Clipping for the prevention of immediate bleeding after polypectomy of pedunculated polyps: a pilot study

Endoscopic polypectomy devices

Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.

A novel technique using endoscopic band ligation for removal of long-stalked (>10 mm) pedunculated colon polyps: A prospective pilot study

BACKGROUND

Endoscopic removal of large and thick-stalked pedunculated colonic polyps, often leads to massive hemorrhage. Several techniques to minimize this complication have not been widely adopted due to some caveats. In order to prevent postpolypectomy bleeding, we invented a novel technique to dissect long-stalked pedunculated colonic polyps using endoscopic band ligation (EBL) by laterally approaching the stalk.

METHODS

In this prospective single-center study, 17 pedunculated polyps in 15 patients were removed between April 2012 and January 2016. We targeted pedunculated polyps with a long stalk length (>10 mm) and a large head (>10 mm) located in the distal colon. After identifying lesions with a colonoscope, we reapproached the middle part of the stalk of the targeted polyp with an EBL-equipped gastroscope to ligate it. Snare polypectomy was performed just above the ligation site of the stalk.

RESULTS

EBL-assisted polypectomy removed all of the lesions successfully, which were confirmed pathologically. There was little technical difficulty associated with the endoscopic procedures, regardless of polyp size and stalk thickness, except for one case with a very large polyp that impeded the visualization of the ligation site. We observed a positive correlation between procedure time and the diameter of the head (spearman ρ = 0.52, P = 0.034). After dissection of the polyp, the EBL bands remained fastened to the dissected stalks in all cases. There was no complication associated with polypectomy for 1 month.

CONCLUSION

EBL-assisted polypectomy is an easy, safe, and effective technique to remove long-stalked pedunculated colonic polyps without postpolypectomy bleeding.

Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding

BACKGROUND

Although prophylactic clip application before polypectomy may prevent postpolypectomy bleeding (PPB), the usefulness of prophylactic clipping in the treatment of large pedunculated polyps is controversial in some prospective randomized studies. This study was conducted to evaluate the efficacy of prophylactic clip application and to investigate the predictors of PPB in large pedunculated colorectal polyps.

METHODS

A total of 137 pedunculated polyps (size ≥1 cm) in 116 patients were prospectively included and randomized into group A (with clipping) and group B (without clipping), and resected. The occurrences of immediate PPB (graded 1-4) and delayed PPB were compared.

RESULTS

Sixty-seven polyps were allocated in group A and 70 polyps in group B. In both groups, the median polyp diameter was 15 mm (P = 0.173) and the median stalk diameter was 3 mm (P = 0.362). Twenty-eight (20.4%) immediate PPB episodes in 137 polyps occurred, 6 (9.0%) in group A and 22 (31.4%) in group B (P = 0.001). However, the occurrence of delayed PPB was not different between the groups (P = 0.943). Prophylactic clip application decreased the occurrence of immediate PPB (odds ratio 0.215, 95% confidence interval 0.081-0.571). Moreover, polyp size ≥20 mm and stalk diameter ≥ 4 mm increased the risk of immediate PPB.

CONCLUSIONS

Clip application before polypectomy of ≥1 cm pedunculated polyps is effective in decreasing the occurrence of immediate PPB. Thus, clip application should be considered before performing snare polypectomy, especially for large polyps with a thick stalk.

TRIAL REGISTRATION

This research was studied a prospective maneuver and enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT01437631). This study was registered on September 19, 2011.

Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps

BACKGROUND AND AIM

Post-polypectomy bleeding (PPB) is the most common adverse event of colonoscopic polypectomy, especially in cases with large pedunculated polyps. To minimize the risk of PPB, several endoscopic preventive methods have been performed. The aim of this prospective, randomized study was to compare the rates of PPB following single (clipping alone) and combined (clipping plus epinephrine-saline injection) methods in prevention of PPB in large pedunculated polyps.

METHODS

Adult patients with pedunculated colorectal polyps with heads ≥ 10 mm were prospectively enrolled from March 2011 to January 2013. Patients were randomized to receive treatment of either clips alone (group A) or clips plus injection of epinephrine-saline (group B) prior to a conventional polypectomy. PPB rate in both groups were compared.

RESULTS

A total of 148 patients with 173 pedunculated colorectal polyps were enrolled. Groups A and B each had 74 patients, with 83 and 90 polyps, respectively. The mean head diameters were 17.2 ± 6.6 and 17.5 ± 6.7 mm in groups A and B, respectively (P = 0.748). Immediate PPB (IPPB) occurred in 10 cases (12.0%) from group A and 13 cases (14.4%) from group B (P = 0.64). There were no cases of delayed PPB or perforation. Multivariate analysis showed that inadequate bowel preparation and large head diameter of polyp were independent risk factors for IPPB.

CONCLUSIONS

The rate of IPPB is relatively high in cases with large pedunculated polyps, but these polyps can be successfully resected by snare polypectomy following use of the single prophylactic clipping method.

Advanced polypectomy and resection techniques

Most colorectal cancer arises from adenomatous polyps. This gradual process may be interrupted by screening and treatment using colonoscopy and polypectomy. Advances in imaging platforms have led to classification systems that facilitate prediction of histologic type and both stratification for and prediction of the risk of invasion. Endoscopic treatment should be the standard of care even for extensive advanced mucosal neoplasm. Technique selection is influenced by lesion features, location, patient factors, and local expertise. Postprocedural complications are more common following advanced resection and endoscopists should be familiar with risk factors, early detection methods, and management.

Endoscopic haemostasis: an overview of procedures and clinical scenarios

Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.

A cost-efficacy decision analysis of prophylactic clip placement after endoscopic removal of large polyps

BACKGROUND & AIMS

Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost-effectiveness of routine clip placement after colon polypectomy.

METHODS

Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted by using TreeAge Pro 2011 Software. Our cost-effectiveness threshold was an incremental cost-effectiveness ratio of $100,000 per quality-adjusted life year. The reference case was a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement.

RESULTS

On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness.

CONCLUSIONS

Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.

Advanced endoscopic resection of colorectal lesions

Advanced endoscopic resection techniques allow curative treatment of difficult colonic lesions and avoid the need for surgery in certain cases. If endoscopic resection is indicated, the choice of the most appropriate resection technique depends on lesion characteristics and endoscopist expertise.