Routine Prophylactic Endoscopic Clipping Is Not Efficacious in the Prevention of Delayed Post-Polypectomy Bleeding: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background and Aims Colorectal cancer (CRC) can be prevented through colonoscopic polypectomy, but this exposes patients to risks, including delayed post-polypectomy bleeding (DPPB). Endoscopists increasingly use clips prophylactically with the aim of preventing DPPB. However, clips are costly, and data to support their efficacy in this context are inconsistent. We performed a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of prophylactic clipping for preventing DPPB. Methods We searched electronic databases and other relevant sources for randomized controlled trials assessing the efficacy of prophylactic clipping versus no clipping for the prevention of DPPB. Pooled relative risks were determined using a fixed-effects model. Subgroup analyses were also performed. Results A total of 2305 citations were initially screened. Seven randomized controlled trials satisfied all criteria for inclusion. The quality of included studies was generally low to moderate. A total of 2851 patients underwent 5405 polypectomies. Delayed post-polypectomy bleeding occurred at an overall pooled rate of 2.5%. No overall benefit of clipping for preventing DPPB was observed, with a pooled relative risk of 0.86 (95% confidence interval [CI], 0.55 to 1.36). No significant patient or polyp factors predicting DPPB were found through subgroup analyses. No publication bias was identified. Conclusions Randomized trials to date do not demonstrate a protective effect of prophylactic clipping for the prevention of DPPB, and therefore, the practice of routine prophylactic clipping appears unjustified. Additional high quality randomized trials are required to identify higher-risk groups that may benefit from prophylactic clipping.

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“…However, most of the polyps in this study were < 1 cm. A subgroup analysis of 122 polyps that were ≥ 2 cm in size also showed no benefit of HC placement [23]. Their conclusions differed from ours, probably due to difference in sample sizes.…”

“…Two previous meta-analyses [23,24] showed conflicting results while evaluating the role of HC placement in prevention of DPPB. Forbes et al [23] also included only RCTs but showed no benefit of HCs in prevention of DPPB; pooled RR (95 % CI) 0.86 (0.55, 1.36). However, most of the polyps in this study were < 1 cm.…”

Endoscopic Management of Post-Polypectomy Bleeding

“…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. 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.…”

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

“…To the best of our knowledge, there has only been one previously published meta-analysis that showed a statistically significant benefit from prophylactic clipping, and this was for large lesions ≥ 2 cm removed by EMR [30]. However, three other meta-analyses showed a trend towards a reduction in DPPB with prophylactic clipping for larger polyps, but did not demonstrate statistical significance [31][32][33].…”