Prophylactic clips to reduce delayed polypectomy bleeding after resection of large colorectal polyps: a systematic review and meta-analysis of randomized trials

Abstract

Prophylactic clips to prevent delayed polypectomy bleeding (DPB) after endoscopic resection of large colorectal polyps remains controversial. We performed a systematic review and meta-analysis to evaluate the efficacy of prophylactic clips for preventing DPB by synthesizing the results of randomized trials. PubMed, Cochrane Library, and EMBASE were searched to October 2019 to identify randomized controlled trials evaluating the efficacy of placing prophylactic clips to reduce DPB after resection of large (≥10mm) colorectal polyps. The primary outcome was DPB defined by GI bleeding after the conclusion of the colonoscopy. Eight studies (n= 3415) met the study criteria, all with a low risk of bias. The overall pooled incidence of DPB was 3.9% (95% confidence interval [CI], 2.4%-5.4%) in patients receiving endoscopic resection of colorectal polyps≥10mm. Placing prophylactic clips reduced DPB in patients receiving prophylactic clips (relative risk [RR], 0.61; 95% CI, 0.43-0.85; I2= 37.8%) compared with no clips with a number needed to treat (NNT) of 52 (95% CI, 31-163). In stratified analyses, placing clips was associated with reduced risks of DPB in patients with polyps≥20mm (RR, 0.54; 95% CI, 0.35-0.84; I2= 0.0%; NNT, 30), nonpedunculated morphology (RR, 0.54; 95% CI, 0.36-0.81; I2= 0.0%; NNT, 39), and located proximal to the hepatic flexure (RR, 0.49; 95% CI, 0.31-0.78; I2= 54.8%; NNT, 25) compared with no clips. Prophylactic clips after endoscopic resection of colorectal polyps≥10mm demonstrated a modest reduction in the risk of DPB. Larger reductions were observed in patients with polyps≥20mm, nonpedunculated morphology, or located proximal to the hepatic flexure.