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Clip closure reduced bleeding after large lesion resection

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Protective benefit seen with complete clip closure

With the advent of routine submucosal lifting prior to endoscopic mucosal resection, perforation now occurs less commonly; however, delayed bleeding following resection remains problematic given the aging population and increasing use of antithrombotic agents. In this study, clip closure resulted in a decrease in post-polypectomy bleeding in patients deemed to be at high risk (at least 8%) for delayed bleeding.

The protective benefit of clip closure was seen almost exclusively in patients who had complete closure of the defect, which was achieved in only 57% of procedures. Clinical efficacy is largely driven by endoscopist skill level and the ability to achieve complete closure. Notably, defects that were successfully clipped were smaller in size, had better accessibility, and were technically easier. Defining such procedural factors a priori is important and may influence whether one should attempt clip closure if complete clip closure is unlikely. Interestingly, the bleeding rate was higher in the control group in lesions proximal to the transverse colon, where clip closure is likely to be most beneficial and cost effective, based on emerging data. It’s worth noting that the clips used in this study were relatively small (11 mm), and not currently available in the United States, although most endoscopic clips function similarly.

Studies such as this provide evidenced-based medicine to endoscopic practice. Hemostatic clips were introduced nearly 20 years ago without evidence for their effectiveness. Future studies are needed, such as those that compare electrocautery-based resection of high-risk polyps with standard clips to over-the-scope clips, and those that compare electrocautery-based resection to cold snare resection.

Todd H. Baron, MD, is a gastroenterologist based at the University of North Carolina, Chapel Hill. He is a speaker and consultant for Olympus, Boston Scientific, and Cook Endoscopy.



Use of clip closure significantly reduced delayed bleeding in patients who underwent resections for large colorectal lesions, based on data from 235 individuals.

Source: American Gastroenterological Association

“Closure of a mucosal defect with clips after resection has long been considered to reduce the risk of bleeding,” but evidence to support this practice is limited, wrote Eduardo Albéniz, MD, of the Public University of Navarra (Spain), and colleagues.

In a study published in Gastroenterology, the researchers identified 235 consecutive patients who had resections of large nonpedunculated colorectal lesions from May 2016 to June 2018. Patients had an average or high risk of delayed bleeding and were randomized to receive scar closure with either 11-mm through-the-scope clips (119 patients) or no clip (116 patients).

Delayed bleeding occurred in 14 control patients (12.1%), compared with 6 clip patients (5%), for a risk reduction of 7%. The clip group included 68 cases (57%) of complete closure and 33 cases (28%) with partial closure, as well as 18 cases of failure to close (15%); only 1 case of delayed bleeding occurred in the clip group after completion of clip closure. On average, six clips were needed for complete closure.

None of the patients who experienced delayed bleeding required surgical or angiographic intervention, although 15 of the 20 patients with bleeding underwent additional endoscopy. Other adverse events included immediate bleeding in 21 clip patients and 18 controls that was managed with snare soft-tip coagulation. No deaths were reported in connection with the study.

Demographics were similar between the two groups, but the subset of patients with complete closure included more individuals aged 75 years and older and more cases with smaller polyps, compared with other subgroups, the researchers noted.

The study findings were limited by several factors, including the difficulty in predicting delayed bleeding, the potential for selection bias given the timing of patient randomization, the lack of information about polyps that were excluded from treatment, and the difficulty in completely closing the mucosal defects, the researchers noted. However, the results suggest that complete clip closure, despite its challenges, “displays a clear trend to reduce delayed bleeding risk,” and is worth an attempt.

The study was supported by the Spanish Society of Digestive Endoscopy. The researchers had no financial conflicts to disclose. MicroTech (Nanjing, China) contributed the clips used in the study.

SOURCE: Albéniz E et al. Gastroenterology. 2019 Jul 27. doi: 10.1053/j.gastro.2019.07.037.

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