Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

Abstract

BACKGROUND & AIMS: Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding. METHODS: We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (!20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse

Endoscopic Management of Post-Polypectomy Bleeding

“…47,48 In a recent multicenter, randomized trial of 1,900 patients undergoing polypectomy of large nonpedunculated colon polyps (≥20 mm), endoscopic clip closure of the mucosal defect was found to reduce the risk of PPB (3.3% vs. 9.6%) and the risk reduction appeared to be largely limited to polypectomies performed in the proximal colon. 49 In contrast, in a separate randomized trial in 1,098 patients undergoing polypectomy of nonpedunculated polyps ≥10 mm, there was no benefit with closure of mucosal defects using prophylactic endoscopic clipping in reducing the rate of delayed PPB, and this finding was consistent with that obtained for large polyps (≥20 mm). 50 Several systematic reviews and meta-analyses [51][52][53][54][55][56] have consistently shown a similar lack of benefit of prophylactic endoscopic clipping of mucosal defects of nonpedunculated polyps up to 19 mm, with inconclusive benefits for nonpedunculated polyps ≥20 mm.…”

“…50 Several systematic reviews and meta-analyses [51][52][53][54][55][56] have consistently shown a similar lack of benefit of prophylactic endoscopic clipping of mucosal defects of nonpedunculated polyps up to 19 mm, with inconclusive benefits for nonpedunculated polyps ≥20 mm. This heterogeneity in polyps ≥20 mm could be due to variations in the polyp location that have not been accounted for in most studies, as was reported in the previously mentioned randomized trial 49 in which a benefit was noted only in the proximal colon. A recent study 57 proposed the use of a Doppler endoscopic probe to detect superficial (<4 mm) arterial blood flow in the post-polypectomy mucosal defect to identify lesions that would benefit from prophylactic endotherapy (clipping, thermal therapy) and showed that mucosal defects ≥15 mm more likely contain arterial blood flow.…”

Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding

“…3,6 Proximal location was the variable with the highest weight in the GSEED-RE score. Accordingly, proximal location was the only variable that demonstrated a statistically significant benefit in the trial conducted by Pohl et al 18 Even though there was a greater DB risk with increased polyp size and in patients on antiplatelet medication, the study did not show a benefit of clipping in those patients; there was no attempt to analyze patients with a combination of risk factors. Furthermore, no DB risk assessment was performed before inclusion and, accordingly, the DB risk of the trial population depended on the relative proportion of high and low DB risk cases.…”

“…3 Recently, a large trial showed a benefit from prophylactic clipping for any LNPCL 20 mm. 18 Although the population included was very large, some polyps (such as distal polyps) had a low DB risk, resulting in a high number needed to treat (n ¼ 28). A proximal location, large size, presence of major comorbidities, and antiplatelet or anticoagulant treatment have been recognized as independent risk factors for DB in 2 large observational studies.…”

“…Other studies including low-risk polyps failed to show a preventive effect of clipping [7][8][9][10]20 or had an number needed to treat that was too large. 18 We only included cases with the EMR technique, reflecting the clinical practice of Western countries. The participation of several hospitals makes the results more generalizable to a real-world setting.…”