Prophylactic clips placed after endoscopic resection of large colorectal polyps (≥10 mm) were associated with a modest reduction in the risk of delayed polypectomy bleeding (DPB), with larger reductions seen in patients with polyps at least 20 mm, according to findings from a systematic review and meta-analysis published in Gastrointestinal Endoscopy. Specifically, in patients with polyps greater than or equal to 10 mm, clip use decreased the incidence of DPB by nearly 40%.
The investigators conducted a literature search through October 2019 to identify randomized controlled trials that evaluated the efficacy of using prophylactic clips to reduce DPB after resection of large colorectal polyps. The primary outcome was DPB as defined by gastrointestinal bleeding after the colonoscopy.
Eight studies published between 2005 and 2019 spanning 3415 total patients were selected for the systematic review and meta-analysis. Four studies were conducted in Japan, 2 in North America, 1 in China, and 1 in Spain.
The overall pooled incidence of DPB was 3.9% (95% CI, 2.4%-5.4%) in patients who had endoscopic resection of colorectal polyps that were at least 10 mm in size. Use of prophylactic clips reduced DPB (relative risk [RR], 0.61; 95% CI, 0.43-0.85; I2 = 37.8%) compared with no clips. The number-needed-to-treat (NNT) to prevent DPB was 52 (95% CI, 31-163).
Stratified analyses showed that placing clips was associated with a reduced risk of DPB in patients with polyps 20 mm or larger (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), or polyps located proximal to the hepatic flexure (RR, 0.49; 95% CI, 0.31-0.78; I2 = 54.8%; NNT, 25) vs not placing clips.
Of note, a lower incidence of postprocedural abdominal pain (RR, 0.19; 95% CI, 0.08-0.46; I2 = 0.0%) with a NNT of 28 was observed with clip use in 2 studies compared with no clips. However, 2 studies found that the placement of prophylactic clips was associated with a longer procedure time (mean difference, 8.3 minutes; 95% CI, 6.1-10.5 minutes; I2 = 94%), in line with what is already known about the time-consuming nature of clip use. A mean 6.8 and 5.2 clips were placed in the 2 studies.
The investigators noted several study limitations. Stratified analysis evaluating other predictors of DPB, such as anticoagulant use and medical comorbidities, was not possible because only a few studies provided the data. Also, evaluating emerging resection techniques (ie, cold and underwater endoscopic mucosal resection) for large colon polyps was not possible.
“Previous meta-analyses have failed to demonstrate a reduction of DPB with prophylactic clips when polyps of all sizes or observational studies were included,” the researchers said. “Our meta-analysis was the first to demonstrate a modest reduction of DPB with placement of prophylactic clips after endoscopic resection of colorectal polyps 10 mm or greater based on randomized trials,” they concluded.
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. Published online October 10, 2020. doi: 10.1016/j.gie.2020.10.004