1
|
O'Mara MA, Emanuel PG, Tabibzadeh A, Duve RJ, Galati JS, Laynor G, Gross S, Gross SA. The Use of Clips to Prevent Post-Polypectomy Bleeding: A Clinical Review. J Clin Gastroenterol 2024; 58:739-752. [PMID: 39008609 DOI: 10.1097/mcg.0000000000002042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 06/06/2024] [Indexed: 07/17/2024]
Abstract
GOALS The goal of this clinical review is to provide an overview of the current literature regarding the utility of prophylactic clips in reducing postpolypectomy bleeding and to provide an expert statement regarding their appropriateness in clinical practice. BACKGROUND Colonoscopy enables the identification and removal of premalignant and malignant lesions through polypectomy, yet complications including postpolypectomy bleeding (PPB) can arise. While various studies have explored applying clips prophylactically to prevent PPB, their effectiveness remains uncertain. STUDY A literature search conducted in PubMed and Embase identified 671 publications discussing clip use postpolypectomy; 67 were found to be relevant after screening, reporting outcomes related to PPB. Data related to clip utilization, polyp characteristics, and adverse events were extracted and discussed. RESULTS The current literature suggests that prophylactic clipping is most beneficial for nonpedunculated polyps ≥20 mm, especially those in the proximal colon. The utility of clipping smaller polyps and those in the distal colon remains less clear. Antithrombotic medication usage, particularly anticoagulants, has been linked to an increased risk of bleeding, prompting consideration for clip placement in this patient subgroup. While cost-effectiveness analyses may indicate potential savings, the decision to clip should be tailored to individual patient factors and polyp characteristics. CONCLUSIONS Current research suggests that the application of prophylactic clips can be particularly beneficial in preventing delayed bleeding after removal of large nonpedunculated polyps, especially for those in the proximal colon and in patients on antithrombotic medications. In addition, for large pedunculated polyps prophylactic clipping is most effective at controlling immediate bleeding.
Collapse
Affiliation(s)
- Matthew A O'Mara
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Peter G Emanuel
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| | | | - Robert J Duve
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Jonathan S Galati
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | | | - Samantha Gross
- Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Seth A Gross
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| |
Collapse
|
2
|
Qi H, Wang Z, Shen F, Yu W, Duan S, Li X, Huang X. Wound infection prevention strategies in colorectal endoscopic mucosal resection: A meta-analysis of prophylactic measures. Int Wound J 2024; 21:e14544. [PMID: 38272812 PMCID: PMC10789545 DOI: 10.1111/iwj.14544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 01/27/2024] Open
Abstract
Colorectal endoscopic mucosal resection (EMR) is associated with the risk of postoperative wound infections, prompting investigations into effective prophylactic measures. This meta-analysis aimed to evaluate the efficacy of various prophylactic interventions in reducing the incidence of wound infections following EMR. Adhering to PRISMA guidelines, we conducted a comprehensive search across multiple databases for randomized controlled trials (RCTs) and cohort studies from 2015 to 2022. We included studies that compared the efficacy of antibiotic prophylaxis and antiseptic measures, with clear data on post-procedure infection rates. Eight studies met our inclusion criteria, and data were extracted for meta-analysis. The risk of bias was assessed using the Cochrane Collaboration tool and the Newcastle-Ottawa Scale. The meta-analysis included 3765 patients from eight RCTs. Prophylactic antibiotics (cefixime and cefuroxime) showed moderate to high efficacy, with infection rates as low as 0% and 0.76%. Prophylactic endoscopic closure and clipping showed the highest efficacy, with zero reported infections. The standardized surgical site infection prevention bundle had lower effectiveness, with an infection incidence of 3.83%. The risk of bias assessment indicated potential performance bias due to lack of blinding, but overall evidence quality was upheld by proper random sequence generation and diligent outcome data monitoring. The effectiveness of specific prophylactic measures, notably prophylactic antibiotics and mechanical closure techniques, has been shown in significantly reducing the risk of wound infections following colorectal EMR.
Collapse
Affiliation(s)
- Haili Qi
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Zhimin Wang
- Department of GastroenterologyXinxiang Central HospitalXinxiangChina
| | - Feifei Shen
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Wei Yu
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Shasha Duan
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Xiaohuan Li
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Xiao Huang
- Zhumadian Central HospitalZhumadianChina
| |
Collapse
|
3
|
Bi D, Zhang LY, Alqaisieh M, Shrigiriwar A, Farha J, Mahmoud T, Akiki K, Almario JA, Shah-Khan SM, Gordon SR, Adler JM, Radetic M, Draganov PV, David YN, Shinn B, Mohammed Z, Schlachterman A, Yuen S, Al-Taee A, Yunseok N, Trasolini R, Bejjani M, Ghandour B, Ramberan H, Canakis A, Ngamruengphong S, Storm AC, Singh S, Pohl H, Bucobo JC, Buscaglia JM, D'Souza LS, Qumseya B, Kumta NA, Kumar A, Haber GB, Aihara H, Sawhney M, Kim R, Berzin TM, Khashab MA. Novel through-the-scope suture closure of colonic EMR defects (with video). Gastrointest Endosc 2023; 98:122-129. [PMID: 36889364 DOI: 10.1016/j.gie.2023.02.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND AND AIMS Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS. METHODS A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding. RESULTS A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate). CONCLUSION TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.
Collapse
Affiliation(s)
- Danse Bi
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | | | | | - Jad Farha
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Tala Mahmoud
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Karl Akiki
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | | | | | - Stuart R Gordon
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jeffrey M Adler
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mark Radetic
- University of Florida, Gainesville, Florida, USA
| | | | | | - Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Zahraa Mohammed
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Sofia Yuen
- NYU Langone Health, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | | | - Heiko Pohl
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | | | | | | | - Anand Kumar
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Mandeep Sawhney
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raymond Kim
- University of Maryland, Baltimore, Maryland, USA
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | |
Collapse
|
4
|
Endoscopic Closure: Tools and Techniques. Gastrointest Endosc Clin N Am 2023; 33:169-182. [PMID: 36375881 DOI: 10.1016/j.giec.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The rapid expansion of third space endoscopy has necessitated development of innovative endoscopic defect closure devices and techniques. This article discusses commonly used endoscopic closure devices and techniques, data on their safety and efficacy, and a description of the authors' own practice patterns.
Collapse
|
5
|
Forbes N, Gupta S, Frehlich L, Meng ZW, Ruan Y, Montori S, Chebaa BR, Dunbar KB, Heitman SJ, Feagins LA, Albéniz E, Pohl H, Bourke MJ. Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials. Gastrointest Endosc 2022; 96:721-731.e2. [PMID: 35667388 DOI: 10.1016/j.gie.2022.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm. METHODS We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses. RESULTS From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of .31 (95% confidence interval [CI], .17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of .78 (95% CI, .17-3.54) and .67 (95% CI, .20-2.22), respectively. CONCLUSIONS Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon.
Collapse
Affiliation(s)
- Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Benjamin R Chebaa
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Kerry B Dunbar
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven J Heitman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Linda A Feagins
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eduardo Albéniz
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain; Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA; Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA; Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
6
|
Yu Z, Albéniz E, Hu J, Li P, Li Q, Hu Y, Chen J, Wang J. Prevention of delayed post-polypectomy bleeding by prophylactic clipping after endoscopic colorectal polypectomy: a meta-analysis. Int J Colorectal Dis 2022; 37:2229-2236. [PMID: 36171411 DOI: 10.1007/s00384-022-04253-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE This meta-analysis aims to investigate the role of prophylactic clipping after endoscopic colorectal polypectomy or endoscopic mucosal resection (EMR) in prevention of delayed bleeding (DB) following polypectomy. METHODS We searched the PubMed, Embase, and Cochrane Library databases for randomized controlled trials comparing the effect of prophylactic clipping versus no clipping on DB since inception to 22nd April 2022. We then performed a meta-analysis using a random-effects model. RESULTS We included 8 studies with 5648 patients and 10,436 lesions. Prophylactic clipping did not reduce the overall risk of DB compared with no clipping (1.54% vs 2.05%; Log RR, -0.29; 95% confidence interval [CI], -0.59, 0.01; P = 0.06). In subgroup analyses, clipping significantly reduced DB rate in polyps ≥ 2 cm (Log RR, -0.63; 95% CI, -1.08, -0.18; P = 0.01), in non-pedunculated polyps (Log RR, -0.63; 95% CI, -1.01, -0.24; P = 0.00), and in large (≥ 2 cm) proximal polyps (Log RR, -0.81; 95% CI, -1.56, 0.05; P = 0.04), but not in polyps < 2 cm (Log RR, 0.01; 95% CI, -.40, 0.42; P = 0.95). CONCLUSION Prophylactic clipping does not prevent post-polypectomy bleeding after all EMR and should not be performed as a routine practice. Although prophylactic clipping may reduce DB rate following resection of large proximal polyps and non-pedunculated polyps, more high-quality studies are needed to determine the effects of factors such as polyp location, polyp morphology, antithrombotic drug use and complete or partial closure on the effectiveness of prophylactic clipping.
