Prophylactic Clipping Using the Over-the-scope Clip (OTSC) System After Complex ESD and EMR of Large Colon Polyps

Overview

Journal Surg Endosc

Publisher Springer

Specialties Gastroenterology
General Surgery
Radiology

Date 2023 Jul 7

PMID 37418148

Authors

T Blasberg

J Hochberger

M Meiborg

C Jung

M Weber

T Brunk

L Leifeld

A Seif Amir Hosseini

E Wedi

Affiliations

Soon will be listed here.

Abstract

Background: Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps.

Methods: This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding.

Results: A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%.

Conclusions: The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.

Citing Articles

Unique closure of large colonic endoscopic submucosal dissection defect using zigzag clip with line pulley securing technique.

Ono K, Ohata K, Kimoto Y, Takeuchi N, Kano Y, Minato Y VideoGIE. 2025; 10(1):51-53.

PMID: 39925399 PMC: 11806421. DOI: 10.1016/j.vgie.2024.09.002.

Closure methods for large defects after gastrointestinal endoscopic submucosal dissection.

Gong R, Wang S, Song J, He Z, Li P, Zhang S J Gastroenterol Hepatol. 2024; 39(12):2511-2521.

PMID: 39175260 PMC: 11660212. DOI: 10.1111/jgh.16722.

References

Jayanna M, Burgess N, Singh R, Hourigan L, Brown G, Zanati S . Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions. Clin Gastroenterol Hepatol. 2015; 14(2):271-8.e1-2. DOI: 10.1016/j.cgh.2015.08.037. View

Ahlenstiel G, Hourigan L, Brown G, Zanati S, Williams S, Singh R . Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc. 2014; 80(4):668-676. DOI: 10.1016/j.gie.2014.04.015. View

Hassan C, Repici A, Sharma P, Correale L, Zullo A, Bretthauer M . Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut. 2015; 65(5):806-20. DOI: 10.1136/gutjnl-2014-308481. View

Peery A, Shaheen N, Cools K, Baron T, Koruda M, Galanko J . Morbidity and mortality after surgery for nonmalignant colorectal polyps. Gastrointest Endosc. 2017; 87(1):243-250.e2. PMC: 5634910. DOI: 10.1016/j.gie.2017.03.1550. View

Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau J, Paspatis G . Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017; 49(3):270-297. DOI: 10.1055/s-0043-102569. View

Burgess N, Metz A, Williams S, Singh R, Tam W, Hourigan L . Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol. 2013; 12(4):651-61.e1-3. DOI: 10.1016/j.cgh.2013.09.049. View

Albeniz E, Fraile M, Ibanez B, Alonso-Aguirre P, Martinez-Ares D, Soto S . A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions. Clin Gastroenterol Hepatol. 2016; 14(8):1140-7. DOI: 10.1016/j.cgh.2016.03.021. View

Buchner A, Guarner-Argente C, Ginsberg G . Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center. Gastrointest Endosc. 2012; 76(2):255-63. DOI: 10.1016/j.gie.2012.02.060. View

Liaquat H, Rohn E, Rex D . Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions. Gastrointest Endosc. 2013; 77(3):401-7. DOI: 10.1016/j.gie.2012.10.024. View

10.

Metz A, Bourke M, Moss A, Williams S, Swan M, Byth K . Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions. Endoscopy. 2011; 43(6):506-11. DOI: 10.1055/s-0030-1256346. View

11.

Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A . Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015; 47(9):829-54. DOI: 10.1055/s-0034-1392882. View

12.

Saito Y, Uraoka T, Yamaguchi Y, Hotta K, Sakamoto N, Ikematsu H . A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc. 2010; 72(6):1217-25. DOI: 10.1016/j.gie.2010.08.004. View

13.

Nakajima T, Saito Y, Tanaka S, Iishi H, Kudo S, Ikematsu H . Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc. 2013; 27(9):3262-70. DOI: 10.1007/s00464-013-2903-x. View

14.

Oka S, Tanaka S, Kanao H, Ishikawa H, Watanabe T, Igarashi M . Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan. Dig Endosc. 2010; 22(4):376-80. DOI: 10.1111/j.1443-1661.2010.01016.x. View

15.

Buddingh K, Herngreen T, Haringsma J, van der Zwet W, Vleggaar F, Breumelhof R . Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case-control study. Am J Gastroenterol. 2011; 106(6):1119-24. DOI: 10.1038/ajg.2010.507. View

16.

Inoue T, Ishihara R, Nishida T, Akasaka T, Hayashi Y, Nakamatsu D . Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial. J Gastroenterol Hepatol. 2020; 36(2):383-390. DOI: 10.1111/jgh.15134. View

17.

Pohl H, Grimm I, Moyer M, Hasan M, Pleskow D, Elmunzer B . Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial. Gastroenterology. 2019; 157(4):977-984.e3. PMC: 8224988. DOI: 10.1053/j.gastro.2019.03.019. View

18.

Albeniz E, Alvarez M, Espinos J, Nogales O, Guarner C, Alonso P . Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding. Gastroenterology. 2019; 157(5):1213-1221.e4. DOI: 10.1053/j.gastro.2019.07.037. View

19.

Yamamoto K, Shimoda R, Ogata S, Hara M, Ito Y, Tominaga N . Perforation and Postoperative Bleeding Associated with Endoscopic Submucosal Dissection in Colorectal Tumors: An Analysis of 398 Lesions Treated in Saga, Japan. Intern Med. 2018; 57(15):2115-2122. PMC: 6120842. DOI: 10.2169/internalmedicine.9186-17. View

20.

Miyakawa A, Kuwai T, Sakuma Y, Kubota M, Nakamura A, Itobayashi E . The efficacy of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection on delayed bleeding. Scand J Gastroenterol. 2021; 56(10):1236-1242. DOI: 10.1080/00365521.2021.1953129. View