Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection

Abstract

Introduction: The most commonly used treatment for advanced colorectal adenomas is endoscopic mucosal resection (EMR). The increased number of EMRs since the introduction of the screening program for colorectal cancer has resulted in an increase in EMR-related complications. This review summarizes the current knowledge for the use of clips for the treatment and prevention of complications after EMR. Areas covered: The historical development of clips is summarized and their properties are evaluated. An overview is presented of the evidence for therapeutic and prophylactic clipping for bleeding or perforation after EMR in the colon. Several clipping techniques are discussed in relation to the efficacy of wound closure. Furthermore, new techniques that will likely influence the use of clips in the future endoscopic practice, such as endoscopic full-thickness resection (eFTR) are also highlighted. Expert commentary: Most research focuses on prophylactic clipping for delayed bleeding after EMR of large adenomas. We advocate a distance of 0.5-1.0 cm between aligning clips. This focus may likely shift from bleeding to perforation. Here, endoscopic treatment with through-the-scope clips and largediameter clips may well replace surgery. The future role of clips will also depend on the further development of new endoscopic technologies, such as eFTR.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

“…Deep muscle injury without overt perforations (Sydney classification Type 2–3) or small perforations (up to 10 mm) recognized during colonoscopy can be managed endoscopically with through the scope clips. Surgery can be avoided for overt perforations (Type 4–5) up to 30mm by using larger capacity over the scope clips (Ovesco ® , Endoscopy AG, Tübingen, Germany, or the Padlock Clip ® Defect Closure System, Steris HC, OH, USA); however, it requires surgical intervention if recognized late or if there is overt contamination ( 83 , 171 , 190 , 209 , 210 ). In selected cases, endoscopic suturing devices (Overstitch Endoscopic Suturing System™, Austin, Texas, USA), which provide full thickness closure, have been used to close larger lesions ( 211 ).…”

External validation of the BEST-J score and a new risk prediction model for ESD delayed bleeding in patients with early gastric cancer

“…The ESD technique may result in a large mucosal defect at the resection site. Closure of the defect with endoscopic hemoclips leaves no submucosal tissue or muscularis mucosa exposed to the polluted environment, which can accelerate wound healing and reduce the rate of bleeding and perforation [ 25 , 26 ]. In addition, the mechanical force generated when the hemoclips are closed can compress the bleeding blood vessels and surrounding tissues so as to achieve the effect of blocking blood flow [ 27 ].…”

Novel clip device for prevention of bleeding after endoscopic papillectomy

“…16 EP is less invasive than surgery; however, due to the anatomical characteristics of the ampulla region, it has a higher risk of complications than endoscopic resection of gastric or colorectal neoplasms. 17,18 In particular, bleeding is a relatively frequent complication after EP that has been reported in 17%-32% of patients, even when limited to studies in recent years. [19][20][21][22] There are several explanations for the high incidence of bleeding after EP.First,the papilla of Vater receives substantial blood supply from several arteries.…”

“…Recently, the indications for EP have been extended to patients with adenocarcinoma confined to the ampulla of Vater 16 . EP is less invasive than surgery; however, due to the anatomical characteristics of the ampulla region, it has a higher risk of complications than endoscopic resection of gastric or colorectal neoplasms 17, 18 . In particular, bleeding is a relatively frequent complication after EP that has been reported in 17%–32% of patients, even when limited to studies in recent years 19–22 .…”