Prophylactic Endoscopic Clipping Does Not Prevent Delayed Postpolypectomy Bleeding in Routine Clinical Practice: A Propensity Score–Matched Cohort Study

Abstract

Introduction: Delayed postpolypectomy bleeding (DPPB) is a relatively common adverse event. Evidence is conflicting on the efficacy of prophylactic clipping to prevent DPPB, and real-world effectiveness data are lacking. We aimed to determine the effectiveness of prophylactic clipping in preventing DPPB in a large screening-related cohort. METHODS: We manually reviewed records of patients who underwent polypectomy from 2008 to 2014 at a screening facility. Endoscopist-, patient- and polyp-related data were collected. The primary outcome was DPPB within 30 days. All unplanned healthcare visits were reviewed; DPPB cases were adjudicated by committee using a criterion-based lexicon. Multivariable logistic regression was performed, yielding adjusted odds ratios (AORs) for the association between clipping and DPPB. Secondary analyses were performed on procedures where one polyp was removed, in addition to propensity score–matched and subgroup analyses. RESULTS: In total, 8,366 colonoscopies involving polypectomy were analyzed, yielding 95 DPPB events. Prophylactic clipping was not associated with reduced DPPB (AOR 1.27; 0.83–1.96). These findings were similar in the single-polyp cohort (n = 3,369, AOR 1.07; 0.50–2.31). In patients with one proximal polyp ≥20 mm removed, there was a nonsignificant AOR with clipping of 0.55 (0.10–2.66). Clipping was not associated with a protective benefit in the propensity score–matched or other subgroup analyses. DISCUSSION: In this large cohort study, prophylactic clipping was not associated with lower DPPB rates. Endoscopists should not routinely use prophylactic clipping in most patients. Additional effectiveness and cost-effectiveness studies are required in patients with proximal lesions ≥20 mm, in whom there may be a role for prophylactic clipping.

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

“…This IPDMA involving 8229 colorectal polyps from 13 studies shows that prophylactic clipping in general did Our findings are in accordance with recent studies on prophylactic clipping that concluded that prophylactic clipping should not be routinely performed after polyp resection in the whole colon, but should be considered for bleeding prevention after large proximal polyp resection. 8,9,12,26,30,31 Based on this, it can well be concluded that in a setting where cost issues do not play an important role, all proximal polyps 20 mm may be routinely clipped. Nonetheless, costs considerations often are an important factor in general care settings.…”

Prophylactic clipping for delayed postpolypectomy bleeding: Moderately effective, but is it feasible in daily practice?

“…In a large cohort study in which the incidence of DPB was retrospectively analyzed in >8300 procedures performed by 47 endoscopists, clipping did not prevent DPB even in proximal polyps >20 mm. 8 Although clearly this is a different population, these real-world data may also partly be explained by the difference in skillset of endoscopists in nonexpert centers because closure of large postpolypectomy defects can be technically very challenging. To emphasize this point, in a recent study in almost 250 patients undergoing piecemeal EMR of polyps >20 mm, complete closure of the defect could not be achieved in >40% of cases.…”

Contemporary management of antithrombotic agents for patients undergoing peroral endoscopic myotomy

“…Copyright ª 2021 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 https://doi.org/10.1016/j.gie.2020.08.026 rates of bleeding after polypectomy 13,14 and sphincterotomy. 15,16 The authors noted nonadherence to practice guidelines in 23.8% of patients, including aspirin being withheld despite being used for secondary prevention, 1 high-risk patient using vitamin K antagonist who did not receive bridge therapy, and patients using antiplatelet therapy or DOACs who were given bridge therapy.…”