Prophylactic Clip Research Articles

Su1647 Cost-Effectiveness of Prophylactic Clipping After Colorectal Endoscopic Mucosal Resection and Economic Impact According to a Bleeding Risk Score

Su1647 Cost-Effectiveness of Prophylactic Clipping After Colorectal Endoscopic Mucosal Resection and Economic Impact According to a Bleeding Risk Score

Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review.

BackgroundBleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding.MethodsMultiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip.ResultsFive hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56–4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42–1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69–2.24; P=0.47) were analyzed.ConclusionsThe use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.

The influence of clips on scars after EMR: clip artifact

Laterally spreading lesions ≥20 mm are conventionally removed by EMR. Endoscopic clips are increasingly used to mitigate the risk of delayed bleeding. Clips may alter the endoscopic appearance of the scar after EMR, interfering with the assessment of adenoma recurrence. We aimed to evaluate this. Prospective, single-center data from the Australian Colonic Endoscopic resection study (January 2011-May 2015) were analyzed. Patients undergoing EMR of laterally spreading lesions with endoscopic clips used at the EMR defect were eligible. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Clips were used in 111 of 885 lesions (12.5%). A total of 62 of 111 clipped lesions had standardized, high-definition, white light, and narrow-band images of the scars after EMR at first surveillance colonoscopy, and the patients were enrolled. Analysis of the images showed 4 situations: a bland scar (N = 27), residual adenoma (N = 6), mucosal elevation with normal pit pattern (N = 14), or granulation tissue related to the presence of residual clips (N = 15). The latter 2 entities were termed post-EMR scar clip artifact (ESCA). Overall, 29 of 62 previously clipped EMR sites (46.8%) had ESCA at a median follow-up of 5.2 months. Twenty scars had residual clips, and 15 of 20 (75.0%) showed ESCA (P = .002). Lesions clipped for prophylaxis of bleeding were more likely to show ESCA than those clipped for deep mural injury or intraprocedural bleeding (65.5% vs 41.7%; P = .006). ESCA was associated with female sex (P = .010) and greater age (P = .011). ESCA is characterized by a nodular elevation of the mucosa with a normal pit pattern and can occur with or without residual clips. Prophylactic clip closure and the presence of residual clips are associated with ESCA. ( NCT01368289.).

329 Does Prophylactic Clip Application After snare Polypectomy Reduce the Risk of Delayed Gastrointestinal Bleeding? a Systematic Review and Meta-Analysis

329 Does Prophylactic Clip Application After snare Polypectomy Reduce the Risk of Delayed Gastrointestinal Bleeding? a Systematic Review and Meta-Analysis

330 A Prophylactic Clip Strategy Is Not Cost Effective for the Prevention of Clinically Significant Bleeding Following Wide-Field Endoscopic Mucosal Resection of Large Colorectal Sessile and Laterally Spreading Lesions

330 A Prophylactic Clip Strategy Is Not Cost Effective for the Prevention of Clinically Significant Bleeding Following Wide-Field Endoscopic Mucosal Resection of Large Colorectal Sessile and Laterally Spreading Lesions

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study

OC-048 Trans-anal Submucosal Endoscopic Resection (taser): A New Endo-surgical Approach To The Resection Of Giant Rectal Lesions

IntroductionTrans-anal surgical (TEMS/TAMIS) and advanced endoscopic resection (ESD, P-EMR) procedures have the potential to provide complete and successful eradication of giant rectal polyps. Both approaches however have limitations in terms...

A Cost-efficacy Decision Analysis of Prophylactic Clip Placement After Endoscopic Removal of Large Polyps

Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost-effectiveness of routine clip placement after colon polypectomy. Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted by using TreeAge Pro 2011 Software. Our cost-effectiveness threshold was an incremental cost-effectiveness ratio of $100,000 per quality-adjusted life year. The reference case was a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement. On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness. Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.