Collapse
Affiliation(s)
- Zheng Yu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Eduardo Albéniz
- Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Navarrabiomed Research Center, UPNA, Pamplona, IdiSNA, Spain
| | - Jing Hu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Peilin Li
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Quan Li
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Yaojun Hu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Jinpin Chen
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| | - Jinpeng Wang
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University, #20, Fuxingmenwai Street, Xicheng District, Beijing, 100038, China
| |
Collapse
|
7
|
Lau LHS, Guo CLT, Lee JKK, Chan CST, Mak JWY, Wong SH, Yip TCF, Wong GLH, Wong VWS, Chan FKL, Tang RSY. Effectiveness of prophylactic clipping in preventing postpolypectomy bleeding in oral anticoagulant users: a propensity-score analysis. Gastrointest Endosc 2022; 96:530-542.e1. [PMID: 35413329 DOI: 10.1016/j.gie.2022.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Evidence of prophylactic clipping is inconsistent except for proximal and large colonic lesions in the general population. Although warfarin and direct oral anticoagulants (DOACs) are significant risk factors of postpolypectomy bleeding (PPB), dedicated studies to examine the benefit of prophylactic clipping in these high-risk patients remain limited. METHODS We performed a propensity score-weighted retrospective cohort study from 2012 to 2020. Patients who received an oral anticoagulant and underwent colonoscopic polypectomy were included. Data were collected on baseline demographics, medications (anticoagulant, antiplatelet, and heparin bridging), and endoscopies (polyp number, location, size, morphology, histopathology, resection method and prophylactic clipping). Propensity-score models with inverse probability of treatment weighting were developed between prophylactic clipping and no clipping groups. Unbalanced variables were included in a doubly robust model with multivariate analysis. The primary outcome was clinically significant delayed PPB, defined as a composite endpoint of hemoglobin drop ≥2 g/dL, blood transfusion, or repeat colonoscopy for hemostasis within 30 days. RESULTS Five hundred forty-seven patients with 1485 polyps were included. Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio [OR], 1.19; 95% confidence interval [CI], .73-1.95; P = .497). The hot resection method was associated with a significantly higher risk of PPB (OR, 9.76; 95% CI, 3.94-32.60; P < .001) compared with cold biopsy or snare polypectomy. In a subgroup analysis, prophylactic clipping was associated with a lower PPB risk in patients on DOACs (OR, .36; 95% CI, .16-.82; P = .015). CONCLUSIONS Prophylactic clipping was not associated with an overall reduced risk of PPB in patients on oral anticoagulants. The use of cold snare polypectomy should be maximized in anticoagulated patients.
Collapse
Affiliation(s)
- Louis H S Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Cosmos L T Guo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Joyce K K Lee
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Clive S T Chan
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Sunny H Wong
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Terry C F Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytic Centre (MDAC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
8
|
Omori J, Goto O, Habu T, Ishikawa Y, Kirita K, Koizumi E, Noda H, Higuchi K, Onda T, Akimoto T, Akimoto N, Itokawa N, Kaise M, Iwakiri K. Prophylactic clip closure for mucosal defects is associated with reduced adverse events after colorectal endoscopic submucosal dissection: a propensity-score matching analysis. BMC Gastroenterol 2022; 22:139. [PMID: 35346047 PMCID: PMC8962491 DOI: 10.1186/s12876-022-02202-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/08/2022] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background
It is unclear whether prophylactic endoscopic closure after colorectal endoscopic submucosal dissection (ESD) reduces the risk of postoperative adverse events due to variability in lesion characteristics. Therefore, we conducted a retrospective study using propensity score matching to evaluate the efficacy of prophylactic clip closure in preventing postoperative adverse events after colorectal ESD.
Methods
This single-center retrospective cohort study included 219 colorectal neoplasms which were removed by ESD. The patients were allocated into the closure and non-closure groups, which were compared before and after propensity-score matching. Post-ESD adverse events including major and minor bleeding and delayed perforation were compared between the two groups.
Results
In this present study, 97 and 122 lesions were allocated to the closure and non-closure groups, respectively, and propensity score matching created 61 matched pairs. The rate of adverse events was significantly lower in the closure group than in the non-closure group (8% vs. 28%, P = 0.008). Delayed perforation occurred in two patients in the non-closure group, whereas no patient in the closure group developed delayed perforation. In contrast, there were no significant differences in other postoperative events including the rate of abdominal pain; fever, white blood cell count, and C-reactive protein; and appetite loss between the two groups.
Conclusions
Propensity score matching analysis demonstrated that prophylactic closure was associated with a significantly reduced rate of adverse events after colorectal ESD. When technically feasible, mucosal defect closure after colorectal ESD may result in a favorable postoperative course.
Collapse
|
9
|
Guo XF, Yu XA, Hu JC, Lin DZ, Deng JX, Su ML, Li J, Liu W, Zhang JW, Zhong QH. Endoscopic management of delayed bleeding after polypectomy of small colorectal polyps: two or more clips may be safe. Gastroenterol Rep (Oxf) 2021; 10:goab051. [PMID: 35382164 PMCID: PMC8972999 DOI: 10.1093/gastro/goab051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/14/2022] Open
Abstract
Background The resection of small colorectal polyps (≤10 mm) is routine for endoscopists. However, the management of one of its main complications, namely delayed (within 14 days) postpolypectomy bleeding (DPPB), has not been clearly demonstrated. We aimed to assess the role of coloscopy in the management of DPPB from small colorectal polyps and identify the associated factors for initial hemostatic success. Methods We conducted a retrospective study of 69 patients who developed DPPB after the removal of colorectal polyps of ≤10 mm and underwent hemostatic colonoscopy at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between April 2013 and June 2021. Demographics, clinical variables, and colonoscopic features were collected independently. We applied univariate and multivariate analyses to assess factors associated with initial hemostatic success. Results General colonoscopy without oral bowel preparation was successfully performed in all the patients, with a median duration of 23.9 (12.5–37.9) minutes. Among 69 patients, 62 (89.9%) achieved hemostasis after initial hemostatic colonoscopy and 7 (10.1%) rebled 2.7 ± 1.1 days after initial colonoscopic hemostasis and had rebleeding successfully controlled by one additional colonoscopy. No colonoscopy-related adverse events occurred. Multivariate analysis showed that management with at least two clips was the only independent prognostic factor for initial hemostatic success (odds ratio, 0.17; 95% confidence interval, 0.03–0.91; P = 0.04). All the patients who had at least two clips placed at the initial hemostatic colonoscopy required no further hemostatic intervention. Conclusions Colonoscopy is a safe, effective, and not too time-consuming approach for the management of patients with DPPB of small colorectal polyps and management with the placement of at least two hemoclips may be beneficial.
