Original article
Alimentary tract
A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions

https://doi.org/10.1016/j.cgh.2016.03.021Get rights and content

Background & Aims

After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk.

Methods

We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding.

Results

Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%–4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0–3), average-risk (score, 4–7), or high-risk (score, 8–10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70–0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively.

Conclusions

The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8–10) had a 40% probability of delayed bleeding.

Section snippets

Patients

The Spanish EMR Group, formed by endoscopists from 23 Spanish hospitals, started a multicenter prospective observational study in February 2013. Nonpedunculated colorectal lesions 2 cm or larger that underwent EMR were recorded consecutively in a centralized database. All patients who had indications for EMR of colorectal lesions were screened for inclusion. Subjects who refused to participate in the study and/or had lesions smaller than 20 mm were excluded. Until February 2015, we collected

General Characteristics of Patients and Lesions

A total of 1255 EMRs of large colorectal lesions were performed consecutively in 1214 patients (Table 1). There were 770 (63.4%) males and their mean age was 67.9 years (range, 24–93 y). The American Society of Anesthesiologists (ASA) score was III or IV in 379 patients (30.5%). A total of 218 (17.5%) patients had antiplatelet therapy prescribed. Aspirin treatment was used during the procedure in 51 patients (4.1%).

The mean lesion size was 30.5 mm (SD, 11.82 mm; range 20–120 mm). Lesion

Discussion

In this multicenter prospective cohort we found that factors associated with DB were patient age 75 years and older, ASA classification of III or IV, aspirin use during EMR, location of the lesion proximal to the transverse colon, a lesion size of 40 mm or larger, and no complete mucosal closure with clips. On the basis of these risk factors, we developed a DB scoring system for EMR of large colorectal lesions.

The risk factors we found to be associated with DB have been described in other

Conclusions

In this large, prospective, multicenter series, 6 simple variables (age, ≥75 y; ASA classification III or IV, aspirin use during EMR, location of lesion proximal to the transverse colon, lesion size ≥40 mm, and no mucosal complete closure with clips) were associated with DB after EMR. We developed a predictive score to estimate the DB risk that could be used in the management of these patients to guide the prophylactic treatment and observation period. It also might be useful in clinical trials

Acknowledgments

The authors would like to acknowledge Carolyn Newey for help in editing the manuscript and Navarrabiomed-Fundación Miguel Servet for their support with the statistical analysis.

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    Conflicts of interest The authors disclose no conflicts.

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