The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis

Abstract

BACKGROUND & AIMS:Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. METHODS:An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding £30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. RESULTS:Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ‡20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat [ 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35a Members of the Prophylactic Clipping Collaborative Group:

Indication of emergency colonoscopy after colorectal endoscopic submucosal dissection: A proposal of hematochezia scale

“…Inoue et al 13 conducted a multicenter, open-label, randomized controlled trial and reported that prophylactic clipping was not effective in preventing post-polypectomy bleeding for < 20 mm colon polyps. On the other hand, according to the results of various meta-analyses, 14,15 prophylactic clip closure may reduce post-polypectomy bleeding.…”

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

“…The study included pedunculated polyps, and most polyps were ,20 mm. Three recent meta-analyses summarized current evidence and reported that prophylactic clip closure reduces CSPEB for all nonpedunculated polyps $20 mm that are located in the proximal colon (transverse colon to the cecum) by 40%-50% (7,18,52). By contrast, there was no apparent benefit for closure of polyps ,20 mm or for polyps $20 mm located in the distal colon.…”

“…First, we do not know whether clip closure may be beneficial for a subset of patients while providing no benefit to others. For instance, it is unclear whether clipping reduces CSPEB among patients on anticoagulants with distal large polyps (23), but the results of a recent meta-analysis with a limited number of patients suggest that it does not (7). Similarly, it is unclear whether clipping is beneficial for all proximal lesions.…”

“…These advantages, however, are reduced/counterbalanced by adverse events (AEs), of which clinically significant post-EMR bleeding (CSPEB) is the most common. CSPEB is defined as delayed bleeding that occurs within 30 days of the procedure and results in an unplanned visit to the emergency department, hospitalization, or reintervention (repeat endoscopy, angiography, or surgery) (5)(6)(7)(8)(9)(10)(11)(12). The mean rate of CSPEB incidence after EMR of LNPCLs is 6%-7% (13,14).…”

Clip Closure Does Not Reduce Risk of Bleeding After Resection of Large Serrated Polyps: Results From a Randomized Trial

“…Recent research suggests that use of endoscopic clips to close the resection site following EMR is beneficial, particularly for polyps over 2 cm and located in the proximal colon. 11 Clipping the resection site closed in this setting has been shown to reduce the incidence of delayed bleeding, an important adverse event (AE) associated with EMR. Using data from a large, international multi-center clinical trial, 12 we aimed to assess whether the benefit of clipping was evident for serrated polyps specifically, and whether there were significant differences in the benefit of clipping between LSPs and large adenomatous polyps.…”