Study Population
Dunedin Hospital is the only secondary/tertiary hospital in the region, providing colonoscopic services to a population of approximately 193,803 [10]. Consecutive patients who underwent colonoscopic polypectomy between January 2007 and June 2009 at Dunedin Hospital, Dunedin, New Zealand were identified retrospectively from the endoscopy reporting database (EndoSmart, Dunedin, New Zealand). Retrospectively, each patients’ colonoscopy report was reviewed for polyp characteristics (sessile, semi-sessile, on a stalk), polyp size, method of polypectomy (cautery snare, hot or cold forceps), and number of polyps removed was recorded. The patients’ medical records were reviewed for demographical data, the indications for colonoscopy, use of NSAIDs, anticoagulant or antiplatelet agents and the prevalence of bleeding following polypectomy. A retrospective review of each patient’s clinical records, hospital files and electronic records was performed to establish the use of medications both prior to and post procedure. These records include general practitioners referral letter, nurse notes, and physicians’ inpatient and outpatient record.
Patients on anticoagulants follow a standardized protocol in our unit. Patients with current warfarin use for valvular heart disease are switched to enoxaparin 5 days prior colonoscopy and instructed to omit the enoxaparin dose on the morning of the procedure. Patients on warfarin for atrial fibrillation are instructed to stop warfarin 5 days prior procedure. Patient with elevated international normalized ratio (INR) greater than 1.5 are rescheduled. Patients on intravenous heparin are instructed to stop infusion 6 hours prior the procedure. Patients taking aspirin and NSAIDs are not told to discontinue the medication prior to procedure.
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Patients’ medical records were used to identify any clinically important delayed post-polypectomy bleeding requiring attendance to hospital. Clinically important delayed post-polypectomy bleeding was defined as lower GI bleeding requiring transfusion, hospitalization, re-intervention or surgery within 30 days of the procedure. Patients who developed mild and self-limiting hematochezia after polypectomy and not requiring re-admission were not included. Dunedin Hospital is the only secondary/tertiary hospital in the region, and all regional hospitals share the same computer inpatient management system. Therefore, all patients who developed significant post-polypectomy bleeding requiring hospital admission were included in the study.
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Patients were excluded if the procedure was performed primarily for acute upper or lower gastrointestinal bleeding. Patients who underwent surgery within 30 days after the procedure for reasons other than bleeding (e.g. colorectal carcinoma) were also excluded (Figure 1).
Statistical significance was assessed by determining the odds ratio (OR) from a conditional logistic model for matched pairs and 95% confidence interval (CI) around the OR were obtained as margins of error. The study is approved by Lower South Regional Ethics Committee, New Zealand.
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