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Yang TC, Wu YH, Lee PC, Chang CY, Lu HS, Chen YJ, Huang YH, Lee FY, Hou MC. Prophylactic clipping after endoscopic mucosal resection of large nonpedunculated colorectal lesions: A meta-analysis. J Gastroenterol Hepatol 2021; 36:1778-1787. [PMID: 33638894 DOI: 10.1111/jgh.15472] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM It is not clear whether prophylactic clipping after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions (LNPCLs) prevents delayed bleeding (DB). We aimed to conduct a meta-analysis to clarify the efficacy of prophylactic clipping in prevention of DB following EMR of LNPCLs. METHODS We searched PubMed, EMBASE, Web of Science, ScienceDirect, Cochrane Library databases, and ClinicalTrials.gov for studies that compared clipping versus (vs) nonclipping in prevention of DB following EMR of LNPCLs. Pooled odds ratio (OR) was determined using a random effects model. The pooled ORs of DB, perforation, and post-polypectomy syndrome in the clipping group compared with the nonclipping group comprised the outcomes. Subgroup analyses based on study design, polyp location, and completeness of wound closure were performed. RESULTS Five studies with a total of 3112 LNPCLs were extracted. Prophylactic clipping reduced the risk of DB compared with nonclipping (3.3% vs 6.2%, OR: 0.494, P = 0.002) following EMR of LNPCLs. In subgroup analysis, prophylactic clipping reduced DB of LNPCLs at proximal location (3.8% vs 9.8%, P = 0.029), but not of them at distal location (P = 0.830). Complete wound closure showed superior efficacy to prevent DB compared with partial closure (2.0% vs 5.4%, P = 0.004). No benefit of clipping for preventing perforation or post-polypectomy syndrome was observed (P = 0.301 and 0.988, respectively). CONCLUSIONS Prophylactic clipping can reduce DB following EMR of LNPCLs at proximal location. Besides, complete wound closure showed superior efficacy to prevent DB compared with partial closure. Further cost analyses should be conducted to implement the most cost-effective strategies.
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Affiliation(s)
- Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Hui Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Yu Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiao-Sheng Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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52
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Benazzato L, Zorzi M, Antonelli G, Guzzinati S, Hassan C, Fantin A. Colonoscopy-related adverse events and mortality in an Italian organized colorectal cancer screening program. Endoscopy 2021; 53:501-508. [PMID: 32725616 DOI: 10.1055/a-1228-9225] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-colonoscopy adverse events are a key quality indicator in population-based colorectal cancer screening programs, and affect safety and costs. This study aimed to assess colonoscopy-related adverse events and mortality in a screening setting. METHODS We retrieved data from patients undergoing colonoscopy within a screening program (fecal immunochemical test every 2 years, 50-69-year-olds, or post-polypectomy surveillance) in Italy between 2002 and 2014, to assess the rate of post-colonoscopy adverse events and mortality. Any admission within 30 days of screening colonoscopy was reviewed to capture possible events. Mortality registries were also matched with endoscopy databases to investigate 30-day post-colonoscopy mortality. Association of each outcome with patient-/procedure-related variables was assessed using multivariable analysis. RESULTS Overall, 117 881 screening colonoscopies (66 584, 56.5 %, with polypectomy) were included. Overall, 497 (0.42 %) post-colonoscopy adverse events occurred: 281 (0.24 %) bleedings (3.69‰/0.68‰, operative/diagnostic procedures) and 65 (0.06 %) perforations (0.75‰/0.29‰, respectively). At multivariable analysis, bleeding was associated with polyp size (≥ 20 mm: odds ratio [OR] 16.29, 95 % confidence interval [CI] 9.38-28.29), 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 with 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 mortality occurred in 15 /117 881 cases (1.27/10 000 colonoscopies). CONCLUSIONS In an organized screening program, post-colonoscopy adverse events were rare but not negligible. The most frequent event was post-polypectomy bleeding, especially after resection of large (≥ 20 mm) and proximal lesions.
