The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis

Ayla S Turan; Heiko Pohl; Mio Matsumoto; Brian S Lee; Masato Aizawa; Federico Desideri; Eduardo Albéniz; Gottumukkala S Raju; Daniel Luba; Maximilien Barret; Suryakanth R Gurudu; Francisco C Ramirez; Wey-Ran Lin; Femke Atsma; Peter D Siersema; Erwin J M van Geenen; Prophylactic Clipping Collaborative Group

doi:10.1016/j.cgh.2021.05.012

The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis

Clin Gastroenterol Hepatol. 2022 Feb;20(2):362-371.e23. doi: 10.1016/j.cgh.2021.05.012. Epub 2021 May 12.

Authors

Ayla S Turan¹, Heiko Pohl², Mio Matsumoto³, Brian S Lee⁴, Masato Aizawa⁵, Federico Desideri⁶, Eduardo Albéniz⁷, Gottumukkala S Raju⁸, Daniel Luba⁹, Maximilien Barret¹⁰, Suryakanth R Gurudu¹¹, Francisco C Ramirez¹¹, Wey-Ran Lin¹², Femke Atsma¹³, Peter D Siersema¹⁴, Erwin J M van Geenen¹⁴; Prophylactic Clipping Collaborative Group

Collaborators

Prophylactic Clipping Collaborative Group:
Douglas K Rex, Brian S Lim, Karl K Kwok, Kazutomo Togashi, Romain Coriat, Sarah B Umar, Chun-Wei Chen, Jochim Terhaar Sive Droste, Ruud Schrauwen, Gijs Kemper

Affiliations

¹ Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Electronic address: aylaturan@radboudumc.nl.
² Section of Gastroenterology and Hepatology, VA White River Junction, White River Junction, Vermont.
³ Department of Gastroenterology, Sapporo Medical Center NTT EC, Sapporo, Japan.
⁴ Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, California.
⁵ Department of Coloproctology, Aizu Medical Center Fukushima Medical University, Aizuwakamatsu, Japan.
⁶ Digestive and Liver Disease Department, Endoscopy Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; Gastroenterology Department, San Maurizio Hospital, Bolzano, Italy.
⁷ Department of Gastroenterology, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain.
⁸ University of Texas MD Anderson Cancer Center, Houston, Texas.
⁹ Monterey Bay Gastroenterology Consultants, Monterey, California.
¹⁰ Department of Gastroenterology, Cochin Hospital, AP-HP, Université de Paris, Paris, France.
¹¹ Department of Gastroenterology, Mayo Clinic, Scottsdale, Arizona.
¹² Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
¹³ Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
¹⁴ Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.

PMID: 33991691
DOI: 10.1016/j.cgh.2021.05.012

Abstract

Background & aims: Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use.

Methods: An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders.

Results: Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52).

Conclusions: Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.).

Keywords: Colorectal Polyp; Delayed Bleeding; Endoscopic Mucosal Resection; Nonpedunculated; Polypectomy; Prophylactic Clipping.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Colonic Polyps* / etiology
Colonic Polyps* / surgery
Colonoscopy / adverse effects
Humans
Postoperative Hemorrhage / epidemiology
Postoperative Hemorrhage / etiology
Postoperative Hemorrhage / prevention & control
Prospective Studies
Retrospective Studies
Surgical Instruments