Collapse
Affiliation(s)
- Xue-Feng Guo
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiang-An Yu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jian-Cong Hu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - De-Zheng Lin
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Xin Deng
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Ming-Li Su
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Juan Li
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei Liu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Wei Zhang
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qing-Hua Zhong
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Corresponding author. Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-20-38254166; Fax: +86-20-38254166;
| |
Collapse
|
10
|
Miyakawa A, Kuwai T, Sakuma Y, Kubota M, Nakamura A, Itobayashi E, Shimura H, Suzuki Y, Shimura K. The efficacy of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection on delayed bleeding. Scand J Gastroenterol 2021; 56:1236-1242. [PMID: 34362282 DOI: 10.1080/00365521.2021.1953129] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Although prophylactic clip closure after endoscopic mucosal resection may prevent delayed bleeding, information regarding colorectal endoscopic submucosal dissection (CR-ESD) is lacking. Therefore, this study evaluated the effect of prophylactic clip closure on delayed bleeding rate after CR-ESD. MATERIALS AND METHODS A total of 614 CR-ESD procedures performed in 561 patients were retrospectively reviewed. The primary outcome, which was delayed bleeding rate, was analyzed between the prophylactic clip closure and non-closure groups. Furthermore, the predictors of delayed bleeding were also evaluated. RESULTS The patients were divided into the clip closure group (n = 275) and non-closure group (n = 339). Delayed bleeding rate was significantly lower in the closure group than in non-closure group (6 cases [2.2%] vs. 20 cases [5.9%], p = .026). The univariate logistic regression analyses revealed that delayed bleeding was significantly associated with laterally spreading tumor-granular-nodular mixed type (LST-G-Mix; odds ratio [OR], 3.77; 95% confidence interval [CI], 1.70-8.34; p = .001). By contrast, prophylactic clip closure was significantly associated with low delayed bleeding rate (OR, 0.36; 95%CI, 0.14-0.90; p = .029). The multivariate logistic regression analyses revealed LST-G-Mix as a significant independent delayed bleeding predictor (OR, 3.25; 95%CI, 1.45-7.32; p = .004), whereas, prophylactic clip closure was identified as a significant independent preventive factor of delayed bleeding (OR, 0.39; 95%CI, 0.15-1.00; p = .049). CONCLUSIONS Prophylactic clip closure after CR-ESD is associated with low delayed bleeding rate. LST-G-Mix promotes delayed bleeding, and performing prophylactic clip closure may be advisable.
Collapse
Affiliation(s)
- Akihiro Miyakawa
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Yukie Sakuma
- Clinical Research Center, Asahi General Hospital, Asahi, Japan
| | - Manabu Kubota
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Akira Nakamura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Ei Itobayashi
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Haruhisa Shimura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Yoshio Suzuki
- Department of Pathology, Asahi General Hospital, Asahi, Japan
| | - Kenji Shimura
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| |
Collapse
|
11
|
Endoscopic characteristics influencing postpolypectomy bleeding in 1147 consecutive pedunculated colonic polyps: a multicenter retrospective study. Gastrointest Endosc 2021; 94:803-811.e6. [PMID: 33857452 DOI: 10.1016/j.gie.2021.03.996] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Postpolypectomy bleeding is the most common adverse event with pedunculated polyps. We clarified the endoscopic characteristics influencing postpolypectomy bleeding for pedunculated colonic polyps. METHODS We reviewed clinical data for 1147 pedunculated colonic polyps removed by polypectomy in 5 Japanese institutions. Pedunculated polyps were defined as polyps with a stalk length ≥5 mm. Analyzed clinical data were age, sex, polyp location/size, stalk length/width, prophylactic clipping or endoloop before polypectomy, injecting the stalk, closing the polypectomy site, antithrombotic agent use, and endoscopist experience. Postpolypectomy bleeding was classified as immediate bleeding or delayed bleeding. RESULTS Immediate and delayed bleeding was observed in 8.5% (97/1147) and 2% (23/1147) of polypectomies, respectively. Comparing immediate bleeding with nonbleeding, multivariate analysis showed that stalk width ≥6 mm (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.4) was a significant risk factor for immediate bleeding. For polyp size ≥15 mm, prophylactic endoloop use (OR, .17; 95% CI, .04-.72) was a significant inhibiting factor. Comparing delayed bleeding with nonbleeding, multivariate analysis showed that prophylactic clipping before polypectomy (OR, 4.2; 95% CI, 1.3-13) and injecting the stalk (OR, 4.0; 95% CI, 1.4-12) were significant risk factors for delayed bleeding. CONCLUSIONS The increased risk for delayed bleeding with injecting the stalk and prophylactic clipping before polypectomy suggests that simple resection with coagulation mode is a suitable strategy in endoscopic resection of pedunculated polyps. Moreover, prophylactic endoloop use was highly likely to inhibit immediate bleeding with polyp size ≥15 mm.
Collapse
|
12
|
Ito T, Takahashi K, Tanabe H, Sato K, Goto M, Sato T, Tanaka K, Utsumi T, Fujinaga A, Kawamoto T, Yanagawa N, Moriichi K, Fujiya M, Okumura T. Safety and efficacy of cold snare polypectomy for small colorectal polyps: A prospective randomized control trial and one-year follow-up study. Medicine (Baltimore) 2021; 100:e26296. [PMID: 34115035 PMCID: PMC8202597 DOI: 10.1097/md.0000000000026296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/04/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
TRIAL DESIGN Elimination of small colorectal polyps with cold snare polypectomy (CSP) is reported to be as safe as hot snare polypectomy (HSP). The effectiveness of CSP has not been clearly defined, and the incidence of long-term recurrence has not been determined. We conducted a randomized control study and one-year follow-up study to assess their safety and efficacy. METHODS Patients with small colorectal polyps were randomized to receive CSP or HSP. Polypectomy was performed to determine the pathological curability, and patients completed a questionnaire about the tolerability of the procedure. Follow-up colonoscopy was performed to determine the local recurrence of adenoma. The major outcome was the non-inferiority of CSP to HSP in the rate of delayed bleeding and minor outcomes, including the incidence of immediate bleeding and perforation, procedural time, and the resection rate. RESULTS A total of 119 participants were recruited in this randomized study and underwent polypectomy. Among the 458 polyps, 332 eligible polyps were analyzed. The rate of adverse events was 0.6% (1/175) for CSP and 0% (0/157) for HSP, which showed the non-inferiority of CSP. While the complete resection rate of CSP was very high (100%), the R0 rate was not satisfactory (horizontal margin, 65.5%; vertical margin, 89.1%). Two local recurrences (2.5%) were observed in the follow-up of 80 adenomas treated with CSP. No recurrence was found in 79 lesions in the HSP group, which was not significant (P = .06). CONCLUSIONS Colorectal polyps were safely resected using CSP, similar to HSP. Most would agree to say that CSP is considered safer than HSP. The main question is then related to efficacy. Our results of the present study demonstrate that recurrence after CSP should be carefully managed for curative treatment.
Collapse
Affiliation(s)
- Takahiro Ito
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | - Keitaro Takahashi
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University
| | - Hiroki Tanabe
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University
| | - Keisuke Sato
- Division of Pathology, Asahikawa-Kousei General Hospital, Japan
| | - Mitsuru Goto
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | - Tomonobu Sato
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | - Kazuyuki Tanaka
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | - Tatsuya Utsumi
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | - Akihiro Fujinaga
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | - Toru Kawamoto
- Department of Gastroenterology, Asahikawa-Kousei General Hospital
| | | | - Kentaro Moriichi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University
| | - Mikihiro Fujiya
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University
| | - Toshikatsu Okumura
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University
| |
Collapse
|
13
|
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: 21] [Impact Index Per Article: 7.0] [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.
Collapse
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
| |
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
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.
Collapse
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)
| |
Collapse
|
16
|
Inoue T, Ishihara R, Nishida T, Akasaka T, Hayashi Y, Nakamatsu D, Ogiyama H, Yamaguchi S, Yamamoto K, Mukai A, Kinoshita K, Yakushijin T, Iijima H, Takehara T. Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial. J Gastroenterol Hepatol 2021; 36:383-390. [PMID: 32511792 DOI: 10.1111/jgh.15134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Prophylactic clipping (PC) after polypectomy has the potential to prevent post-polypectomy bleeding (PPB). We aimed to evaluate the effectiveness of PC in preventing PPB for < 20-mm polyps. METHODS This multicenter, open-label, randomized controlled trial conducted from December 2013 to June 2017 at 10 institutions randomly assigned 1080 patients with < 20-mm colon polyps to the non-PC and PC groups. Allocation factors were institution, antiplatelet drug use, and polyp number. The primary endpoint was differences in PPB rates between the groups. The severity of PPB and post-procedural abdominal symptoms were also investigated. These endpoints in intention-to-treat and per-protocol (PP) analyses were evaluated. RESULTS We investigated 1039 patients with 2960 lesions. There was no significant difference between the groups in characteristics including age, sex, hypertension, diabetes, hyperlipidemia, antiplatelet drug use, and lesion characteristics such as type and size. Excluding the clip used in the non-PC group, intraoperative bleeding, and deviation of protocol, 903 patients were investigated in PP analysis. There was no significant difference in the PPB rate between the non-PC and PC groups (2.7% vs 2.3%, P = 0.6973 [intention-to-treat analysis]; 3.0 vs 2.4%, P = 0.7353 [PP analysis]). Severe PPB (≥ grade 3) was similar between the groups. Total procedure time was significantly shorter in the non-PC group than in the PC group (31 vs 36 min, P = 0.0002). Post-procedural abdominal fullness was less common in the non-PC group than in the PC group (20.8% vs 25.6%, P = 0.0833). CONCLUSION Prophylactic clipping is not effective in preventing PBB for < 20-mm colon polyps (UMIN000012163).
