Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study
submitted 12 November 2013
accepted after revision 11 March 2014
15 May 2014 (eFirst)
Background and study aims: The effectiveness of the prophylactic clip for the prevention of postpolypectomy bleeding in pedunculated colonic polyps has not been confirmed. The aim of this prospective, randomized study was to compare the efficacy of prophylactic clip and endoloop application in the prevention of postpolypectomy bleeding in large pedunculated polyps.
Patients and methods: A total of 195 patients who had pedunculated colorectal polyps, with heads ≥ 10 mm and stalks ≥ 5 mm in diameter, were included in the study between July 2010 and January 2013. Polyps were randomized to receive either clips or endoloops. Both devices were applied to the base of the stalk before conventional snare polypectomy. Bleeding complications were analyzed with a noninferiority margin of 5 %.
Results: A total of 203 polyps were included in the study (98 in the clip group and 105 in the endoloop group). Bleeding occurred after five polypectomies in the clip group (5.1 %) and after six in the endoloop group (5.7 %) (P = 0.847). Noninferiority of the prophylactic clip to the endoloop could not be confirmed (absolute bleeding rate difference – 0.6 %, 95 % confidence interval – 5.6 % to 6.8 %) due to small sample size. Immediate bleeding episodes occurred in 4/5 polyps in the clip group and 5/6 polyps in the endoloop group. Delayed bleeding occurred in one polyp in each group.
Conclusions: These results suggest that the application of a prophylactic clip is as effective and safe as an endoloop in the prevention of postpolypectomy bleeding in large pedunculated colonic polyps.
Clinical trial registration: ClinicalTrials.gov (NCT01406379)
- 1 Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
- 2 Mandel JS, Church TR, Bond JH et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 2000; 343: 1603-1607
- 3 Winawer SJ, Zauber AG, O’Brien MJ et al. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med 1993; 328: 901-906
- 4 Fatima H, Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 2007; 17: 145-156
- 5 Sorbi D, Norton I, Conio M et al. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 2000; 51: 690-696
- 6 Dominitz JA, Eisen GM, Baron TH et al. Complications of colonoscopy. Gastrointest Endosc 2003; 57: 441-445
- 7 Di Giorgio P, De Luca L, Calcagno G et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy 2004; 36: 860-863
- 8 Dobrowolski S, Dobosz M, Babicki A et al. Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 2004; 18: 990-993
- 9 Iishi H, Tatsuta M, Narahara H et al. Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc 1996; 44: 594-597
- 10 Paspatis GA, Paraskeva K, Theodoropoulou A et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 2006; 101: 2805 ; quiz 2913
- 11 Rohde H, Guenther MW, Budde R et al. Randomized trial of prophylactic epinephrine-saline injection before snare polypectomy to prevent bleeding. Endoscopy 2000; 32: 1004-1005
- 12 Kim HS, Kim TI, Kim WH et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 2006; 101: 1333-1341
- 13 Dobrowolski S, Dobosz M, Babicki A et al. Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy. Gastrointest Endosc 2006; 63: 1004-1009
- 14 Hsieh YH, Lin HJ, Tseng GY et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology 2001; 48: 1379-1382
- 15 Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc 1991; 5: 70-74
- 16 Cariani G, Di Marco M, Roda E. Endoloop-assisted polypectomy for large pedunculated colorectal polyps. Surg Endosc 2007; 21: 1676-1677
- 17 Iida Y, Miura S, Munemoto Y et al. Endoscopic resection of large colorectal polyps using a clipping method. Dis Colon Rectum 1994; 37: 179-180
- 18 Katsinelos P, Chatzimavroudis G, Papaziogas B et al. Endoclipping-assisted resection of large colorectal polyps. Surg Laparosc Endosc Percutan Tech 2008; 18: 19-23
- 19 Luigiano C, Ferrara F, Ghersi S et al. Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome. Dig Dis Sci 2010; 55: 1726-1731
- 20 Kouklakis G, Mpoumponaris A, Gatopoulou A et al. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 2009; 23: 2732-2737
- 21 Katsinelos P, Kountouras J, Paroutoglou G et al. Endoloop-assisted polypectomy for large pedunculated colorectal polyps. Surg Endosc 2006; 20: 1257-1261