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Affiliation(s)
- Luca Benazzato
- Gastroenterology Department, Local Health Unit Scaligera, Verona, Italy
| | - Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
| | | | | | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alberto Fantin
- Gastroenterology, Istituto Oncologico Veneto IOV-IRCCS, Padova, Italy
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53
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Lorenzo-Zúñiga V, Bustamante-Balén M, Pons-Beltrán V. Prevention of late complications with coverage agents in endoscopic resection of colorectal lesions: Current landscape in gastrointestinal endoscopy. World J Gastroenterol 2021; 27:1563-1568. [PMID: 33958843 PMCID: PMC8058649 DOI: 10.3748/wjg.v27.i15.1563] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/05/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic removal of large (≥ 20 mm) non-pedunculated colorectal lesions (LNPCLs) may result in major adverse events, such as delayed bleeding (DB) and delayed perforation (DP), despite closure of the mucosal defects with clips. Topical application of a coverage agent refers to the creation of a shield with a biocompatible medical device (tissue or hydrogel) with proven bioactive properties. Coverage of the eschar after endoscopic resection provides shielding protection to prevent delayed complications. The aim of the present review was to systematically collect and review the currently available literature regarding the prevention of DB and DP with coverage agents after endoscopic mucosal resection or endoscopic submucosal dissection of LNPCLs.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Endoscopy Unit, Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia 46026, Spain
| | | | - Vicente Pons-Beltrán
- Digestive Diseases Department, La Fe Polytechnic University Hospital, Valencia 46026, Spain
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54
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Chen B, Du L, Luo L, Cen M, Kim JJ. Prophylactic clips to reduce delayed polypectomy bleeding after resection of large colorectal polyps: a systematic review and meta-analysis of randomized trials. Gastrointest Endosc 2021; 93:807-815. [PMID: 33049265 DOI: 10.1016/j.gie.2020.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Prophylactic clips to prevent delayed polypectomy bleeding (DPB) after endoscopic resection of large colorectal polyps remains controversial. We performed a systematic review and meta-analysis to evaluate the efficacy of prophylactic clips for preventing DPB by synthesizing the results of randomized trials. METHODS PubMed, Cochrane Library, and EMBASE were searched to October 2019 to identify randomized controlled trials evaluating the efficacy of placing prophylactic clips to reduce DPB after resection of large (≥10 mm) colorectal polyps. The primary outcome was DPB defined by GI bleeding after the conclusion of the colonoscopy. RESULTS Eight studies (n = 3415) met the study criteria, all with a low risk of bias. The overall pooled incidence of DPB was 3.9% (95% confidence interval [CI], 2.4%-5.4%) in patients receiving endoscopic resection of colorectal polyps ≥10 mm. Placing prophylactic clips reduced DPB in patients receiving prophylactic clips (relative risk [RR], 0.61; 95% CI, 0.43-0.85; I2 = 37.8%) compared with no clips with a number needed to treat (NNT) of 52 (95% CI, 31-163). In stratified analyses, placing clips was associated with reduced risks of DPB in patients with polyps ≥20 mm (RR, 0.54; 95% CI, 0.35-0.84; I2 = 0.0%; NNT, 30), nonpedunculated morphology (RR, 0.54; 95% CI, 0.36-0.81; I2 = 0.0%; NNT, 39), and located proximal to the hepatic flexure (RR, 0.49; 95% CI, 0.31-0.78; I2 = 54.8%; NNT, 25) compared with no clips. CONCLUSIONS Prophylactic clips after endoscopic resection of colorectal polyps ≥10 mm demonstrated a modest reduction in the risk of DPB. Larger reductions were observed in patients with polyps ≥20 mm, nonpedunculated morphology, or located proximal to the hepatic flexure.
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Affiliation(s)
- Binrui Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Lijun Du
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Liang Luo
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Mengsha Cen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - John J Kim
- Division of Gastroenterology & Hepatology, Loma Linda University Health, Loma Linda, California, USA
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55
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Prophylactic clipping for delayed postpolypectomy bleeding: Moderately effective, but is it feasible in daily practice? Gastrointest Endosc 2021; 93:816-817. [PMID: 33741086 DOI: 10.1016/j.gie.2020.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
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56
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Bishay K, Meng ZW, Frehlich L, James MT, Kaplan GG, Bourke MJ, Hilsden RJ, Heitman SJ, Forbes N. Prophylactic clipping to prevent delayed colonic post-polypectomy bleeding: meta-analysis of randomized and observational studies. Surg Endosc 2021; 36:1251-1262. [PMID: 33751224 DOI: 10.1007/s00464-021-08398-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/12/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Delayed post-polypectomy bleeding (DPPB) is a commonly described adverse event following polypectomy. Prophylactic clipping may prevent DPPB in some patient subgroups. We performed a meta-analysis to assess both the efficacy and real-world effectiveness of prophylactic clipping. METHODS We performed a database search through March 2020 for clinical trials or observational studies assessing prophylactic clipping and DPPB. Pooled risk ratios (RR) were calculated using random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to elucidate clinical or methodological factors associated with effects on outcomes. RESULTS A total of 2771 citations were screened, with 11 randomized controlled trials (RCTs) and 9 observational studies included, representing 24,670 colonoscopies. DPPB occurred in 2.0% of patients overall. The pooled RR of DPPB was 0.47 (95% CI 0.29-0.77) from RCTs enrolling only patients with polyps ≥ 20 mm. Remaining pooled RCT data did not demonstrate a benefit for clipping. The pooled RR of DPPB was 0.96 (95% CI 0.61-1.51) from observational studies including all polyp sizes. For patients with proximal polyps of any size, the RR was 0.73 (95% CI 0.33-1.62) from RCTs. Meta-regression confirmed that polyp size ≥ 20 mm significantly influenced the effect of clipping on DPPB. CONCLUSION Pooled evidence demonstrates a benefit when clipping polyps measuring ≥ 20 mm, especially in the proximal colon. In lower-risk subgroups, prophylactic clipping likely results in little to no difference in DPPB.