Collapse
Affiliation(s)
- Takuya Inoue
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Center, Osaka, Japan.,Department of Gastroenterology and Hepatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterology, Kaizuka City Hospital, Kaizuka, Japan
| | - Hideharu Ogiyama
- Department of Gastroenterology, Itami City Hospital, Itami, Japan
| | | | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Akira Mukai
- Department of Gastroenterology, Sumitomo Hospital, Osaka, Japan
| | - Kazuo Kinoshita
- Department of Gastroenterology, Otemae Hospital, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Osaka Gut Forum, Osaka, Japan
| |
Collapse
|
17
|
Turan AS, Moons LMG, Schreuder RM, Schoon EJ, Terhaar Sive Droste JS, Schrauwen RWM, Straathof JW, Bastiaansen BAJ, Schwartz MP, Hazen WL, Alkhalaf A, Allajar D, Hadithi M, van der Spek BW, Heine DGDN, Tan ACITL, de Graaf W, Boonstra JJ, Voogd FJ, Roomer R, de Ridder RJJ, Kievit W, Siersema PD, Didden P, van Geenen EJM. Clip placement to prevent delayed bleeding after colonic endoscopic mucosal resection (CLIPPER): study protocol for a randomized controlled trial. Trials 2021; 22:63. [PMID: 33461579 PMCID: PMC7813164 DOI: 10.1186/s13063-020-04996-7] [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] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) for large colorectal polyps is in most cases the preferred treatment to prevent progression to colorectal carcinoma. The most common complication after EMR is delayed bleeding, occurring in 7% overall and in approximately 10% of polyps ≥ 2 cm in the proximal colon. Previous research has suggested that prophylactic clipping of the mucosal defect after EMR may reduce the incidence of delayed bleeding in polyps with a high bleeding risk. METHODS The CLIPPER trial is a multicenter, parallel-group, single blinded, randomized controlled superiority study. A total of 356 patients undergoing EMR for large (≥ 2 cm) non-pedunculated polyps in the proximal colon will be included and randomized to the clip group or the control group. Prophylactic clipping will be performed in the intervention group to close the resection defect after the EMR with a distance of < 1 cm between the clips. Primary outcome is delayed bleeding within 30 days after EMR. Secondary outcomes are recurrent or residual polyps and clip artifacts during surveillance colonoscopy after 6 months, as well as cost-effectiveness of prophylactic clipping and severity of delayed bleeding. DISCUSSION The CLIPPER trial is a pragmatic study performed in the Netherlands and is powered to determine the real-time efficacy and cost-effectiveness of prophylactic clipping after EMR of proximal colon polyps ≥ 2 cm in the Netherlands. This study will also generate new data on the achievability of complete closure and the effects of clip placement on scar surveillance after EMR, in order to further promote the debate on the role of prophylactic clipping in everyday clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT03309683 . Registered on 13 October 2017. Start recruitment: 05 March 2018. Planned completion of recruitment: 31 August 2021.
Collapse
Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands.
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Màxima Medical Center, Veldhoven, Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, Netherlands
| | - Daud Allajar
- Department of Gastroenterology and Hepatology, Hospital St. Jansdal, Harderwijk, Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Bas W van der Spek
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Dimitri G D N Heine
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina hospital, Nijmegen, Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leids University Medical Center, Leiden, Netherlands
| | - Fia J Voogd
- Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Wietske Kievit
- IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
| | | |
Collapse
|
18
|
Xu Y, Zhong S, Liang W, Lin XL. The risk factors for delayed bleeding after endoscopic resection of colorectal tumors: a meta-analysis. Expert Rev Gastroenterol Hepatol 2020; 14:1083-1092. [PMID: 32721191 DOI: 10.1080/17474124.2020.1801416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The most common complication of post-colorectal endoscopic resection is delayed bleeding. The assessment of risk factors for delayed bleeding provides important and useful information in standard clinical operations. The risk factors have been previously reported; however, they remain inconsistent across different studies. AREAS COVERED In this meta-analysis, the patient conditions, lesion-related factors, and operation-related factors were compared between delayed bleeding and no bleeding. PubMed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched to identify eligible studies. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated along with heterogeneity. EXPERT OPINION This study is the first meta-analysis to investigate risk factors for colorectal delayed bleeding. We found several risk factors contributing to this condition: colorectal tumors located in the proximal colon, a history of antithrombotic drug use, high-grade intraepithelial neoplasia or early cancer, piecemeal resection, intraoperative hemorrhage, no clip placement, and severe submucosal fibrosis. Despite our findings, we also conclude that more high-quality, large-scale clinical randomized controlled studies are needed due to limited retrospective studies at present. Future therapeutic colonoscopies should focus on precise diagnosis, treatment safety, and management during the perioperative period.
Collapse
Affiliation(s)
- Yanqin Xu
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Shishun Zhong
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Wei Liang
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Xiao Lu Lin
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| |
Collapse
|
19
|
Kamal F, Khan MA, Khan S, Marella HK, Nelson T, Khan Z, Ahmad D, Tombazzi C, Ismail MK, Howden CW. Prophylactic hemoclips in prevention of delayed post-polypectomy bleeding for ≥ 1 cm colorectal polyps: meta-analysis of randomized controlled trials. Endosc Int Open 2020; 8:E1102-E1110. [PMID: 32904803 PMCID: PMC7458729 DOI: 10.1055/a-1164-6315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/01/2020] [Indexed: 10/26/2022] Open
Abstract
Background and aim Studies evaluating the role of prophylactic hemoclips (HC) in prevention of delayed post-polypectomy bleeding (DPPB) have reported conflicting results. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the role of prophylactic HC placement in prevention of DPPB for polyps ≥ 1 cm in size. Methods We reviewed several databases to identify RCTs evaluating the role of HC in prevention of DPPB. The outcomes assessed included prevention of DPPB with polyps 1 to 1.9 cm, ≥ 2 cm, any polyp ≥ 1 cm, proximal colon polyps, distal colon polyps, and perforation. We analyzed data using a fixed effect model and reported summary pooled risk ratios (RR) with 95 % confidence intervals (CI). We assessed heterogeneity with the I 2 statistic. Results We included nine RCTs with 4550 patients. For polyps ≥ 2 cm, there was a statistically significantly lower risk of DPPB with use of HC; RR 0.55, 95 % CI 0.36, 0.86. There was also a statistically significantly lower risk for proximal colon polyps ≥ 2 cm; RR 0.41 (0.24, 0.70) but no significant difference for distal polyps; RR 1.23 (0.45, 3.32). There was also no significant difference in risk for polyps 1 to 1.9 cm; RR 1.07 (0.59, 1.97). There was no significant reduction in risk of perforation with HC use for any polyp size. Conclusions Prophylactic HC placement is effective in prevention of DPPB from proximal colon polyps ≥ 2 cm, but of no significant benefit for polyps 1 to 1.9 cm in size or for distal colon polyps ≥ 2 cm.
Collapse
Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Muhammad A. Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Salman Khan
- Division of Gastroenterology, University of Arkansas Medical Sciences, Little Rock, AR
| | - Hemnishil K. Marella
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Tamara Nelson
- Medical Sciences Library, University of Tennessee Health Science Center, Memphis, TN
| | - Zubair Khan
-
Division of Gastroenterology, University of Texas-Houston, Houston, Texas, United
States
| | - Dina Ahmad
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Claudio Tombazzi
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mohammad K. Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Colin W. Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| |
Collapse
|
20
|
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
| |
Collapse
|
21
|
Gao LY, Liu XQ, Huang X. Effect of prophylactic clipping on adverse events after colorectal endoscopic resection: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2020; 28:710-718. [DOI: 10.11569/wcjd.v28.i15.710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The effect of prophylactic hemoclip placement on the risk of adverse events such as delayed bleeding and perforation after colorectal polypectomy is still unclear. Its efficiency has not been confirmed and there is no consensus on the usefulness of prophylactic clipping.
