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Prevention of Bleeding After Endoscopic Resection of Colonic Polyps: to Clip or not to Clip

  • Stomach (P Malfertheiner, Section Editor)
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Abstract

Purpose of review

Endoscopic resection of large colonic lesions once thought only amenable to surgery is now standard treatment, but post-procedure bleeding has been common, occurring in 5–10% of patients. This review summarizes efficacy data on clip closure to reduce bleeding risk, selection of polyps, costs and limitations.

Recent findings

Randomized control trials and meta-analysis provide strong evidence for the benefit of prophylactic clip closure to prevent bleeding after endoscopic resection of large ≥ 20-mm proximal polyps, but not for smaller polyps or for large polyps in the distal colon. Clip closure techniques need to be improved, and further research may help to better identify which patients may most benefit from prophylactic closure.

Summary

Post-procedure bleeding is the most common complication after large polyp resection. Clip closure of the mucosal defect after resection of all proximal 20-mm polyps should be attempted because it reduces bleeding risk by at least half.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Reumkens A, Rondagh EJ, Bakker CM, et al. Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies. Am J Gastroenterol. 2016;111(8):1092–101.

    Article  Google Scholar 

  2. Kothari ST, Huang RJ, Shaukat A, Agrawal D, Buxbaum JL, Abbas Fehmi SM, et al. ASGE review of adverse events in colonoscopy. Gastrointest Endosc. 2019;90:863–76.

    Article  Google Scholar 

  3. Hassan C, Repici A, Sharma P, Correale L, Zullo A, Bretthauer M, et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut. 2016;65(5):806–20.

    Article  CAS  Google Scholar 

  4. Feagins LA, Smith AD, Kim D, Halai A, Duttala S, Chebaa B, et al. Efficacy of prophylactic hemoclips in prevention of delayed post-polypectomy bleeding in patients with large colonic polyps. Gastroenterology. 2019;157(4):967–76.

    Article  Google Scholar 

  5. Kaltenbach T, Anderson JC, Burke C, et al. Endoscopic removal of colorectal lesions—recommendations by the US multi-society task force on colorectal cancer. Gastrointest Endosc. 2020;91(3):486–519.

    Article  Google Scholar 

  6. Hayashi I, Yonezawa TM, Kuwabara T, et al. The study on stanch clips for the treatment by endoscopy. Gastroenterol Endosc. 1975;17:92–101.

    Google Scholar 

  7. Xavier AT, Campos JF, Robinson L, Lima EJM, da Rocha LCM, Arantes VN. Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications. Ann Gastroenterol. 2020;33(6):563–70.

    PubMed  PubMed Central  Google Scholar 

  8. Lin HJ, Hsieh YH, Tseng GY, Perng CL, Chang FY, Lee SD. A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding. Am J Gastroenterol. 2002;97:2250–4.

    Article  Google Scholar 

  9. Shin EJ, Ko CW, Magno P, Giday SA, Clarke JO, Buscaglia JM, et al. Comparative study of endoscopic clips: duration of attachment at the site of clip application. Gastrointest Endosc. 2007;66:757–61.

    Article  Google Scholar 

  10. Parikh ND, Zanocco K, Keswani RN, Gawron AJ. A cost-efficacy decision analysis of prophylactic clip placement after endoscopic removal of large polyps. Clin Gastroenterol Hepatol. 2013;11(10):1319–24.

    Article  Google Scholar 

  11. Elliott TR, Tsiamoulos ZP, Thomas-Gibson, et al. Factors associated with delayed bleeding after resection of large nonpedunculated colorectal polyps. Endoscopy. 2018;50:790–9.

    Article  Google Scholar 

  12. Burgess NG, Metz AJ, Williams SJ, Singh R, Tam W, Hourigan LF, et al. Risk factors for Intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol. 2014;12(4):651–61.

    Article  Google Scholar 

  13. Albéniz E, Fraile M, Ibañez B, et al. A scoring system to determine risk of delayed bleeding after endoscopic mucosal resection of large colorectal lesions. Clin Gastroenterol Hepatol. 2016;14:1140–7.

