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Endoscopic clip reduces delayed bleeding events after polyp resection
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WASHINGTON — Closing mucosal defects following the removal of large colorectal polyps using an endoscopic clip was effective in reducing the incidence of delayed bleeding events and other complications, according to research presented at Digestive Disease Week.
Heiko Pohl, MD, of the VA Medical Center in White River Junction, Vt., said it was previously unknown if this kind of closure helped reduce delayed bleeding after the removal of non-pedunculated polyps at least 20 mm in size.
“The major problem with large polyp resection is really bleeding,” Pohl said in a presentation. “It occurs in 5% to 10% of resections, and it’s been a major challenge.”
Pohl and colleagues conducted a multicenter, randomized trial of 925 patients. They randomly assigned patients to an endoscopic clipping group (n = 455) or a control group (n = 470). The primary outcome was the incidence of severe delayed bleeding, defined as requiring hospitalization, transfusion or intervention to control the bleeding after the patient leaves the endoscopy unit and within 30 days of the procedure.
Pohl and colleagues found that delayed bleeding rates were lower in the endoscopic clipping group compared with the control group (3.7% vs. 7.2%; P = .02). Additionally, the rate of overall serious adverse events was lower in the clip group compared with the control group (5.3% vs. 9.8%; P = .009).
Pohl said the benefit of clipping appears to be limited to the proximal colon, where the incidence of delayed bleeding was lower in the clip group compared with the control group (3.3% vs. 9.8%; P = .001). In cases of distal polyp resection, researchers observed no protective effect of clip closure when comparing the clip and control groups. – by Alex Young
Reference :
Pohl H, et al. Abstract 886. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.
Disclosures: Pohl reports financial ties to Boston Scientific. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.
Perspective
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John R. Saltzman, MD, FACP, FACG, FASGE, AGAF
This is an interesting area as it validates a previously reported study. In 2013, Douglas K. Rex, MD, FASGE, AGAF, MACG, and his group reported in large polyps that were removed (2 cm or greater), prophylactic clipping reduced bleeding rates. Rex showed that if these polyps were not clipped, there was a 9.7% bleeding rate; however, if these polyps were fully clipped, the bleeding rate was 1.8%. Other investigators tried to reproduce this in unselected polypectomy patients and could not find a benefit from prophylactic clipping. Still, many physicians started clipping polypectomy sites, resulting in a huge expense with uncertain clinical benefits.
This study is a well-done, large, prospective multicenter study with clear inclusion criteria from respected centers. They took 2-cm and larger polypectomy sites and randomized patients to having clips or no clips. They essentially reproduced the original data from the Rex group. If they did not clip the polypectomy site, the bleeding and adverse event rates were double that of the clipped group. They also showed clips were most beneficial in the right side of the colon vs. the left side.
This study suggests a clinical benefit to the use of prophylactic clips to completely close large polypectomy resection sites, especially on the right side of the colon. I would have liked to see in their analyses how many clips per case they used and a cost effectiveness analysis. Additional work needs to be done to determine how best to target clips at post polypectomy sites and to determine if there is benefit to prophylactic clipping of smaller polyps, especially in patients on anti-thrombotic medications.
Reference:
Liaquat H, et al. Gastrointest Endosc. 2013;doi: 10.1016/j.gie.2012.10.024.
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