Clinical outcomes of endoscopic resection for nonampullary duodenal high-grade dysplasia and intramucosal carcinoma

This study retrospectively analyzed the clinical outcomes of endoscopic resection of 26 sporadic (i. e., not associated with polyposis syndrome) nonampullary duodenal lesions representing high-grade dysplasia or intramucosal carcinoma (duodenal HGD/IMC) in 23 patients. No severe complications such as perforation were observed, but three cases of delayed bleeding were seen. The use of endoscopic clips significantly decreased the delayed bleeding rate (0/19, 0%) compared with cases in which clips were not used (3/7, 42.9%; P = 0.013, χ2 test). Eighteen lesions (69.2%) were removed by en bloc resection. The follow-up period after resection was 25.5 ± 23.3 months. Two lesions (7.7%) that recurred locally were detected at the first surveillance endoscopy 3 months after resection. These lesions were 22 and 15 mm in size respectively and were resected piecemeal. Endoscopic resection is an effective and safe procedure for treating duodenal HGD/IMC. En bloc resection and prophylactic clip usage are encouraged.

Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions

Endoscopic resection of large colorectal lesions is associated with high complication rates. To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. Retrospective study. Tertiary referral center. Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. Delayed hemorrhage, postpolypectomy syndrome, and perforation. There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. Retrospective design. Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted.

Prophylactic Clip Application Before Endoscopic Resection of Large Pedunculated Colorectal Polyps in Patients Receiving Anticoagulation or Antiplatelet Medications

The aim of the present study was to evaluate the safety of prophylactic endoclipping before resection of large pedunculated colorectal polyps in patients with uninterrupted anticoagulation or antiplatelet therapy. In a single tertiary referral center, patients with normal coagulation parameters and those with uninterrupted anticoagulation or antiplatelet medications, who underwent prophylactic endoclipping before resection of large pedunculated colorectal polyps (polyp's head diameter >10 mm), were evaluated retrospectively. Demographic, clinical, and laboratory parameters, polyp characteristics, number of clips used for endoclipping, histology of resected polyps, the polypectomy technique, and postpolypectomy complications were recorded and compared. In 64 patients with large pedunculated colorectal polyps, successful endoclipping before resection was achieved. Eleven patients (17.2%) had uninterrupted anticoagulation (n = 4) or antiplatelet (n = 7) medications. Statistical analysis showed no significant differences in age, sex, indications for colonoscopy, location of polyps, size of polyp head or stalk, coexisting small polyps, histology of resected polyps, and polypectomy techniques among patients with normal coagulation parameters (group A) and patients on uninterrupted anticoagulant or antiplatelet treatment (group B). Coronary artery disease, hypertension, and atrial fibrillation were significantly more prevalent in group B. No immediate or delayed postpolypectomy hemorrhage occurred in either group. One patient (1.9%) in group A developed postpolypectomy coagulation syndrome and was successfully treated conservatively. Follow-up evaluation demonstrated no recurrence of polyps or cancer development. According to our experience, uncomplicated polypectomy of large pedunculated colorectal polyps can be performed by prophylactic endoclipping in patients receiving anticoagulation or antiplatelet medications.

Prophylactic Clip Application after Polypectomy of Large Colon Polyps

Prophylactic Clip Application after Polypectomy of Large Colon Polyps

Risk Factors for Delayed Bleeding After Endoscopic Resection for Large Colorectal Tumors

Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures. This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection. The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04). Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.

Su1481 Large Sessile Colorectal Polyps: Reduction in Delayed Bleeding With Prophylactic Clipping

Resection of large (≥ 2cm) sessile colorectal polyps is associated with an increased risk of complications. We performed a retrospective assessment of the impact of prophylactic closure of polypectomy sites using Microvasive Resolution clips. There were 537 sessile colorectal polyps ≥ 2cm in size removed from 482 patients. We successfully completed follow up for complications by telephone after 30 days for 474 polyps. Mean age of the 420 patients with complete follow up was 67.4 years, mean polyp size 32.3mm, and 253 polyps were ≥ 3cm in size.

