Prophylactically clipping large proximal colorectal lesions after resection may reduce risk of postprocedural bleeding, according to a meta-analysis involving nine randomized controlled trials.
Across all lesions, prophylactic clipping had no significant benefit, but when considering only large proximal lesions, clipping reduced bleeding risk by 63%, reported lead author Marco Spadaccini, MD, of Humanitas University, Rozzano, Italy, and colleagues.
According to the investigators, these findings emphasize the relevance of polyp size and location when assessing bleeding risk, which may influence future clinical guidance.
“Despite lack of high-quality evidence, prophylactic clipping has been advocated as a technique to reduce the risk of postprocedural bleeding,” the investigators wrote in Gastroenterology, referring to the European Society of Gastrointestinal Endoscopy recommendation that is based on patient risk factors.
Although previous meta-analyses reported that prophylactic clipping had no protective effect, these studies were “at high risk of bias” and predominantly evaluated lesions less than 20 mm in diameter, the investigators wrote.
Dr. Spadaccini and colleagues suggested that data from more recent, high-quality, randomized controlled trials could be used to identify subgroups that may benefit from clipping. This knowledge is particularly valuable considering the “costs and technical complexity” involved in the procedure, they noted.
The present meta-analysis comprised nine trials that included 7,197 colorectal lesions, of which 49.2% were proximally located and 22.5% were large (at least 20 mm in diameter).
Across all lesions, postprocedural bleeding occurred in 2.2% of clipped lesions and 3.3% of nonclipped lesions, a difference that was not statistically significant (P = .072). But for lesions 20 mm or larger, clipping was associated with a significantly lower rate of bleeding (4.3% vs. 7.6%; relative risk, 0.51; 95% CI, 0.33-0.78; P = .020). Similarly, clipping in the proximal location was independently associated with reduced bleeding risk (3.0% vs. 6.2%; RR, 0.53; 95% CI, 0.35-0.81; P less than .001). A multilevel meta-regression added further clarity by combining both size and location; it showed that clipping had a significant protective effect for large proximal lesions (RR, 0.37; 95% CI, 0.22-0.61; P = .021), but not for those that were small and proximal (RR, 0.88; 95% CI, 0.48-1.62; P = .581).
“According to our meta-analysis, routine practice of endoscopic clipping as a prophylactic intervention does not reduce the risk of postpolypectomy bleeding,” the investigators wrote. “However, clipping was effective in reducing the risk of postprocedural bleeding by nearly 50% for large lesions. If such lesions do not undergo endoscopic clipping, there was fourfold increase in the baseline risk of post-procedural bleeding as compared with those less than 20 mm.”
While the present analysis suggested that clipping was beneficial only for large lesions in the proximal colon, the investigators noted that the protective effect of clipping large lesions in the distal colon (RR, 0.70; 95% CI, 0.22-2.27) was “somewhat intermediate ... albeit not statistically significant” and driven by data from one trial.
“[T]his was not confirmed by other studies generating some uncertainty on the benefit of prophylactic clipping for large distal lesions,” the investigators wrote. “Thus, the decision for large and distal lesions should be tailored, especially taking into consideration other patient- and polyp-risk factors for postprocedural bleeding, such as the use of anti-thrombotic agents or intraprocedural bleeding.”
In contrast, the findings indicated that clipping is unnecessary for lesions less than 20 mm, the investigators wrote.
They went on to explain that clinical application of these findings could result in “significant cost savings” because one bleeding event would be prevented for every 23 large lesions clipped.
“Considering that clips are expensive and their placement might be technically demanding, prophylactic clipping tailored for a subgroup of higher-risk lesions/patients would decrease in parallel both adverse events and costs,” the investigators concluded.
The investigators reported no external funding or conflicts of interest.
ginews@gastro.org
SOURCE: Spadaccini M et al. Gastroenterology. 2020 Apr 1. doi: 10.1053/j.gastro.2020.03.051.