Prophylactic Clip Closure to Decrease Postendoscopic Mucosal Resection Bleeding

colon polyps, CRC, colorectal cancer
Investigators assessed the efficacy of prophylactic clip closure at reducing postendoscopic mucosal resection bleeding in the right colon.

Prophylactic clip closure to decrease clinically significant postendoscopic mucosal resection (post-EMR) bleeding for treatment of large colorectal polyps should be adopted as a standard of care, according to a randomized controlled study published in The Lancet Gastroenterology & Hepatology (ClinicalTrials.gov Identifier: NCT02196649).1

While EMR is key in the management of large (≥20 mm), nonpedunculated colorectal polyps, clinically significant post-EMR bleeding has been found to occur in 7% of cases, more often in the right colon. 2 Researchers at a tertiary center in Australia sought to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon.1

In total, 231 patients referred for EMR of large, nonpedunculated colorectal polyps in the right colon between February 4, 2016, and December 15, 2020, were randomly assigned to either the clip (n=118) or control (no clip; n=113) groups. The primary endpoint of the study was clinically significant post-EMR bleeding, defined as hematochezia requiring an emergency department visit, hospitalization, or reintervention within 14 days post-EMR.

Among the clip and control groups, the average participants’ age was 70 and 71 years, 41% and 50% were women, and 25% and 29% were taking antithrombotic agents at the time of the study, respectively.

The researchers found that in the intention-to-treat analysis, clinically significant post-EMR bleeding occurred less often in the clip group than in the control group (4 patients [3.4%] vs 12 patients [10.6%]; P=.031; absolute risk reduction [ARR], 7.2%).

Clinically significant post-EMR bleeding remained lower in the clip vs control group in the per-protocol analysis (1 patient [1.1%] vs 9 patients [9.4%]; P =.019; ARR, 8.2%).

There were no differences between the clip and control groups in terms of adverse events, including delayed perforation (1 patient [<1%] vs 1 patient [<1%]) and post-EMR pain (4 patients [3%] vs 6 patients [5%]). In addition, no deaths were reported.

Investigators acknowledge study results may not be easily replicated, as the endoscopists performing the EMR procedures were highly trained. Additionally, due to a small sample size, researchers were unable to perform certain subanalyses to investigate the effects of anticoagulation and antiplatelet treatments on bleeding rates. 

The researchers concluded, “Our results show that not only was clip closure efficacious, but it was also safe to perform with no increase in other adverse events or recurrence noted at surveillance colonoscopy.”1

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

References

  1. Gupta S, Sidhu M, Shahidi N, et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol. 2022;7(2):152-160. doi: 10.1016/S2468-1253(21)00384-8
  2. Metz AJ, Bourke MJ, Moss A, Williams SJ, Swan MP, Byth K. Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions. Endoscopy. 2011;43(6):506-511. doi: 10.1055/s-0030-1256346