AIM To assess the efficacy of prophylactic clipping on adverse events after endoscopic resection of colorectal polyps.
METHODS We performed a search of PubMed, EMBASE, Cochrane library, and Wanfang databases for studies comparing the effect of clipping vs no clipping on adverse events following endoscopic resection. The quality of the included studies was performed. Statistical analysis was performed using Revman5.3 software.
RESULTS We identified seven eligible randomized trials from the database search, involving a total of 3777 patients, which included 1880 patients who used prophylactic hemoclips (clip group) and 1897 who did not use (no clip group). Meta-analysis results showed that the delayed bleeding rate of the clip group was significantly lower than that of the no clip group (2.55% vs 4.48%, P = 0.01, 95%CI: 0.40-0.80). There was no significant difference in postoperative perforation rate between the clip group and no clip group (0.66% vs 1.04%, P = 0.42, 95%CI: 0.21-1.92). Subgroup analysis showed that the prophylactic effect on delayed bleeding was mainly observed in polyps with a size of ≥ 20 mm, and the preventive effect in polyps less than 20 mm was poor (RR = 1.18, 95%CI: 0.62-2.23, P = 0.62; RR = 0.47, 95%CI: 0.29-0.77, P = 0.003). There was no significant difference in the effect of prophylactic hemoclips on the prevention of delayed bleeding after resection of proximal and distal colonic polyps (RR = 0.57, 95%CI: 0.18-1.80, P = 0.34; RR = 0.78, 95%CI: 0.06-10.33, P = 0.85).
CONCLUSION Prophylactic hemoclips can prevent the occurrence of delayed bleeding after colorectal polypectomy, which is mainly observed in the lesions ≥ 20 mm. In addition, hemoclips have little preventive effect on postoperative perforation.
Collapse
Affiliation(s)
- Li-Ying Gao
- Department of Gastroenterology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310002, Zhejiang Province, China
| | - Xi-Qiao Liu
- Department of Gastroenterology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310002, Zhejiang Province, China
| | - Xuan Huang
- Department of Gastroenterology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310002, Zhejiang Province, China
| |
Collapse
|
22
|
Spadaccini M, Albéniz E, Pohl H, Maselli R, Thoguluva Chandrasekar V, Correale L, Anderloni A, Carrara S, Fugazza A, Badalamenti M, Iwatate M, Antonelli G, Enguita-Germán M, Álvarez MA, Sharma P, Rex DK, Hassan C, Repici A. Prophylactic Clipping After Colorectal Endoscopic Resection Prevents Bleeding of Large, Proximal Polyps: Meta-analysis of Randomized Trials. Gastroenterology 2020; 159:148-158.e11. [PMID: 32247023 DOI: 10.1053/j.gastro.2020.03.051] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS The benefits of prophylactic clipping to prevent bleeding after polypectomy are unclear. We conducted an updated meta-analysis of randomized trials to assess the efficacy of clipping in preventing bleeding after polypectomy, overall and according to polyp size and location. METHODS We searched the MEDLINE/PubMed, Embase, and Scopus databases for randomized trials that compared the effects of clipping vs not clipping to prevent bleeding after polypectomy. We performed a random-effects meta-analysis to generate pooled relative risks (RRs) with 95% CIs. Multilevel random-effects metaregression analysis was used to combine data on bleeding after polypectomy and estimate associations between rates of bleeding and polyp characteristics. RESULTS We analyzed data from 9 trials, comprising 71897 colorectal lesions (22.5% 20 mm or larger; 49.2% with proximal location). Clipping, compared with no clipping, did not significantly reduce the overall risk of postpolypectomy bleeding (2.2% with clipping vs 3.3% with no clipping; RR, 0.69; 95% confidence interval [CI], 0.45-1.08; P = .072). Clipping significantly reduced risk of bleeding after removal of polyps that were 20 mm or larger (4.3% had bleeding after clipping vs 7.6% had bleeding with no clipping; RR, 0.51; 95% CI, 0.33-0.78; P = .020) or that were in a proximal location (3.0% had bleeding after clipping vs 6.2% had bleeding with no clipping; RR, 0.53; 95% CI, 0.35-0.81; P < .001). In multilevel metaregression analysis that adjusted for polyp size and location, prophylactic clipping was significantly associated with reduced risk of bleeding after removal of large proximal polyps (RR, 0.37; 95% CI, 0.22-0.61; P = .021) but not small proximal lesions (RR, 0.88; 95% CI, 0.48-1.62; P = .581). CONCLUSIONS In a meta-analysis of randomized trials, we found that routine use of prophylactic clipping does not reduce risk of postpolypectomy bleeding overall. However, clipping appeared to reduce bleeding after removal of large (more than 20 mm) proximal lesions.
Collapse
Affiliation(s)
- Marco Spadaccini
- Humanitas Research Hospital, Digestive Endoscopy Unit, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Rozzano, Italy.
| | - Eduardo Albéniz
- Navarrabiomed Research Institute/Public University of Navarra/IdiSNA, Endoscopy Research Department, Pamplona, Spain
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Digestive Endoscopy Unit, Hanover, New Hampshire
| | - Roberta Maselli
- Humanitas Research Hospital, Digestive Endoscopy Unit, Rozzano, Italy
| | | | - Loredana Correale
- Humanitas Research Hospital, Digestive Endoscopy Unit, Rozzano, Italy
| | - Andrea Anderloni
- Humanitas Research Hospital, Digestive Endoscopy Unit, Rozzano, Italy
| | - Silvia Carrara
- Humanitas Research Hospital, Digestive Endoscopy Unit, Rozzano, Italy
| | | | | | - Mineo Iwatate
- Sano Hospital, Gastrointestinal Center and Institute of Minimally Invasive Endoscopic Care, Kobe, Japan
| | | | - Mónica Enguita-Germán
- Navarrabiomed Research Institute/Public University of Navarra/IdiSNA, Endoscopy Research Department, Pamplona, Spain
| | - Marco Antonio Álvarez
- Indiana University School of Medicine, Digestive Endoscopy Unit, Indianapolis, Indiana
| | - Prateek Sharma
- Kansas City Veterans Affairs Medical Center, Gastroenterology and Hepatology, Kansas City, Missouri
| | - Douglas K Rex
- Nuovo Regina Margherita Hospital, Digestive Endoscopy Unit, Rome, Italy
| | - Cesare Hassan
- Hospital del Mar, Gastroenterology Department, Barcelona, Spain
| | - Alessandro Repici
- Humanitas Research Hospital, Digestive Endoscopy Unit, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Rozzano, Italy
| |
Collapse
|
23
|
Forbes N, Hilsden RJ, Lethebe BC, Maxwell CM, Lamidi M, Kaplan GG, James MT, Razik R, Hookey LC, Ghali WA, Bourke MJ, Heitman SJ. Prophylactic Endoscopic Clipping Does Not Prevent Delayed Postpolypectomy Bleeding in Routine Clinical Practice: A Propensity Score-Matched Cohort Study. Am J Gastroenterol 2020; 115:774-782. [PMID: 32167938 PMCID: PMC7192541 DOI: 10.14309/ajg.0000000000000585] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/03/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Delayed postpolypectomy bleeding (DPPB) is a relatively common adverse event. Evidence is conflicting on the efficacy of prophylactic clipping to prevent DPPB, and real-world effectiveness data are lacking. We aimed to determine the effectiveness of prophylactic clipping in preventing DPPB in a large screening-related cohort. METHODS We manually reviewed records of patients who underwent polypectomy from 2008 to 2014 at a screening facility. Endoscopist-, patient- and polyp-related data were collected. The primary outcome was DPPB within 30 days. All unplanned healthcare visits were reviewed; DPPB cases were adjudicated by committee using a criterion-based lexicon. Multivariable logistic regression was performed, yielding adjusted odds ratios (AORs) for the association between clipping and DPPB. Secondary analyses were performed on procedures where one polyp was removed, in addition to propensity score-matched and subgroup analyses. RESULTS In total, 8,366 colonoscopies involving polypectomy were analyzed, yielding 95 DPPB events. Prophylactic clipping was not associated with reduced DPPB (AOR 1.27; 0.83-1.96). These findings were similar in the single-polyp cohort (n = 3,369, AOR 1.07; 0.50-2.31). In patients with one proximal polyp ≥20 mm removed, there was a nonsignificant AOR with clipping of 0.55 (0.10-2.66). Clipping was not associated with a protective benefit in the propensity score-matched or other subgroup analyses. DISCUSSION In this large cohort study, prophylactic clipping was not associated with lower DPPB rates. Endoscopists should not routinely use prophylactic clipping in most patients. Additional effectiveness and cost-effectiveness studies are required in patients with proximal lesions ≥20 mm, in whom there may be a role for prophylactic clipping.
