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Reply to Fan et al.
27 November 2014 (online)
We read the Letter by Fan et al. with great interest and would like to respond to their concerns.
First, there is indeed a typographical error in Table 4. As pointed out by Fan et al., stalk diameter should be ≤ 10 mm and > 10 mm, and not ≤ 1.0 mm and > 1.0 mm, respectively, as shown. An erratum has been published in issue 9.[*]
As pointed out by Fan et al., different skill levels of endoscopists might influence the study outcome. Many aspects of colonoscopy procedures are operator dependent . Because our trial was a multicenter study, the skill levels of the colonoscopists and assistants differed between hospitals. However, performance of the procedure by only a few colonoscopy experts might limit the “generalizability” of the results. We believe that multicenter trials with several participating doctors, including expert colonoscopists and trainees, are necessary for the generalizability of the procedure to be determined.
Polypectomy without discontinuation of warfarin in anticoagulated patients increases the risk of postpolypectomy bleeding by approximately 10 % . According to previous papers, there is a significant increase in postpolypectomy bleeding rates among anticoagulated patients despite temporary cessation of warfarin   . In our study, three patients who experienced immediate bleeding were taking anticoagulant or antiplatelet therapy prior to colonoscopy. In the endoloop group, one patient was taking antiplatelet therapy. In the clip group, one patient was taking antiplatelet agents and the other was taking anticoagulant therapy. These patients were instructed to discontinue the use of these drugs at least 5 days before the polypectomy procedure and to restart these drugs if there was no hematochezia for 1 day after the procedure.
Regarding costs, Luigiano et al.  previously reported that endoloop-assisted polypectomy was less costly (€ 86.2 ± 23.1) compared with the endoclip-assisted technique (€ 297.3 ± 150.2). Higher procedural costs were related to the head size, stalk size, and to postpolypectomy bleeding in the endoclip-assisted polypectomy. In our study, the mean number of devices used was 1.5 clips and 1.0 endoloop. Usually the cost of an endoloop is one and a half times more than that of a clip. Therefore, the device costs were similar between the groups. As the number of clips used was related to polyp stalk diameter, the cost will increase in proportion to stalk diameter in the clip group. The procedural cost of polypectomy is also variable between countries. More investigation is required to determine the cost-effectiveness of these two devices.
As we mentioned in our paper, the data suggested that the prophylactic clip is as effective and safe as the endoloop, with a similarly low complication rate, for the prevention of postpolypectomy bleeding in large pedunculated colonic polyps. However, in our study, noninferiority of the prophylactic clip to the endoloop could not be confirmed because of the small sample size. In addition, even now, we do not know how effective the prophylactic clip is compared with no prophylactic treatment. Large-scale, randomized, controlled clinical trials are required to prove the effectiveness of prophylactic clips for the prevention of postpolypectomy bleeding in pedunculated colonic polyps.
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