Effect of prophylactic endoscopic clipping for prevention of delayed bleeding after endoscopic papillectomy for ampullary neoplasm: a multicenter randomized trial

Abstract

Background Endoscopic clip placement is technically challenging using a duodenoscope, limiting their application for treatment of bleeding after endoscopic papillectomy. This study evaluated the efficacy of newly designed clips to prevent bleeding after endoscopic papillectomy. Methods Patients (n = 80) with suspected benign adenomas on the major papilla who were scheduled for endoscopic papillectomy with or without clipping were randomized. A new duodenoscope-compatible clip capable of being rotated, reopened, and repeatedly repositioned was used. The primary end point was incidence of delayed bleeding. Results The clipping procedure was successful in all patients. The incidence of delayed bleeding was nonsignificantly higher in the no-clipping group than in the clipping group (31.6 % [95 % confidence interval (CI) 19.1–47.5] vs. 15.0 % [95 %CI 7.1–29.1]). The incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis did not differ significantly between the groups (clipping vs. no-clipping: 17.5 % [95 %CI 8.7–31.9] vs. 5.3 % [95 %CI 1.5–17.3]), and all cases were mild. Conclusions Placement of the newly designed rotatable clip was technically feasible and tended to have a protective effect by preventing delayed bleeding after endoscopic papillectomy, although statistical significance was not reached.

Efficacy analysis of hemostatic spray following endoscopic papillectomy: A multicenter comparative study

“…However, previous studies [11][12][13][14][15] on this topic were limited in that the sample sizes were too small to show that the hemostatic spray was effective for post-sphincterotomy bleeding, and no study has yet investigated the use of a hemostatic spray after EP. In the present study, we used Nexpowder, which consists of oxidized dextran and succinic acid modified amino acids, which are biodegradable and biocompatible.…”

“…13 Recently, a rotatable clip showed protective effect for delayed EP bleeding; however, it did not show any statistical significance when compared with that in the non-clipping group, and the prevalence of pancreatitis was relatively high in the clipping group without statistical significance. 14 Submucosal injection of diluted epinephrine before EP did not prevent delayed post-EP bleeding compared with simple snare papillectomy. 15 Recently, as an another emerging method, the application of hemostatic spray powder was proven to be effective for non-variceal upper gastrointestinal bleeding (UGIB).…”

“…Preventive closure of the frenulum by clipping after EP was found to be effective for the prevention of delayed bleeding, but the number is too small to generalize in clinical practice 13 . Recently, a rotatable clip showed protective effect for delayed EP bleeding; however, it did not show any statistical significance when compared with that in the non‐clipping group, and the prevalence of pancreatitis was relatively high in the clipping group without statistical significance 14 . Submucosal injection of diluted epinephrine before EP did not prevent delayed post‐EP bleeding compared with simple snare papillectomy 15 …”

Preemptive clipping for post-ampullectomy bleeding: the jury is still out

“…Thus, the study published in this issue of Endoscopy by Park et al [5], represents a very logical assessment of preemptive hemostatic clipping of the ampullary resection site, using a po-tentially more effective hemostatic clip [6]. This clip purportedly has a more flexible mechanical construction, offering improved functionality even when used through a duodenoscope.…”

Post‐papillectomy bleeding: Hemostatic powder to the rescue?

“…4 Endoscopic clip placement while using a duodenoscope can be challenging, but there is a suggestion that placement of a duodenoscope-compatible clip may potentially reduce the risk of bleeding. 5 When post-papillectomy bleeding occurs, it is treated with standard endoscopic hemostasis techniques such as adrenaline injection, clip application, or coagulation. When these techniques fail, angio-embolization or even surgery may be needed.…”