Collapse
Affiliation(s)
- Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Robert J. Hilsden
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Brendan Cord Lethebe
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;
| | - Courtney M. Maxwell
- Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Mubasiru Lamidi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Gilaad G. Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T. James
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Roshan Razik
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - William A. Ghali
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J. Bourke
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Steven J. Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta, Canada
| |
Collapse
|
24
|
Li DF, Chang X, Fang X, Wang JY, Yu ZC, Wei C, Xiong F, Xu ZL, Zhang DG, Liu TT, Luo MH, Wang LS, Yao J. Colonoscopic post-polypectomy bleeding in patients on uninterruptedclopidogrel therapy: A systematic review and meta-analysis. Exp Ther Med 2020; 19:3211-3218. [PMID: 32266017 PMCID: PMC7132234 DOI: 10.3892/etm.2020.8597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Current guidelines recommend temporary cessation of clopidogrel for 7-10 days for patients on clopidogrel undergoing colonoscopy with polypectomy. However, recent prospective randomized controlled trials have advocated for uninterrupted clopidogrel, due to similar post-polypectomy bleeding (PPB) rates with and without continued clopidogrel therapy. Thus, a meta-analysis was conducted to assess the risk of PPB rate in patients on continued clopidogrel therapy. Systemically identified publications were used to compare the rate of PPB in patients on continued clopidogrel therapy with those who had interrupted clopidogrel therapy. The primary outcome was the incidence of PPB. The secondary outcomes were immediate PPB, delayed PPB and serious cardio-thrombotic events. This study has been registered in PROSPERO (no. CRD42018118325). A total of five studies were identified, which included 655 patients in the continued clopidogrel group and 6620 patients in the control group. There was an increased risk of PPB with continued clopidogrel [P=0.0003; risk ratio (RR), 1.96; 95% confidence interval (CI), 1.36-2.83). The rate of immediate PPB was slightly higher in the continued clopidogrel group (5.77% vs. 1.77%, respectively), but was not statistically significant (P=0.06; RR, 1.57; 95%CI, 0.98-2.51). The rate of delayed PPB was increased in the continued clopidogrel group (P=0.0008; RR, 3.10; 95%CI, 1.60-5.98). However, no significant difference in serious cardio-thrombotic events was observed within 30 days (P=0.74; RR, 0.78; 95%CI, 0.18-3.40). Although continued clopidogrel therapy decreased the incidence of serious cardio-thrombotic events, the risk of delayed PPB was increased. Therefore, endoscopists should make all preparations to prevent bleeding in the perioperative period for patients at high thrombotic risk and on continued clopidogrel therapy, if polypectomy cannot be reasonably postponed.
Collapse
Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Xin Chang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Xue Fang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Jian-Yao Wang
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Zhi-Chao Yu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Cheng Wei
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Feng Xiong
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Zheng-Lei Xu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ding-Guo Zhang
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ting-Ting Liu
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Ming-Han Luo
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Li-Sheng Wang
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| | - Jun Yao
- Department of Gastroenterology, The Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, Guangdong 518020, P.R. China
| |
Collapse
|
25
|
Chang K, Lee BS, Tekeste T, Nguyen A, Adeyemo M, Girgis A, Kwok KK, Crowson HM, Burris AO, Attam R, Chaya CT, Durbin TE, Giap AQ, Hunt GC, Iskander J, Kao KT, Lim BS. The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study. BMC Gastroenterol 2020; 20:60. [PMID: 32143633 PMCID: PMC7060595 DOI: 10.1186/s12876-020-01199-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/20/2020] [Indexed: 12/31/2022] Open
Abstract
Background Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions. Method This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage. Results A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893. Conclusion Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.
Collapse
Affiliation(s)
- Karen Chang
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Brian S Lee
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Timnit Tekeste
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Andrew Nguyen
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Mopelola Adeyemo
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Agathon Girgis
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Karl K Kwok
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA, 90027, USA
| | - H Michael Crowson
- Department of Educational Psychology, The University of Oklahoma, 820 Van Vleet Oval, Collings Hall, Room 321, Norman, OK, 73019-2041, USA
| | - Alicia O Burris
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Rajeev Attam
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, 9353 Imperial Highway, Downey, CA, 90242, USA
| | - Charles T Chaya
- Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, 10800 Magnolia Avenue, Riverside, CA, 92505, USA
| | - Theodore E Durbin
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, 3440 E La Palma Avenue, Anaheim, CA, 92806, USA
| | - Andrew Q Giap
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, 3440 E La Palma Avenue, Anaheim, CA, 92806, USA
| | - Gordon C Hunt
- Department of Gastroenterology, Kaiser Permanente San Diego Medical Center, 9445 Clairemont Mesa Blvd, San Diego, CA, 92123, USA
| | - John Iskander
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Kevin T Kao
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, 9353 Imperial Highway, Downey, CA, 90242, USA
| | - Brian S Lim
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA. .,Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, 10800 Magnolia Avenue, Riverside, CA, 92505, USA.
