Prophylactic Clip Placement in Delayed Polypectomy Bleeding Involving Large Colon Polyps
Annie Shergill* and Luis Nasiff
Larkin Community Hospital, Palm Springs Campus, Hialeah, FL, USA
*Corresponding author
Annie Shergill, Larkin Community Hospital, Palm Springs Campus, Hialeah, FL, USA.
Large colon polyps (> 10 mm) always pose an endoscopic challenge in terms of successful resection. Malignant potential associated with large polyps necessitates complete endoscopic resection endoscopically if possible. However, an important aspect to be aware of is the delayed polypectomy bleeding that results from removal of such large polyps. So far, the mainstay to prevent this complication is placement of prophylactic clips. We review literature evaluating if this intervention is indeed effective and improves any outcomes post polypectomy.
A meta-analysis of randomized control trials assessed the risk reduction of delayed polypectomy bleeding after placement of prophylactic clips for polyps more than or equal to 10 mm [1]. The mean polyp size in the study was 21.3 mm and mean number of 4.8 clips were placed. Follow-up post-polypectomy ranged from 7 to 30 days. The majority of polypectomies (60.6%) were performed via endoscopic mucosal resection (EMR), while 38% were performed by conventional polypectomy and 1.4% via endoscopic submucosal dissection (ESD). Patients who underwent prophylactic clip placement had reduced incidence of delayed polypectomy bleeding. This result was more amplified in even larger polyps measuring > 20 mm, non-pedunculated polyps and location of the polyp to be proximal to hepatic flexure. Specifically, prophylactic clips reduced delayed polypectomy bleeding in patients who underwent EMR No protective effects were seen in patients with cold snare polypectomy and those underwent ESD.
The CLIPPER trial is a randomized controlled superiority trial conducted in the Netherlands evaluating the efficacy of prophylactic clipping after EMR of polyps > 20 mm in size [2]. While the results of this study are still awaited, a large prospective study like this will shine light on numerous aspects of application of prophylactic clipping and its significant impact on post-polypectomy complications. Similar trials are needed to guide incorporating prophylactic clipping in standard clinical practice.
References
- 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. 2021. 93: 807-815.
- Turan AS, Moons LMG, Schreuder RM, Schoon EJ, Terhaar Sive Droste JS, et al. Clip placement to prevent delayed bleeding after colonic endoscopic mucosal resection (CLIPPER): study protocol for a randomized controlled trial. Trials 2021. 22: 63.
