A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions

Abstract

The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.

Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding

“…The mean DB rate for EMR of large (2 cm) nonpedunculated colorectal lesions (LNPCLs) is between 2.6% and 9.7%. [1][2][3][4][5] DB risk has been associated with proximal polyp location, large lesions, major comorbidities, antiplatelet treatment, and patient age. 3,6 Closure of a mucosal defect with clips after resection has long been considered to reduce the risk of bleeding.…”

“…In addition, in the Spanish Endoscopy Society Endoscopic Resection Group (GSEED-RE) score, the absence of complete clip closure of the mucosal defect was an independent risk factor for DB. 3 In this RCT, we aimed to clarify the efficacy of prophylactic complete closure of mucosal defects after EMR of LNPCLs in preventing DB in selected cases with higher than average DB risk. We intended to analyze the preventive effect of complete closure with clips as both an intention-totreat (ITT) and a per-protocol (PP) analysis.…”

Polyp Resection - Controversial Practices and Unanswered Questions

“…Proximal polyp location, size, and bleeding during the resection have been identified as risk factors for delayed bleeding. 9, 55, 62, 63, 64, 65 Age, comorbidities, use of anticoagulation, and electrocautery setting have been reported risks in some but not other studies. 63, 65, 66 …”

“…63 Similarly, clip closure was associated with lower bleeding risk in a recent prospective multicenter cohort study from Spain. 65 Although both studies support the use of clips, a major concern is an uncontrolled study design with the possibility of patient selection bias and unmeasured factors that may affect bleeding risk. Although the study from Spain was large (1214 patients), the lack of a standardized resection protocol, a clear definition of outcomes and assurance of complete outcome assessment are some of the limitations.…”

“…63, 65, 67 A large retrospective single endoscopist study found that complete clip closure after removal of ≥20 mm polyps among 225 patients was associated with a 2% bleeding risk, significantly lower than the 10% observed in 247 historical controls, who did not undergo prophylactic clipping. 63 Similarly, clip closure was associated with lower bleeding risk in a recent prospective multicenter cohort study from Spain.…”