| |
Collapse
|
26
|
Shah ED, Pohl H, Rex DK, Morales SJ, Feagins LA, Law R. Routine Prophylactic Clip Closure Is Cost Saving After Endoscopic Resection of Large Colon Polyps in a Medicare Population. Gastroenterology 2020; 158:1164-1166.e3. [PMID: 31738918 DOI: 10.1053/j.gastro.2019.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/26/2019] [Accepted: 11/08/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Heiko Pohl
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Division of Gastroenterology, Department of Veterans Affairs, White River Junction, Vermont
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shannon J Morales
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Linda A Feagins
- Division of Gastroenterology, University of Texas at Austin Dell Medical School, Austin, Texas; VA North Texas Healthcare System, Dallas, Texas
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
| |
Collapse
|
27
|
Jacobs C, Draganov PV, Yang D. To clip or not to clip: still no closure for all. Transl Gastroenterol Hepatol 2019; 4:80. [PMID: 31872144 DOI: 10.21037/tgh.2019.10.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/27/2019] [Indexed: 01/03/2023] Open
Affiliation(s)
- Chelsea Jacobs
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, Gainesville, FL, USA
| |
Collapse
|
28
|
Albéniz E, Álvarez MA, Espinós JC, Nogales O, Guarner C, Alonso P, Rodríguez-Téllez M, Herreros de Tejada A, Santiago J, Bustamante-Balén M, Rodríguez Sánchez J, Ramos-Zabala F, Valdivielso E, Martínez-Alcalá F, Fraile M, Elosua A, Guerra Veloz MF, Ibáñez Beroiz B, Capdevila F, Enguita-Germán M. Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding. Gastroenterology 2019; 157:1213-1221.e4. [PMID: 31362007 DOI: 10.1053/j.gastro.2019.07.037] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/16/2019] [Accepted: 07/21/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS It is not clear whether closure of mucosal defects with clips after colonic endoscopic mucosal resection (EMR) prevents delayed bleeding, although it seems to have no protective effects when risk is low. We performed a randomized trial to evaluate the efficacy of complete clip closure of large (≥2 cm) nonpedunculated colorectal lesions after EMR in patients with an estimated average or high risk of delayed bleeding. METHODS We performed a single-blind trial at 11 hospitals in Spain from May 2016 through June 2018, including 235 consecutive patients who underwent EMR for large nonpedunculated colorectal lesions with an average or high risk of delayed bleeding (based on Spanish Endoscopy Society Endoscopic Resection Group score). Participants were randomly assigned to groups that received closure of the scar with 11-mm through-the-scope clips (treated, n = 119) or no clip (control, n = 116). The primary outcome was proportion of patients in each group with delayed bleeding, defined as evident hematochezia that required medical intervention within 15 days after colonoscopy. RESULTS In the clip group, complete closure was achieved in 68 (57%) cases, with partial closure in 33 (28%) cases and failure to close in 18 (15%) cases. Delayed bleeding occurred in 14 (12.1%) patients in the control group and in 6 (5%) patients in the clip group (absolute risk difference, reduction of 7% in the clip group; 95% confidence interval, -14.7% to 0.3%). After completion of the clip closure, there was only 1 (1.5%) case of delayed bleeding (absolute risk difference, reduction of 10.6%; 95% confidence interval, -4.3% to 17.9%). CONCLUSIONS In a randomized trial of patients with large nonpedunculated colorectal lesions undergoing EMR, we found that clip closure of mucosal defects in patients with a risk of bleeding can be a challenge, but also reduces delayed bleeding. Prevention of delayed bleeding required complete clip closure. ClinicalTrials.gov ID: NCT02765022.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - José Santiago
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | | | | | | | | | | | | | - Berta Ibáñez Beroiz
- Navarrabiomed, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas, Pamplona, Spain
| | - Ferrán Capdevila
- Navarrabiomed, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Mónica Enguita-Germán
- Navarrabiomed, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| |
Collapse
|
29
|
Turan AS, Ultee G, Van Geenen EJM, Siersema PD. Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection. Expert Rev Med Devices 2019; 16:493-501. [PMID: 31109217 DOI: 10.1080/17434440.2019.1618707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The most commonly used treatment for advanced colorectal adenomas is endoscopic mucosal resection (EMR). The increased number of EMRs since the introduction of the screening program for colorectal cancer has resulted in an increase in EMR-related complications. This review summarizes the current knowledge for the use of clips for the treatment and prevention of complications after EMR. AREAS COVERED The historical development of clips is summarized and their properties are evaluated. An overview is presented of the evidence for therapeutic and prophylactic clipping for bleeding or perforation after EMR in the colon. Several clipping techniques are discussed in relation to the efficacy of wound closure. Furthermore, new techniques that will likely influence the use of clips in the future endoscopic practice, such as endoscopic full-thickness resection (eFTR) are also highlighted. EXPERT COMMENTARY Most research focuses on prophylactic clipping for delayed bleeding after EMR of large adenomas. We advocate a distance of 0.5-1.0 cm between aligning clips. This focus may likely shift from bleeding to perforation. Here, endoscopic treatment with through-the-scope clips and large-diameter clips may well replace surgery. The future role of clips will also depend on the further development of new endoscopic technologies, such as eFTR.
Collapse
Affiliation(s)
- A S Turan
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - G Ultee
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - E J M Van Geenen
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - P D Siersema
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| |
Collapse
|
30
|
Ayoub F, Westerveld DR, Forde JJ, Forsmark CE, Draganov PV, Yang D. Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis. World J Gastroenterol 2019; 25:2251-2263. [PMID: 31143075 PMCID: PMC6526150 DOI: 10.3748/wjg.v25.i18.2251] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/22/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes.
AIM To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm.
METHODS We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using a random-effects model.
RESULTS Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies (I2 = 0%, P = 0.67).
CONLUSION Prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.
Collapse
Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Donevan R Westerveld
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Justin J Forde
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| |
Collapse
|
31
|
Forbes N, Frehlich L, James MT, Hilsden RJ, Kaplan GG, Wilson TA, Lorenzetti DL, Tate DJ, Bourke MJ, Heitman SJ. 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. J Can Assoc Gastroenterol 2018; 2:105-117. [PMID: 31294373 PMCID: PMC6619410 DOI: 10.1093/jcag/gwy033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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.
Collapse
Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Levi Frehlich
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Hilsden
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd A Wilson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Steven J Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
32
|
Lin D, Soetikno RM, McQuaid K, Pham C, Doan G, Mou S, Shergill AK, Somsouk M, Rouse RV, Kaltenbach T. Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications. Gastrointest Endosc 2018; 87:1106-1113. [PMID: 29208464 DOI: 10.1016/j.gie.2017.11.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy. METHODS We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding. RESULTS There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001). CONCLUSION We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.
Collapse
Affiliation(s)
- David Lin
- Division of Gastroenterology, University of California Los Angeles Medical Center, Los Angeles, California, USA; Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Roy M Soetikno
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Kenneth McQuaid
- Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| | - Chi Pham
- Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Gilbert Doan
- Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Shanshan Mou
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Amandeep K Shergill
- Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Robert V Rouse
- Department of Pathology, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Tonya Kaltenbach
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA; Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
33
|
Mangira D, Ket SN, Majeed A, Gibson PR, Brown G. Postpolypectomy prophylactic clip closure for the prevention of delayed postpolypectomy bleeding: A systematic review. JGH OPEN 2018; 2:105-110. [PMID: 30483572 PMCID: PMC6206987 DOI: 10.1002/jgh3.12047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/31/2018] [Indexed: 12/21/2022]
Abstract
Delayed postpolypectomy bleeding (DPPB) is the most common complication of colonoscopic polypectomy. Prophylactic clipping after an uncomplicated polypectomy is increasingly used, but it is unclear if this results in the prevention of DPPB. This study aimed to review prophylactic clip use and its effect on the rates of DPPB. MEDLINE, Embase, and the Cochran Library were systematically searched for studies (1995–March 2017) that used prophylactic hemoclips and assessed DPPB as an outcome. Of 1402 articles identified, nine papers were eligible for inclusion, evaluating 4311 patients and 7783 polyps; 118 patients experienced a DPPB, and 49 of these patients received prophylactic clips. There was no significant difference in DPPB rates in patients who received prophylactic clipping compared to those who did not (odd ratio: 0.8; 95% confidence interval: 0.36–1.77; P = 0.56). There was also no significant difference in the DPPB of polyps <20 mm compared with polyps ≥20 mm. Clip application for prophylactic management of an uncomplicated polypectomy has not been demonstrated to reduce the risk of DPPB, casting doubt on the use of this costly practice.
Collapse
Affiliation(s)
- Dileep Mangira
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia.,Department of Gastroenterology Western Health and Melbourne University Melbourne Victoria Australia
| | - Shara N Ket
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia
| | - Ammar Majeed
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia
| | - Peter R Gibson
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia
| | - Gregor Brown
- Department of Gastroenterology The Alfred Hospital and Monash University Melbourne Victoria Australia.,Epworth Hospital Melbourne Victoria Australia
| |
Collapse
|
34
|
Jaruvongvanich V, Prasitlumkum N, Assavapongpaiboon B, Suchartlikitwong S, Sanguankeo A, Upala S. Risk factors for delayed colonic post-polypectomy bleeding: a systematic review and meta-analysis. Int J Colorectal Dis 2017; 32:1399-1406. [PMID: 28779355 DOI: 10.1007/s00384-017-2870-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Delayed post-polypectomy bleeding (PPB) is an infrequent but serious adverse event after colonoscopic polypectomy. Several studies have tried to identify risk factors for delayed PPB, with inconsistent results. This meta-analysis aims to identify significant risk factors for delayed PPB. METHODS MEDLINE and EMBASE databases were searched through January 2016 for studies that investigated the risk factors for delayed PPB. Pooled odds ratio (OR) for categorical variables and mean differences (MD) for continuous variables and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity of effect size was quantified using the Q statistic and I 2. RESULTS Twelve articles involving 14,313 patients were included. The pooled delayed PPB rate was 1.5% (95%CI, 0.7-3.4%), I 2 = 96%. Cardiovascular disease (OR = 1.55), hypertension (OR = 1.53), polyp size > 10 mm (OR = 3.41), and polyps located in the right colon (OR = 1.60) were identified as significant risk factors for delayed PPB, whereas age, sex, alcohol use, smoking, diabetes, cerebrovascular disease, pedunculated morphology, and carcinoma histology were not. CONCLUSIONS Cardiovascular disease, hypertension, polyp size, and polyp location were associated with delayed PPB. More caution is needed when removing polyps in patients with these risk factors. Future studies are warranted to determine appropriate preventive hemostatic measures in these patients.
