The Effect of Prophylactic Hemoclip Usage on the Risk of Delayed Post-Endoscopic Mucosal Resection Bleed for Upper and Lower Gastrointestinal Lesions

Abstract

Introduction: Endoscopic mucosal resection (EMR) of gastrointestinal (GI) lesions is associated with complications such as bleeding. Hemoclips are used for acute bleeds as well as for prevention of delayed bleeding. There is paucity of studies that examine the prophylactic use of hemoclips in EMR of both upper and lower GI lesions while there are some studies that address this question for colorectal lesions. Methods: Retroactive review of the prospectively collected Kaiser Permanente Southern California (KPSC) EMR registry was performed. Lesions in both upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were captured. Results: Total of 676 lesions were resected via EMR. Mean age at diagnosis was 64 ± 0.43 years. 192 lesions were from the upper GI tract and 484 from lower (Table 1). Mean size of the lesions was 25 ± 0.58 mm (range 1.2 - 100 mm). Pathology results are listed in Table 2. Endoclips were used for 352 lesions (52%). There were no statistical differences between hemoclip group (HG) and no-hemoclip group (NHG) in terms of age, gender, usage of ablative methods, aspirin/nonsteroidal anti-inflammatory drugs, anti-coagulation, and co-morbidities (hypertension, diabetes, CAD, CVA). NHG had more lesions resected via piecemeal technique (81.7% vs 68.9, P=0.0002) and slightly higher proportion of patients on anti-platelet agents (5% vs 2%, P=0.0319) although they are routinely discontinued prior to EMR. 25 cases resulted in delayed bleed, 13 (3.7%) in HG and 12 (3.4%) in NHG, P=0.86. Results did not change when cases with immediate bleeding were excluded (HG 3% vs NHG 3.6%, P=0.68). There was no difference when the analysis was stratified by upper GI lesions (HG 3.6 % vs NHG 1.3 %, P=0.32) and lower (HG 3.8% vs NHG 4.2%, P=0.81). There was no difference when stratified by size<20mm (HG 0.7% vs NHG 1.8%, P=0.41) and ≥ 20mm (HG 5.8% vs NHG 3.9%, P=0.36). Total number of clips used in cases without immediate bleed was 824 (mean 1.36 ± 0.09 clips per patient). With average cost of the four different types of clips used being $193, the total cost for prophylactic hemoclip usage was $159,032.Table: Table. Location of lesions resected by EMRTable: Table. Pathology results of lesions resected by EMRConclusion: In this retrospective analysis, hemoclip application did not result in decreased delayed post-EMR bleed for upper and lower GI tract lesions. Total expenditure for prophylactic hemoclip usage was $159,032.