    Article  Google Scholar 

  14. Liaquat H, Rohn E, Rex DK. Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions. Gastrointest Endosc. 2013;77(3):401–7.

    Article  Google Scholar 

  15. Bahin FF, Rasouli KN, Byth K, Hourigan LF, Singh R, Brown GJ, et al. Prediction of clinically significant bleeding following wide-field endoscopic resection of large sessile and laterally spreading colorectal lesions: a clinical risk score. Am J Gastroenterol. 2016;111(8):1115–22.

    Article  Google Scholar 

  16. • Albéniz E, Gimeno-Garcia AZ, Fraile M, et al. Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions. Gastrointest Endosc. 2019;91(4):868–78. This study evaluates the Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and Australian Colonic Endoscopic Resection (ACER) model for prediction of delayed bleeding after EMR of large superficial colorectal lesions and presents the updated model GSEED-RE2 which achieves better bleeding prediction.

    Article  Google Scholar 

  17. Lau LH, Guo CL, Yip TC, et al. Risks of post-colonoscopic polypectomy bleeding and thromboembolism with warfarin and direct oral anticoagulants: a population-based analysis. Gut 2021. https://doi.org/10.1136/gutjnl-2020-323600.

  18. Shioji K, Suzuki Y, Kobayashi M, Nakamura A, Azumaya M, Takeuchi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc. 2003;57(6):691–4.

  19. Albéniz E, Alvarez MA, Espinos JC, et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology. 2019;157(5):1213–21.

    Article  Google Scholar 

  20. Shaleve Y, Sabo E, Bourke MJ, Klein A. Computerized image analysis of blood vessels within mucosal defects for the prediction of delayed bleeding following colonic endoscopic mucosal resection: a pilot study. Endoscopy. 2020. https://doi.org/10.1055/a-1258-8992.

  21. Tullavardhana T, Akranurakkul P, Ungkitphaiboon W, Songtish D. Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: a meta-analysis of randomized controlled studies. Ann Med Surg (Lond). 2017;19:65–73.

    Article  Google Scholar 

  22. Bahin FF, Naidoo M, Williams SJ, Hourigan LF, Ormonde DG, Raftopoulos SC, et al. Prophylactic endoscopic coagulation to prevent bleeding after wide-field endoscopic mucosal resection of large sessile colon polyps. Clin Gastroenterol Hepatol. 2015;13(4):724–30.

    Article  Google Scholar 

  23. Zhang Q, Han B, Xu J, Gao P, Shen Y. Clip closure of defect after endoscopic resection in patients with larger colorectal tumors decreased the adverse events. Gastrointest Endosc. 2015;82(5):904–9.

    Article  Google Scholar 

  24. Pohl H, Grimm IS, Moyer MT, et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology. 2019;157(4):977–84. This large randomized controlled trial shows that endoscopic clip closure of the mucosal defect following resection of large colon polyps reduces risk of post-procedure bleeding.

  25. • Spadaccini M, Albéniz E, Pohl H, et al. Prophylactic clipping after colorectal endoscopic resection prevents bleeding of large, proximal polyps: meta-analysis of randomized trials. Gastroenterology. 2020;159(1):148–58. This meta-analysis provides a good review of data from nine randomized controlled trials that supports clipping of large (≥20 mm) proximal lesions.

    Article  Google Scholar 

  26. Matsumoto M, Kato M, Oba K, Abiko S, Tsuda M, Miyamoto S, et al. Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding. Dig Endosc. 2016;28(5):570–6.

    Article  Google Scholar 

  27. Ortiz O, Rex DK, Ian G et al. Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps. Endoscopy. 2020. https://doi.org/10.1055/a-1332-6727.

  28. Shah E, Pohl H, Rex DK, et al. Routine prophylactic clip closure is cost saving after endoscopic resection of large colon polyps in a Medicare population. Gastroenterology. 2020;158(4):1164–1166.e3.

