No benefits seen with clipping after endoscopic resection in large serrated polyps
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Among patients with large serrated polyps, the risk for bleeding after endoscopic mucosal resection was low, with no significant benefit seen with resection clipping, according to a study.
“[This] study suggests that endoscopic clipping is not necessary to prevent post-polypectomy bleeding after [endoscopic mucosal resection] of large serrated polyps,” Seth D. Crockett, MD, MPH, associate professor in the division of gastroenterology and hepatology at University of North Carolina School of Medicine, and colleagues wrote. “In contrast, there does appear to be a significant benefit of clipping after resection of large adenomatous polyps, particularly those located in the proximal colon.”
Crockett and colleagues randomly assigned patients with large ( 20 mm) non-pedunculated polyps who underwent endoscopic mucosal resection to either clipping of the resection base or no clipping. Investigators included 179 patients with 199 large serrated polyps and 730 patients with 771 adenomatous polyps. Severe post-procedure bleeding within 30 days of colonoscopy served as the primary outcome.
Five patients with large serrated polyps developed post-procedure bleeding vs. 42 patients with adenomas. Among patients with large serrated polyps, Crockett and colleagues observed no difference in post-procedure bleeding rates between patients in the clip group compared with those in the control group (2.3% vs. 3.3%).
Among those with adenomatous polyps, clipping correlated with a lower risk for post-procedure bleeding (3.9% vs. 7.6%; P = .03). In addition, clipping correlated with lower overall serious adverse events (5.5% vs. 10.6%; P = .012).
“Clipping should be considered following resection of large adenomatous polyps in the proximal colon in order to reduce risk of post-procedure bleeding, but is not beneficial for patients with large serrated polyps,” the authors wrote.
Perspective
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Emre Gorgun, MD, FACS, FASCRS
I agree with the authors that clipping, especially after resection of large sessile serrated polyps, is not routinely indicated and unlikely to be of any major benefit, unless there is a specific area of concern either from a bleeding or perforation standpoint.
Although I am well-aware of the publications on adenomatous polyps — and clipping is reported to correlate with a lower risk for post-procedure bleeding — based on my experience, I would challenge this practice. I do believe that selective clipping after ESD and EMR is more effective from various angles. It is important after ESD to observe the tissue resection site carefully and effectively use forced coagulation or spray coagulation settings for bleeding. Additionally, observing the site for any muscle defects or perforations and selectively clipping these specific areas is required. Therefore, I believe that clip closure of the entire mucosal defect is not necessarily needed nor possible in many instances. At Cleveland Clinic’s Endoluminal Surgery Center, our approach after ESD and EMR is that selective clipping after tissue resection is more effective.
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