The effect of prophylactic hemoclip placement and risk factors of delayed post-polypectomy bleeding in polyps sized 6 to 20 millimeters: a propensity score matching analysis

Risk factors of post-polypectomy bleeding and recurrence in children with colorectal polyps after endoscopic mucosal resection: a retrospective cohort study

BACKGROUND

The incidence rate of colorectal polyps in children has gradually increased in recent years. It is still unclear whether endoscopic mucosal resection (EMR) can be performed in children with colorectal polyps as well as their incidences of post-polypectomy bleeding and recurrence. This retrospective study was performed to explore the feasible of EMR in children with colorectal polyps and analyze the risk factors of post-polypectomy bleeding and recurrence.

METHODS

Patients aged younger than 18 years diagnosed with colorectal polyps and received EMR for polypectomy between January 2017 and December 2021 were included in this study. The baseline data of included patients were retrospectively collected. All complications related to polypectomy were recorded during follow up via telephone, internet, or outpatient department, including post-polypectomy bleeding, perforation and polyp recurrence. Patients with and without post-polypectomy complications were divided into 2 groups. The risk factors of post-polypectomy bleeding and polyp recurrence were analyzed using multivariable logistic regression models after adjusting potential risk factors using univariable regression models.

RESULTS

A total of 589 patients were included in this retrospective study. There were 333 male patients and 256 female patients, and their average age was 4.4±1.9 years old. The average diameter of their polyps was 8.4±2.8 mm, and 542 (92.0%) polyps presented as pedunculated lesions. A total of 540 (91.7%) polyps were diagnosed as juvenile polyps and 509 (86.4%) patients had only 1 polyp. There were a total of 75 cases of post-polypectomy complications (12.7%). The most common complication was early post-polypectomy bleeding (5.3%), followed by polyp recurrence (3.7%). Post-polypectomy bleeding occurred the most on the third and fourth day after EMR polypectomy. Larger polyps (OR =1.742, P<0.001), sessile lesions (OR =3.150, P=0.019), and multiple polyps (OR =4.372, P=0.003) were identified to be related to the incidence of post-polypectomy bleeding. Besides, sessile lesions (OR =3.887, P=0.026) were identified as the main risk factor and older patients (OR =0.606, P=0.004) had lower potential for post-polypectomy recurrence.

CONCLUSIONS

More attention should be paid to large, sessile, and multiple polyps during the procedure of EMR in children. The small number of patients in this study limits further analysis of results and a large sample study should be performed.

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

BACKGROUND & AIMS

Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use.

METHODS

An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders.

RESULTS

Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52).

CONCLUSIONS

Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.).

Risk factors of delayed post-polypectomy bleeding after treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection

Context

Gastrointestinal polyps are common gastrointestinal diseases that involve localised hyperplastic masses derived from gastrointestinal mucosa.

Aims

To investigate the risk factors of delayed post-polypectomy bleeding (DPPB) after the treatment of gastrointestinal polyps with snare-assisted endoscopic sub-mucosal dissection (ESD) and to construct a nomogram model to predict the risk of DPPB.

Settings and Design

A total of 226 patients who underwent snare-assisted ESD for gastrointestinal polyps from May 2018 to November 2020 were divided into DPPB group (n = 10) and non-DPPB group (n = 216).

Subjects and Methods

The correlations of clinical data and endoscopic data with DPPB were compared. Univariate analysis was performed to screen the influencing factors of DPPB. Multivariate logistic regression analysis was used to screen the risk factors of DPPB, which was employed to construct a nomogram prediction model.

Statistical Analysis Used

SPSS 16.0 software was utilised for statistical analysis. Numerical data were expressed as percentage (n [%]), and Chi-square test was performed for univariate analysis. The significant factors (P < 0.05) in univariate analysis were included in multivariate logistic regression analysis, and the variables with statistical significance (P < 0.05) were considered as independent risk factors. The factors were used to construct a nomogram model for predicting the risk of DPPB. Bootstrap method was employed to perform repeated sampling 1000 times for internal verification. The consistency index (C-index) was used to evaluate the discrimination of the model, and C-index ≥0.70 represented a good discrimination. Two-tailed P < 0.05 indicated that a difference was statistically significant.

Results

Univariate and multivariate logistic regression analyses revealed that hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding were the independent risk factors for DPPB (P < 0.05). The C-index of the nomogram model for predicting the risk of DPPB was 0.791, indicating a good discrimination. The calibration curve showed that the mean absolute error between predicted and actual DPPB occurrence risks was 0.014, indicating a high accuracy.

Conclusions

Hypertension, polyp location, polyp diameter, polyp morphology and intra-operative bleeding are the independent risk factors for DPPB, and the nomogram model established based on these factors for prediction has good discrimination and accuracy. Therefore, it is recommended to perform targeted intervention for high-risk groups to reduce the incidence of DPPB.

Prophylactic clipping to prevent delayed colonic post-polypectomy bleeding: meta-analysis of randomized and observational studies

BACKGROUND AND AIMS

Delayed post-polypectomy bleeding (DPPB) is a commonly described adverse event following polypectomy. Prophylactic clipping may prevent DPPB in some patient subgroups. We performed a meta-analysis to assess both the efficacy and real-world effectiveness of prophylactic clipping.

METHODS

We performed a database search through March 2020 for clinical trials or observational studies assessing prophylactic clipping and DPPB. Pooled risk ratios (RR) were calculated using random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to elucidate clinical or methodological factors associated with effects on outcomes.

RESULTS

A total of 2771 citations were screened, with 11 randomized controlled trials (RCTs) and 9 observational studies included, representing 24,670 colonoscopies. DPPB occurred in 2.0% of patients overall. The pooled RR of DPPB was 0.47 (95% CI 0.29-0.77) from RCTs enrolling only patients with polyps ≥ 20 mm. Remaining pooled RCT data did not demonstrate a benefit for clipping. The pooled RR of DPPB was 0.96 (95% CI 0.61-1.51) from observational studies including all polyp sizes. For patients with proximal polyps of any size, the RR was 0.73 (95% CI 0.33-1.62) from RCTs. Meta-regression confirmed that polyp size ≥ 20 mm significantly influenced the effect of clipping on DPPB.

CONCLUSION

Pooled evidence demonstrates a benefit when clipping polyps measuring ≥ 20 mm, especially in the proximal colon. In lower-risk subgroups, prophylactic clipping likely results in little to no difference in DPPB.