Prophylactic Clipping After Colorectal Endoscopic Submucosal Dissection: Meta-analysis of Randomized Controlled Trials

Aims Endoscopic submucosal dissection (ESD) is an increasingly adopted treatment for large non-pedunculated colorectal polyps, offering a minimally invasive, potentially curative approach for early colorectal cancer while reducing recurrence risk. Despite these benefits, ESD carries a relevant risk of adverse events (AEs), particularly delayed bleeding (DB), which occurs in up to 9% of cases, as well as delayed perforation (DP) and post-electrocoagulation syndrome (PECS). These complications lead to extended hospital stays, higher healthcare costs, and additional interventions. A systematic closing approach may mitigate these risks, enabling safer outpatient management and reducing healthcare burdens. However, the preventive effect of this strategy remains uncertain. To address this, we conducted a systematic review and meta-analysis of all available randomized controlled trials (RCTs) to evaluate the benefits of prophylactic clipping after colorectal ESD.

Methods The study adhered to PRISMA guidelines and included RCTs published up to October 2024. A systematic literature search was conducted using PubMed, Embase, and SCOPUS, focusing on RCTs involving adults undergoing colorectal ESD. Eligible studies compared prophylactic clipping to no clipping. The primary outcome was the risk of DB, and secondary outcomes included the risks of DP and PECS. Statistical analyses were performed using R software with both fixed-effects and random-effects models to calculate risk ratios (RRs) and 95% confidence intervals (CIs). Heterogeneity was assessed using I² statistics. This study was funded by the AIRC IG Grant 2023 (GAIN Project) ì, No. 29220 [1] [2] [3].

Results The meta-analysis included four RCTs conducted in Asia, encompassing 684 patients (336 in the clipping group and 348 in the control group). Prophylactic clipping significantly reduced the risk of DB. The estimates of DB and severe DB risk were 6.95% (95% CI, 0.01–13.92) and 4.10% (95% CI, 0.95–7.26), vs 2.04% (95% CI, 0.01–4.06), and 0.89% (95% CI, -1.00–1.97), for control and clip groups, respectively. A significant difference between the 2 groups was noted for both DB and severe DB with a relative risk (RR) of 3.14 (95% CI, 1.61–6.16; p=<0.05) and 3.79 (95% CI, 1.13–12.68; p=<0.05), No significant differences were observed for DP (RR: 1.35, 95% CI: 0.42–4.28) or PECS (RR: 0.94, 95% CI: 0.65–1.35).

Conclusions Prophylactic clipping significantly reduces the risk of DB and severe DB after colorectal ESD, enabling safer outpatient ESD management, enhancing patient outcomes and reducing healthcare resource use. Although future research should identify patient subgroups that benefit most, these findings support adopting prophylactic clipping in clinical practice guidelines

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

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