Prevention of delayed post-polypectomy bleeding by prophylactic clipping after endoscopic colorectal polypectomy: a meta-analysis

Complete closure utilizing titanium clips minimizes delayed postpolypectomy bleeding after colorectal endoscopic mucosal resection: a retrospective analysis

Background

Delayed postpolypectomy bleeding (DPPB) constitutes one of the most prevalent complications following endoscopic mucosal resection (EMR) for colonic polyps and can be life-threatening. It has been affirmed that prophylactic clip closure can effectively diminish the risk of DPPB for colonic polyps exceeding 20 mm in the right half of the colon after EMR. Nevertheless, there remains controversy regarding whether prophylactic clip closure can prevent postoperative bleeding for polyps measuring less than 20 mm. To date, no literature has reported whether the complete closure of titanium clips following EMR for colorectal polyps ⩽20 mm can effectively prevent delayed bleeding.

Objectives

The aim of this study is to determine whether complete closure can prevent delayed postoperative bleeding and analyze the related factors that might influence delayed postoperative bleeding.

Design

In this retrospective study, a total of 1259 colorectal polyps detected in 1025 patients between January 2020 and October 2024 were evaluated for EMR.

Methods

Univariate and logistic regression analyses were conducted to assess patient-related, polyp-related, and procedure-related factors.

Results

DPPB was observed in 37 patients, representing an incidence rate of 3.6%. Logistic regression analysis indicated that male (odds ratio, 3.870; 95% confidence interval (CI), 1.594-9.396; p = 0.003), presence of large polyps (OR, 1.158; 95% CI, 1.044-1.285; p = 0.006), and partial closure (OR, 5.447; 95% CI, 2.250-13.186; p < 0.001) are significant risk factors for the development of DPPB.

Conclusion

Male, polyp size, and partial closure have been identified as potential risk factors for the development of DPPB. While gender and polyp size are immutable factors, partial closure is particularly associated with an increased risk of DPPB. Therefore, it is imperative to ensure complete closure of the wound following EMR to minimize the occurrence of DPPB.

Multicentre randomised controlled trial of a self-assembling haemostatic gel to prevent delayed bleeding following endoscopic mucosal resection (PURPLE Trial)

BACKGROUND

Prophylactic application of a haemostatic gel to the resection field may be an easy way to prevent delayed bleeding, a frequent complication after endoscopic mucosal resection (EMR).

OBJECTIVE

We aimed to evaluate if the prophylactic application of a haemostatic gel to the resection field directly after EMR can reduce the rate of clinically significant delayed bleeding events.

DESIGN

We conducted a prospective randomised trial of patients undergoing hot-snare EMR of flat lesions in the duodenum (≥10 mm) and colorectum (≥20 mm) at 15 German centres. Prophylactic clip closure was not allowed, but selective clipping or coagulation could be used prior to randomisation to treat intraprocedural bleeding or for prophylactic closure of visible vessels. Patients were randomised to haemostatic gel application or no prophylaxis. The primary endpoint was delayed bleeding within 30 days.

RESULTS

The trial was stopped early due to futility after an interim analysis. The primary endpoint was analysed in 232 patients (208 colorectal, 26 duodenal). Both groups were comparable in age, sex, comorbidities and lesion characteristics. Preventive measures, such as selective clipping or coagulation, were applied prior to randomisation in 51.9% of cases, with no difference between groups. Delayed bleeding occurred in 14 cases (11.7%; 95% CI 7.1% to 18.6%) after Purastat and in 7 cases (6.3%; 95% CI 3.1% to 12.3%) in the control group (p=0.227), with no difference between colorectal and duodenal subgroups.

CONCLUSION

The application of a haemostatic gel following EMR of large flat lesions in the duodenum and colorectum does not reduce the rate of delayed bleeding.

The Use of Clips to Prevent Post-Polypectomy Bleeding: A Clinical Review

GOALS

The goal of this clinical review is to provide an overview of the current literature regarding the utility of prophylactic clips in reducing postpolypectomy bleeding and to provide an expert statement regarding their appropriateness in clinical practice.

BACKGROUND

Colonoscopy enables the identification and removal of premalignant and malignant lesions through polypectomy, yet complications including postpolypectomy bleeding (PPB) can arise. While various studies have explored applying clips prophylactically to prevent PPB, their effectiveness remains uncertain.

STUDY

A literature search conducted in PubMed and Embase identified 671 publications discussing clip use postpolypectomy; 67 were found to be relevant after screening, reporting outcomes related to PPB. Data related to clip utilization, polyp characteristics, and adverse events were extracted and discussed.

RESULTS

The current literature suggests that prophylactic clipping is most beneficial for nonpedunculated polyps ≥20 mm, especially those in the proximal colon. The utility of clipping smaller polyps and those in the distal colon remains less clear. Antithrombotic medication usage, particularly anticoagulants, has been linked to an increased risk of bleeding, prompting consideration for clip placement in this patient subgroup. While cost-effectiveness analyses may indicate potential savings, the decision to clip should be tailored to individual patient factors and polyp characteristics.

CONCLUSIONS

Current research suggests that the application of prophylactic clips can be particularly beneficial in preventing delayed bleeding after removal of large nonpedunculated polyps, especially for those in the proximal colon and in patients on antithrombotic medications. In addition, for large pedunculated polyps prophylactic clipping is most effective at controlling immediate bleeding.

Review article: Advances in the management of lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved.

AIMS

To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion.

RESULTS

The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients.

CONCLUSIONS

The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Dietary restriction after cold snare polypectomy of colorectal polyp for prevention of delayed bleeding

Background and Aim

Cold snare polypectomy (CSP) for small colorectal polyps is a safe technique; however, there is little evidence on whether dietary restriction after CSP is essential. This study aimed to determine whether dietary restriction after CSP is necessary to prevent delayed bleeding.

Methods

This is a randomized, controlled, non-inferiority trial conducted between November 2021 and March 2022. Patients with non-pedunculated small colorectal polyps (<10 mm) and who did not take anticoagulants were randomly allocated to two groups: (i) the normal diet (ND) group, and (ii) the low-residue diet (LRD) group. The ND group was instructed to eat anything after CSP, whereas the LRD group was advised to take LRD for 3 days after CSP. The primary endpoint was the occurrence of delayed major bleeding that needed endoscopic hemostasis.

Results

A total of 193 patients (average 57.5 years old, 51.9% male) were enrolled in the study. Subsequently, 97 and 96 patients were allocated to the ND and LRD group, respectively. The occurrence of delayed major bleeding was 1.0% in the ND group and 2.1% in the LRD group (95% confidence interval [CI]: -4.4% to 2.4%; difference: -1.1%), which showed the non-inferiority of the ND group. In addition, there was no difference between the two groups with respect to the occurrence of minor delayed bleeding (3.1% and 4.2%, respectively; difference: -1.1% [95% CI: -6.4% to 4.2%]).

Conclusion

Dietary restriction after CSP for low-bleeding-risk colorectal polyps is not necessary for the prevention of delayed bleeding (Registration number: UMIN000045669).