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Affiliation(s)
- Kirles Bishay
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Zhao Wu Meng
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Matthew T James
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia.,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Robert J Hilsden
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada
| | - Steven J Heitman
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada
| | - Nauzer Forbes
- Division of Gastroenterology, Department of Medicine, University of Calgary, TRW 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada. .,Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada.
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Forbes N, Heitman SJ, Bourke MJ. When Evaluating the Benefit of Prophylactic Clipping Following Polypectomy, Not All of the Answers Are Found in Randomized Trials. Gastroenterology 2021; 160:1428-1429. [PMID: 32931785 DOI: 10.1053/j.gastro.2020.04.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/30/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Nauzer Forbes
- Department of Community Health Sciences, University of Calgary and Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Community Health Sciences, University of Calgary and Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital and Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Gangwani MK, Ahuja P, Aziz A, Rani A, Lee-Smith W, Aziz M. Role of prophylactic hemoclip placement in prevention of delayed post-polypectomy bleeding for large colon polyps: a meta-analysis of randomized controlled trials. Ann Gastroenterol 2021; 34:392-398. [PMID: 33948065 PMCID: PMC8079868 DOI: 10.20524/aog.2021.0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022] Open
Abstract
Background Polypectomy is a widely used and effective procedure to treat precancerous polyps. Delayed post-polypectomy bleeding (DPPB), a common complication of polypectomy, may diminish the utility of this procedure. Previous data on the efficacy of hemoclips has been conflicting, therefore we aimed to collectively evaluate and analyze the data to reach a definitive conclusion on the efficacy of using hemoclips to prevent incidences of DPPB in patients with large polyps (≥10 mm). Methods We identified a total of 261 studies based on our previously defined search strategy. After screening, we included 6 randomized controlled trials. A meta-analysis was performed comparing the use of prophylactic application of hemoclips to a standard group without prophylactic clip placement for large polyps. Results We found a statistically significant reduction in the incidence of DPPB when using hemoclips for large polyps. The overall incidence of DPPB was lower in the hemoclip group compared to the standard group for all large polyps ≥10 mm (relative risk 0.51, 95% confidence interval 0.35-0.75; P=0.01; I 2=0%). Conclusions The use of hemoclips in achieving hemostasis for large polyps has a beneficial effect and appears to prevent DPPB. This reinforces the routine clinical practice of using hemoclips in polypectomy procedures.
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Affiliation(s)
- Manesh Kumar Gangwani
- Department of Internal Medicine, Mercy Hospital St. Louis, MO, USA (Manesh Kumar Gangwani)
| | - Priyanka Ahuja
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto University, Larkana, Pakistan (Priyanka Ahuja)
| | - Abeer Aziz
- Department of Medicine, Aga Khan University, Karachi, Pakistan (Abeer Aziz)
| | - Anooja Rani
- Department of Medicine, Dow University of Health Sciences, Pakistan (Anooja Rani)
| | - Wade Lee-Smith
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio, USA (Wade Lee-Smith)
| | - Muhammad Aziz
- Department of Gastroenterology, University of Toledo Medical Center, Ohio, USA (Muhammad Aziz)
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Endoscopic Shielding With Platelet-rich Plasma After Resection Of Large Colorectal Lesions. Surg Laparosc Endosc Percutan Tech 2021; 31:376-377. [PMID: 33538545 DOI: 10.1097/sle.0000000000000898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Platelet-rich plasma (PRP) has demonstrated efficacy as submucosal injection before endoscopic mucosal resection or local injection after endoscopic submucosal dissection of nonpedunculated colorectal lesions. METHODS The EndoPRP study was a prospective single-center study to analyze the efficacy of PRP shield after endoscopic mucosal resection of large nonpedunculated colorectal lesio with impossible clip closure, assessed by the incidence of delayed bleeding (DB) and delayed perforation, and percentage of mucosal restoration after 4 weeks (mucosal healing rate). RESULTS Shielding technique with PRP was performed in 4 patients, aged 52 to 80, with 4 lesions at rectum (mean size 53.7±20.6 mm, range 35 to 80 mm). DB occurred in 1 lesion (25% of all lesions), no required blood transfusion or endoscopic treatment. No postoperative delayed perforation occurred. Mucosal healing rate was of 78.6% after 4 weeks. CONCLUSIONS PRP shield failed in prevent DB, probably due to migration and failure in the adherence in large wounds. Future comparative studies are needed to confirm these data.