    Article  Google Scholar 

  29. Albéniz E, Enguita-Germán M, Gimeno-García AZ, et al. The answer to “When to Clip” after colorectal endoscopic mucosal resection based on a cost-effectiveness analysis. Am J Gastroenterol. 2021; 1;116(2):311–18.

  30. Shah ED, Pohl H, Rex DK, Wallace MB, Crockett SD, Morales SJ, et al. Valuing innovative endoscopic techniques: prophylactic clip closure after endoscopic resection of large colon polyps. Gastrointest Endosc. 2020;91(6):1353–60.

    Article  Google Scholar 

  31. Peery AF, Cools KS, Strassle PD, et al. Increasing rates of surgery for patients with nonmalignant colorectal polyps in the United States. Gastroenterology. 2018;154(5):1352–1360.e3.

    Article  Google Scholar 

  32. Matsuda T, Fujii T, Emura F, Kozu T, Saito Y, Ikematsu H, et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest Endosc. 2004;60(5):836–8.

    Article  Google Scholar 

  33. Kantsevoy SV. The development of the overstitch system and its potentials. Gastrointest Endosc Clin N Am. 2020;30(1):107–14.

    Article  Google Scholar 

  34. Kolb JM, Hammad H. The use of the overstitch to close endoscopic resection defects. Gastrointest Endosc Clin N Am. 2020;30(1):163–71.

    Article  Google Scholar 

  35. Pedersen IB, Loberg M, Hoff G, et al. Polypectomy techniques among gastroenterologists in Norway - a nationwide survey. Endosc Int Open. 2018;6(7):812–20.

    Article  Google Scholar 

  36. Duloy AM, Kaltenbach TR, Keswani RN. Assessing colon polypectomy competency and its association with established quality metrics. Gastrointest Endosc. 2018;87(3):635–44.

    Article  Google Scholar 

  37. Piraka C, Saeed A, Waljee AK, et al. Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm. Endosc Int Open. 2017;5(3):184–9.

    Article  Google Scholar 

  38. Ket SN, Mangira D, Ng A, Tjandra D, Koo JH, la Nauze R, et al. Complications of cold versus hot snare polypectomy of 10-20 mm polyps: a retrospective cohort study. JGH Open. 2019;4(2):172–7.

    Article  Google Scholar 

  39. van Hattem WA, Shahidi N, Vosko S, et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut. 2020:gutjnl-2020-321753. https://doi.org/10.1136/gutjnl-2020-321753.

  40. Mangira D, Cameron K, Simons K, Zanati S, LaNauze R, Raftopoulos S, et al. Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm. Gastrointest Endosc. 2020;91(6):1343–52.

    Article  Google Scholar 

  41. Metz AJ, Bourke MJ, Moss A, Williams S, Swan M, Byth K. Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions. Endoscopy. 2011;43:506–11.

    Article  CAS  Google Scholar 

  42. Abraham NS. Antiplatelets, anticoagulants, and colonoscopic polypectomy. Gastrointest Endosc. 2020;91(2):257–65.

    Article  Google Scholar 

  43. Gandhi S, Narula N, Mosleh W, Marshall JK, Farkouh M. Meta-analysis: colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy. Aliment Pharmacol Therap. 2013;37:947–52.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756, USA

    Sehrish Jamot MD & Heiko Pohl MD

  2. Department of Gastroenterology and Hepatology, White River Junction Veterans Administration Medical Center, White River Junction, VT, 05009, USA

    Heiko Pohl MD

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Contributions

SJ and HP authored first draft, tables and figures, and critical revisions and approved final draft.

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Correspondence to Sehrish Jamot MD.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Sehrish Jamot declares that she has no potential conflicts of interest.

Heiko Pohl declare that the views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. Heiko Pohl has received research funding from Cosmo and Steris.

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Jamot, S., Pohl, H. Prevention of Bleeding After Endoscopic Resection of Colonic Polyps: to Clip or not to Clip. Curr Treat Options Gastro 19, 337–350 (2021). https://doi.org/10.1007/s11938-021-00344-z

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