Su1289 Efficacy of Bowel Preparation With the Use of a General Diet Versus a Clear Liquid Diet With Polyethylene Glycol Electrolyte Solution

in a structured colonoscopy report with well-defined fields to capture all the data. Main Outcome Measurements: We analyzed the synchronous polyp burden rate in patients with 1cm polyps. Results: 137 patients were found to have 185 polyps measuring 1cm during 155 colonoscopies. Mean age: 61.23; SexMen : Women: 68:69; BMI: 27.1. Caucasians: 115 (83.9%); History of abdominal surgery: 85 (62%). Colonoscopy: 155 colonoscopies were performed in total (index endoscopy followup endoscopy within 6 months). Indication (n 155): Screening: 55; Surveillance of polyps: 51; Symptoms: 14; Referral for EMR: 35; Boston Bowel Preparation Scale: 8.95 0.37 EMR of 1 cm polyp: Size: 1-2cm: 140; 2cm: 45; Paris Classification of 1 cm polyps: Documented in the last 82 of 185 polyps: 0-IIa:72%; 0-IIb: 1.2%; 0-Is: 18.3%; 0-Ip: 8.5%. En-bloc EMR: 83.2% of lesions. APC of the edges: 51% of EMR defects; Prophylactic clip closure: 84.9% of EMR defects. Complications: Perforation: 0; Bleeding: 4 (2 required clip hemostasis). Local recurrence: 1 (tubular adenoma). Nature of pathology of 1cm polyp: Majority are serrated adenomas and tubular adenomas. See table 1. Synchronous Polyp Burden in patients with 1cm polyp : Majority are tubular adenomas, with a total adenoma burden per patient of 3.71. See table 2. Conclusions: Patients with large colon polyps are associated with a high polyp burden. Hence, it is critical to clear the colon of all the polyps in addition to confirming complete eradication of the large polyp after the EMR to prevent colon cancer in this high risk group.

Endoscopic Mucosal Resection: Not Your Father's Polypectomy Anymore

Endoscopic mucosal resection (EMR) is a continuously evolving technique that has revolutionized the diagnosis, staging, and treatment of superficial neoplasms throughout the digestive tract. As a minimally invasive technique, it offers an alternative to operative resection and mucosal ablation. For neoplasms limited to the mucosa, EMR compares equivalently with operative resection for R0 status (no residual neoplasia) and favorably for morbidity and mortality. In contrast with mucosal ablation, EMR delivers a more precise and predictable depth of tissue effect and, most important, provides the resected specimen for histopathologic analysis. EMR was pioneered in Eastern Asia as a technique for resection of early gastric cancers. Incrementally, the tools and techniques for EMR have evolved to be employed around the globe for eradication of superficial lesions throughout the esophagus, stomach, small bowel, and colon. Owing to improvements in endoscopic detection and recognition, more sessile, flat, depressed, and even subepithelial lesions are being identified for which endoscopic resection is being adopted. Moreover, the implementation of surveillance strategies for various gastrointestinal conditions, such as Barrett’s esophagus, has fostered image guided detection and eradication of premalignant and early malignant lesions, incorporating EMR for diagnosis, staging, and therapy. This review focuses on the techniques, applications, and limitations of EMR for lesions throughout the digestive tract.

525 Comparison of Prophylactic Clip and Detachable Snare for the Prevention of Postpolypectomy Bleeding for the Large Pedunculated Colonic Polyps: A Prospective, Randomized Study

Ethnicity White Black Hispanic Asian American Indian Other Unknown 1685 (82.64%) 157 (7.70%) 136 (6.67%) 34 (1.67%) 21 (1.03%) 5 (0.25%) 1 (0.05%) ASA Class I II III IV Unknown 197 (9.66%) 1128 (55.32%) 541 (26.53%) 43 (2.11%) 130 (6.38%) Warfarin Use Yes No 250 (12.26%) 1789 (87.74%) Procedure Setting Inpatient Outpatient Unknown 554 (27.17%) 1183 (58.02%) 302 (14.81%) Practice Type Community Academic VA 1423 (69.79%) 272 (13.34%) 344 (16.87%) Fellow Involvement Yes No 484 (23.74%) 1555 (76.26%) Prep Quality Excellent Good Fair Poor Unknown 420 (20.60%) 723 (35.46%) 429 (21.04%) 187 (9.17%) 280 (13.73%) Cecum Intubated (Missing 17) Yes 1919 (94.11%) No 120 (5.89%) TI Intubated (Missing 17) Yes 699 (34.28%) No 1340 (65.72%)