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60
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The Cost of Clipping-How Much Does Price Matter? Am J Gastroenterol 2021; 116:276-277. [PMID: 33306507 DOI: 10.14309/ajg.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
Clip closure is effective for large (≥ 20 mm) nonpedunculated polyps in the proximal colon. The cost-effectiveness analysis by Albeniz et al. found that selective clipping of polyps at a minimum risk (>13% in the United States, >10% in Spain) is worthwhile clipping. Although such model is theoretically sound, clinical practice should be primarily guided by efficacy data. Moreover, the analysis is very sensitive to the high price of clips, which is likely to reduce in the foreseeable future.
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The Answer to "When to Clip" After Colorectal Endoscopic Mucosal Resection Based on a Cost-Effectiveness Analysis. Am J Gastroenterol 2021; 116:311-318. [PMID: 33149001 DOI: 10.14309/ajg.0000000000000943] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Delayed bleeding (DB) is the most common major complication of endoscopic mucosal resection (EMR). Two randomized clinical trials recently demonstrated that clip closure after EMR of large nonpedunculated colorectal polyps (LNPCPs) reduces the risk of DB. We analyzed the cost-effectiveness of this prophylactic measure. METHODS EMRs of LNCPCPs were consecutively registered in the ongoing prospective multicenter database of the Spanish EMR Group from May 2013 until July 2017. Patients were classified according to the Spanish Endoscopy Society EMR group (GSEED-RE2) DB risk score. Cost-effectiveness analysis was performed for both Spanish and US economic contexts. The average incremental cost-effectiveness ratio (ICER) thresholds were set at 54,000 € or $100,000 per quality-adjusted life year, respectively. RESULTS We registered 2,263 EMRs in 2,130 patients. Applying their respective DB relative risk reductions after clip closure (51% and 59%), the DB rate decreased from 4.5% to 2.2% in the total cohort and from 13.7% to 5.7% in the high risk of the DB GSEED-RE2 subgroup. The ICERs for the universal clipping strategy in Spain and the United States, 469,706 € and $1,258,641, respectively, were not cost effective. By contrast, selective clipping in the high-risk of DB GSEED-RE2 subgroup was cost saving, with a negative ICER of -2,194 € in the Spanish context and cost effective with an ICER of $87,796 in the United States. DISCUSSION Clip closure after EMR of large colorectal lesions is cost effective in patients with a high risk of bleeding. The GSEED-RE2 DB risk score may be a useful tool to identify that high-risk population.
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Xavier AT, Campos JF, Robinson L, Lima EJM, da Rocha LCM, Arantes VN. Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications. Ann Gastroenterol 2020; 33:563-570. [PMID: 33162733 PMCID: PMC7599350 DOI: 10.20524/aog.2020.0526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/26/2020] [Indexed: 12/26/2022] Open
Abstract
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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Affiliation(s)
- Amaury Teixeira Xavier
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes).,Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | - Júlia Faria Campos
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes).,Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | - Lucinda Robinson
- Department of Medicine, Flinders Medical Centre, Adelaide, Australia (Lucinda Robinson)
| | - Elmar José Moreira Lima
- Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | | | - Vitor Nunes Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes)
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63
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Mack A, Mangira D, Moss A. Prevention of delayed post-polypectomy bleeding: Should we amend the 2017 ESGE Guideline? Endosc Int Open 2020; 8:E1111-E1114. [PMID: 32898199 PMCID: PMC7458743 DOI: 10.1055/a-1196-1602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Alexandra Mack
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
| | - Dileep Mangira
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
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