Collapse
Affiliation(s)
- Veeravich Jaruvongvanich
- Department of Internal Medicine, University of Hawaii, Honolulu, HI, USA
- Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Narut Prasitlumkum
- Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sakolwan Suchartlikitwong
- Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Department of Internal Medicine, Texas Tech Medical Center, Lubbock, TX, USA
| | - Anawin Sanguankeo
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, 13326, USA
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sikarin Upala
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, 13326, USA.
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
35
|
Yamashina T, Fukuhara M, Maruo T, Tanke G, Marui S, Sada R, Taki M, Ohara Y, Sakamoto A, Henmi S, Sawai Y, Saito S, Nishijima N, Nasu A, Komekado H, Sekikawa A, Asada M, Tumura T, Kita R, Kimura T, Osaki Y. Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis. Endosc Int Open 2017; 5:E587-E594. [PMID: 28670615 PMCID: PMC5482743 DOI: 10.1055/s-0043-105578] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 02/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Cold snare polypectomy (CSP) for small colorectal polyps has lower incidence of adverse events, especially delayed postpolypectomy bleeding (DPPB). However, few data are available on comparisons of the incidence of DPPB of CSP and hot polypectomy (HP). The aim of this study was to evaluate the incidence of DPPB after CSP and compare it with that of HP. A propensity score model was used as a secondary analysis. PATIENTS AND METHODS This was a retrospective cohort study conducted in a single municipal hospital. We identified 539 patients with colorectal polyps from 2 mm to 11 mm in size who underwent CSP (804 polyps in 330 patients) or HP (530 polyps in 209 patients) between July 2013 and June 2015. RESULTS There were no cases of DPPB in the CSP group. Conversely, DPPB occurred in 4 patients (1.9 %) after HP, resulting in a significant difference between the CSP and HP groups (0.008 % vs 0 %, P = 0.02). Propensity score-matching analysis created 402 matched pairs, yielding a significantly higher DPPB rate in the HP group than CSP group (0.02 % vs 0 %, P = 0.04). However, significantly more patients in the CSP group had unclear horizontal margins that precluded assessment (83 vs 38 cases, P < 0.001). The retrieval failure rate was significantly higher in the CSP group than in the HP group (3 % vs 0.7 %, P = 0.01). CONCLUSIONS DPPB was less frequent with CSP than HP, as selected by the propensity score-matching model. Our findings indicate that CSP is recommended polypectomy in daily clinical setting. However, special care should be taken during polyp retrieval and horizontal margin assessment, and these issues could be taken into account in follow-up after CSP.
Collapse
Affiliation(s)
- Takeshi Yamashina
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan,Corresponding author Takeshi Yamashin Department of Gastroenterology and HepatologyOsaka Red Cross HospitalOsaka, Japan30 Fudegasaki, Tenouji, Osaka 543-8555Japan(+81) 6-(6774)-5131
| | - Manabu Fukuhara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takanori Maruo
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Gensho Tanke
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryota Sada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Mio Taki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yoshiaki Ohara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Azusa Sakamoto
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shinichiro Henmi
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yugo Sawai
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Sumio Saito
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Norihiro Nishijima
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akihiro Nasu
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hideyuki Komekado
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akira Sekikawa
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takehiko Tumura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryuichi Kita
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Toru Kimura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yukio Osaki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| |
Collapse
|
36
|
Nishizawa T, Suzuki H, Goto O, Ogata H, Kanai T, Yahagi N. Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies. United European Gastroenterol J 2017; 5:859-867. [PMID: 29026600 DOI: 10.1177/2050640616687837] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/06/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIM The efficacy of clipping for preventing delayed bleeding after colorectal endoscopic resection is still controversial. To assess the efficacy of prophylactic clipping, we conducted a meta-analysis of randomized controlled trials. METHODS We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified seven eligible randomized trials from the database search, and compared the effect of clipping versus non-clipping with respect to delayed bleeding and perforation. Data from eligible studies were combined to calculate pooled odds ratios (ORs). RESULTS Postoperative bleeding was observed in 41 of 1526 cases (2.7%) without clipping and in 32 of 1533 cases (2.1%) with clipping (OR 0.76, 95% CI: 0.39-1.47, p = 0.414). There was no significant heterogeneity among the trial results (I-Square = 26.7%, p = 0.22). In the subgroup analysis based on small tumor size (<20 mm) and large tumor size (≥20 mm), there were no significant differences. Compared with non-clipping, the pooled OR of developing perforation with clipping was 1.00 (95% CI: 0.14-7.25), indicating no significant difference between the two groups. CONCLUSIONS Prophylactic clipping did not decrease the occurrence of delayed bleeding after colorectal endoscopic resection. Clipping could be of interest in patients with a high risk of bleeding (anticoagulation) or large lesions, but with the available trials data to prove this are scarce.
Collapse
Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekazu Suzuki
- Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
37
|
Park CH, Jung YS, Nam E, Eun CS, Park DI, Han DS. Comparison of Efficacy of Prophylactic Endoscopic Therapies for Postpolypectomy Bleeding in the Colorectum: A Systematic Review and Network Meta-Analysis. Am J Gastroenterol 2016; 111:1230-43. [PMID: 27402502 DOI: 10.1038/ajg.2016.287] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/09/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although various endoscopic therapies have been suggested for preventing bleeding after colorectal polypectomy, the optimal therapy has yet to be fully clarified. We assessed the comparative efficacy of prophylactic therapies for postpolypectomy bleeding through a network meta-analysis combining direct and indirect comparisons. METHODS We searched for all relevant randomized controlled trials published up until January 2016 examining the effects of prophylactic therapy for bleeding after colorectal polypectomy. The types of prophylactic therapy were classified as mechanical therapy, epinephrine-saline injection therapy, coagulation therapy, combined therapy, or no prophylactic therapy. Combined therapy was defined as a combination of two or more types of therapy including mechanical therapy, epinephrine-saline injection therapy, and coagulation therapy. We performed a Bayesian network meta-analysis for all prophylactic therapies. RESULTS Fifteen studies with 3,462 patients were included in the meta-analysis. Compared with no prophylactic therapy, both epinephrine-saline injection and mechanical therapy showed superiority for preventing early postpolypectomy bleeding with a moderate quality of evidence (injection therapy, risk ratio (RR; 95% credible interval (CrI))=0.32 (0.11-0.67); mechanical therapy, RR (95% CrI)=0.13 (0.03-0.37)). Combined therapy did not show a statistically significant difference for decreasing the risk of early bleeding compared with injection or mechanical therapies, respectively (combined vs. injection therapy: RR (95% CrI)=0.35 (0.10-1.00); combined vs. mechanical therapy: RR (95% CrI)=0.88 (0.23-3.00)). In cases of delayed bleeding, no type of prophylactic therapy decreased the risk of bleeding compared with no prophylactic therapy. CONCLUSIONS Either mechanical therapy or injection therapy reduced the risk of early postpolypectomy bleeding. As for delayed bleeding, none of the prophylactic therapies was associated with a lower risk of bleeding compared with no prophylactic therapy.
Collapse
Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yoon Suk Jung
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Dong Il Park
- Department of Internal Medicine, Division of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| |
Collapse
|
38
|
Boumitri C, Mir FA, Ashraf I, Matteson-Kome ML, Nguyen DL, Puli SR, Bechtold ML. Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review. Ann Gastroenterol 2016; 29:502-508. [PMID: 27708518 PMCID: PMC5049559 DOI: 10.20524/aog.2016.0075] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/01/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Bleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding. METHODS Multiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip. RESULTS Five hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56-4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42-1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69-2.24; P=0.47) were analyzed. CONCLUSIONS The use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.
Collapse
Affiliation(s)
- Christine Boumitri
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Fazia A Mir
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Imran Ashraf
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Michelle L Matteson-Kome
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Douglas L Nguyen
- Department of Medicine, University of California, Irvine (Douglas L. Nguyen), USA
| | - Srinivas R Puli
- Department of Medicine, University of Illinois, Peoria (Srinivas R. Puli), USA, USA
| | - Matthew L Bechtold
- Department of Medicine, University of Missouri, Columbia (Christine Boumitri, Fazia A. Mir, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| |
Collapse
|