The Role of Prophylactic Clips in Endoscopic Mucosal Resection (EMR)

Background: Endoscopic clips are a commonly used therapy for haemorrhage and perforation associated with polypectomy, including EMR. The benefit of their prophylactic use in closing mucosal defects & preventing these complications remains uncertain. Aim: To study the complication rates in patients receiving prophylactic clips to close mucosal defects following EMR. Methods: A retrospective review of 39 EMR procedures performed in 30 patients who received prophylactic clips between 6/10/06 - 3/11/08 was undertaken.

Predictors of Failure and Complications in Extracolonic Endoscopic Mucosal Resection (EMR)

Background: EMR is an endoscopic technique developed for removal of sessile neoplasms confined to superficial layers of the GI tract. Determinants as to what factors predict failure (i.e. residual disease) at follow-up endoscopy for extracolonic EMRs are based on relatively small series in the U.S. The aim of this study is to identify risk factors for failure in esophageal, stomach and duodenal mucosal resections. Methods: The following information was collected from 125 lesions in patients undergoing EMR from June, 1999 to July, 2008 in this retrospective study: patient age, patient sex, endoscopist, prior biopsy, lesion site, lesion size, injection fluid, lifting sign, EMR method, supplemental methods, prophylactic clips, specimen, EMR failure as assessed at follow-up endoscopy, and complications.

Risk Factors for Delayed Bleeding After Endoscopic Resection for Large Colorectal Tumors

Background: Techniques of Endoscopic Resection (ER) have been advanced recently so that large colorectal tumors can be treated endoscopically. We sometimes experienced delayed bleeding after ER. Only a few reports, however, have described the risk factors for delayed bleeding. Aim: To clarify the risk factors for delayed bleeding after ER for large colorectal tumors larger than 20 mm in diameter. Methods: ER (standard polypectomy, en-bloc EMR and piecemeal EMR) was performed on 405 colorectal tumors larger than 20 mm in diameter at the National Cancer Center Hospital, Tokyo from January 2003 to December 2006. Delayed bleeding was defined as clinical evidence of bleeding manifested by melena or hematochezia within 0 to 14 days after the procedure and requiring endoscopic hemostasis. Risk factors for delayed bleeding were retrospectively assessed among clinicopathological features (age, gender, tumor location, size, macroscopic type, final histopathological result, method of resection and application of prophylactic clip or not). Results: The overall rate of delayed bleeding was 4.2% (17/405). The mean interval between the time of ER and delayed bleeding was 4.0 ± 3.8 days (range 1-14 days). All delayed bleeding was successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without surgical intervention or blood transfusion. The incidence of delayed bleeding in each group was as follows; age (<70 vs.≥70) ; 4.4% vs. 3.8%, gender (M vs. F) ; 5.9% vs. 1.3%, tumor location (cecum/colon vs. rectum) ; 3.9% vs. 5.2%, size (<29 mm vs. ≥30 mm) ; 3.2% vs. 6.1%, macroscopic type (polypoid/sessile vs. LST) ; 2.7% vs. 5.4%, final histopathological result (adenoma vs. carcinoma) ; 3.8% vs. 4.4%, method of resection (En-bloc resection vs. piecemeal resection) ; 3.1% vs. 5.2%, prophylactic clip (using vs. not using) ; 1.7% vs. 6.1%. By univariate analysis, delayed bleeding rate was significantly higher in male (p = 0.037) and the group without prophylactic clip placement (p = 0.043). Conclusion: The results of this study indicated that male patients and patients without prophylactic clip placement had significantly higher incidence of delayed bleeding after endoscopic treatments for large colorectal tumors.