occurred in the control group. The maximal diameter of the resected specimen did not differ between anticoagulated patients and controls (median 17 mm; 25%>75% percentile: 15–18 mm vs 17 mm; 25%>75% percentile: 15–20 mm; p=0.68). No perforations were observed in either groups. The number of bleeding events did not differ between groups (p=0.85), neither for acute (p=0.60) or delayed bleeding (p=0.46).
Conclusion 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.
Competing interests None declared.