Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps

Abstract

Background. Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of ≥20 mm non-pedunculated polyps reduces the incidence of severe delayed bleeding, especially in proximal polyps. Aim: Evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. Methods: This is a post-hoc analysis of the CLIP STUDY (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when there was no remaining visible mucosal defect and clips were <1cm apart. Factors associated with complete closure were evaluated in multivariable analysis. Results: 458 patients (age 65, 58% men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4%) and was not complete for 156 (31.6%). Factors associated with complete closure in adjusted analysis were smaller polyp size (OR 1.06 for every mm decrease [1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]). Conclusions: Complete clip closure was not achieved for almost 1 out of 3 resected large non-pedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable and highlight the need for alternative closure options and preventative bleeding measures.

Prophylactic clipping after endoscopic mucosal resection of large nonpedunculated colorectal lesions: A meta‐analysis

“…21 The post-hoc analysis revealed complete closure was more likely for smaller polyp size, for serrated polyps, if access was easy, if submucosal lifting was complete, or if a polyp could be removed en-bloc. 38 Although good access and en-bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. Currently, there are large through-the-scope clips, up to 16 mm in open width, available for closing large mucosal defects.…”

“…A RCT reported one‐third of resection sites of LNPCL could not be completely closed 21 . The post‐hoc analysis revealed complete closure was more likely for smaller polyp size, for serrated polyps, if access was easy, if submucosal lifting was complete, or if a polyp could be removed en‐bloc 38 . Although good access and en‐bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable.…”

Dual Channel Endoscopic Mucosal Resection

“…Size does matter; one study found that for every 1 mm decrease in polyp size, there is 6% greater odds of achieving clip closure. 18 However, regardless of size, one of the other benefits of DC-EMR is the advanced ability of clip closure using this dual-channel technology. The clip can be inserted in one working channel and the biopsy forceps can be placed in the other channel.…”

A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study

“…The complete closure rate de-scribed in the literature for TTS clip monotherapy for large (≥ 20 mm) nonpedunculated colorectal polyps has varied widely from 57 % to 68 % [13][14][15]. The largest multicenter study of TTS clip monotherapy post-endoscopic mucosal resection of colorectal lesions of ≥ 20 mm reported a complete closure rate of 68.4 % [13,16]. Importantly, this meant that clip closure was not feasible for almost one in three mucosal resection defects.…”