Prophylactic Clipping After Colorectal Endoscopic Resection Prevents Bleeding of Large, Proximal Polyps: Meta-analysis of Randomized Trials

Spadaccini, Marco; Albéniz, Eduardo; Pohl, Heiko; Maselli, Roberta; Chandrasekar, Viveksandeep Thoguluva; Correale, Loredana; Anderloni, Andrea; Carrara, Sandro; Fugazza, Alessandro; Badalamenti, Matteo; Iwatate, Mineo; Antonelli, Giulio; Enguita-Germán, Mónica; Álvarez, Marco Antonio Santamaría; Sharma, Prateek; Rex, Douglas K.; Hassan, Cesare; Repici, Alessandro

doi:10.1053/j.gastro.2020.03.051

Cited by 71 publications

(57 citation statements)

References 31 publications

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“…We also showed that increasing polyp size, especially at a cutoff of 20 mm, is the main predictor of post-resection bleeding, with an additional role for proximal location. This indirectly supports a selective policy of post-polypectomy clipping for large and proximal lesions, when considering the substantial efficacy shown by clipping for this selected subgroup of lesions [10]. As size ≥ 20 mm and proximal location were also risk factors for perforation, such prophylactic clipping could also have some beneficial effect on this adverse event, although evidence is controversial [11].…”

Section: Discussionmentioning

confidence: 56%

“…The implications of adverse events on mortality are relevant. On the one hand, we know that adverse events are concentrated in those few lesions that are larger than 20 mm, especially if they are nonpedunculated and located proximally [10,14]. On the other hand, we also know that these lesions are the most technically demanding and require skills in advanced endoscopic resection.…”

Section: Discussionmentioning

confidence: 99%

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Colonoscopy-related adverse events and mortality in an Italian organized colorectal cancer screening program

Benazzato¹,

Zorzi

Antonelli

et al. 2020

Endoscopy

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Background and Aims Post-colonoscopy adverse events (AE) are a key quality indicator in population-based colorectal cancer screening programs, affecting safety and costs. Aim of this study was to assess colonoscopy-related AE and mortality in a screening setting. Methods We retrieved data from a cohort of patients undergoing colonoscopy within a screening program (Faecal Immunochemical Test every 2 years, 50 to 69 years old, or post-polypectomy surveillance) in Italy between 2002 and 2014, to assess the rate of post-colonoscopy related AE and mortality. Any admission within 30 days of a screening colonoscopy was reviewed to capture any possible AE. Mortality registries were also matched with endoscopy database to investigate 30-day post colonoscopy mortality rate. Association of each outcome with patient/procedure related variables was assessed with multivariable analysis. Results Overall, 117,881 screening colonoscopies (66,584, 56.5%, with polypectomy) were included. Overall, 497/117,881 (0.42%) post-colonoscopy AE occurred: 281 (0.24%) bleedings and 65 (0.05%) perforations (3.7‰/0.7‰, operative/diagnostic procedures, p<0.001). At multivariable analysis, bleeding was associated to polyp size (≥20mm: OR 16.29, 95%CI: 9.39-28.29), proximal location (OR 1.46, 95%CI: 1.14-1.87), and histology severity (high-risk adenoma, OR 5.6, 95%CI: 2.43-12.91), while perforation was associated to endoscopic resection (OR 2.91, 95%CI: 1.62-5.22), polyp size (OR 4.34, 95%CI: 1.46-12.92) and proximal location (OR 1.94, 95%CI: 1.12-3.37). Post-colonoscopy death occurred in 15/117,881 (1.27x10,000) cases. Conclusions In an organised screening program, post-colonoscopy AE are a rare but not negligible eventuality. The most frequent is post-polypectomy bleeding, especially after resection of large (≥20mm) and proximal lesions.

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Section: Discussionmentioning

confidence: 56%

Section: Discussionmentioning

confidence: 99%

Colonoscopy-related adverse events and mortality in an Italian organized colorectal cancer screening program

Benazzato¹,

Zorzi

Antonelli

et al. 2020

Endoscopy

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“…The conclusions of Kamal et al's meta-analysis are supported by another meta-analysis recently accepted for publication by Spadaccini et al [34]. Their review of nine RCTs demonstrated an almost 50 % risk reduction in DPPB with prophylactic clipping in proximal colonic polyps ≥ 2 cm, but no significant benefit from clipping overall.…”

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confidence: 87%

Prevention of delayed post-polypectomy bleeding: Should we amend the 2017 ESGE Guideline?

2020

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“…The results showed that the benefit of clipping in reducing bleeding was significant for large polyps (clipped vs. unclipped, odds ratio [OR] 0.54, 95%CI 0.30-0.97; P=0.041), and proximal lesions >20 mm (clipped vs. unclipped, OR 0.34, 95%CI 0.19-0.65; P=0.021). Thus if such lesions were not clipped, there would be 4-fold increase in the baseline risk of post-polypectomy bleeding [ 51 ]. According to 2 American guidelines, in non-pedunculated polyps >20 mm, whose Paris classification is of type 0-Is or type 0-II [ 52 ], the closure of the endoscopic resection area with clips decreases the incidence of late bleeding, especially in the right colon [ 42 , 43 ] ( Fig.…”

Section: Prophylactic Use Of Endoclipsmentioning

confidence: 99%

Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications

Xavier

Campos

Robinson

et al. 2020

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Endoscopic clipping has become a common practice among endoscopists. Several models are available, most frequently being introduced via the working channel of the endoscope (through-the-scope); however, larger clips can also be mounted onto the distal tip of the endoscope (over-the-scope). The main indications for endoclip placement include providing effective mechanical hemostasis for bleeding lesions and allowing endoscopic closure of gastrointestinal perforations. Endoclips can also be used prophylactically after endoscopic resection; however, this practice is still controversial. This review discusses the main indications for endoscopic clipping in the esophagus, stomach, duodenum and colon to manage acute bleeding lesions, and the criteria to be used in the prevention of delayed post-polypectomy bleeding.

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Prophylactic Clipping After Colorectal Endoscopic Resection Prevents Bleeding of Large, Proximal Polyps: Meta-analysis of Randomized Trials

Cited by 71 publications

References 31 publications

Colonoscopy-related adverse events and mortality in an Italian organized colorectal cancer screening program

Colonoscopy-related adverse events and mortality in an Italian organized colorectal cancer screening program

Prevention of delayed post-polypectomy bleeding: Should we amend the 2017 ESGE Guideline?

Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications

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