April 19, 2022

Bleeding complications after endoscopic mucosal resection (EMR) of large colorectal lesions are common and are frequently associated with unplanned hospital admissions, blood transfusions and the need for additional interventions. The use of prophylactic clip closure of the mucosal defect after EMR is one option being studied to address this problem. However, multiple recent studies show that this approach has not been universally effective. According to Norio Fukami, M.D., identifying which patients would benefit most from prophylactic clipping would be a helpful development for clinicians performing EMR. Dr. Fukami is a therapeutic endoscopist and researcher at Mayo Clinic in Arizona.

In a commentary published in The Lancet Gastroenterology & Hepatology in 2022, Dr. Fukami and Mayo Clinic gastroenterology fellow Sonmoon Mohapatra, M.B.B.S., describe approaches to prevent post-EMR bleeding and analyze the findings of a single-center randomized control trial co-authored by Dr. Gupta and colleagues. The trial results, published in the same issue of The Lancet Gastroenterology & Hepatology, examined the use of prophylactic clip placement for clinically significant post-EMR bleeding in the right colon. The following Q&A summarizes some of the key points that Drs. Fukami and Mohapatra share in their commentary.

What clarification do the study results published by Dr. Gupta and colleagues provide about risk of post-EMR bleeding in patients treated with prophylactic clip closure?

The well-designed, randomized controlled trial focused on the effect of clip closure after EMR for large (2 cm or more) nonpolypoid lesions in the right colon. The median size of included lesions was larger than that in other trials (40 mm versus 30 mm). This trial demonstrated that the risk of post-EMR bleeding was significantly lower in the group treated using clips compared with the control group (3.4% versus 10.6%).

What did the researchers learn about the average of number clips used, factors associated with the highest risk of post-procedure bleeding and the effectiveness of clip closure in reducing procedure-related bleeding?

Investigators noted that the median number of clips used was five. In the control group, bleeding risk was highest in the cecum (19%) compared with the risk of bleeding occurring within the rest of the right colon (3%). The researchers observed that clip closure reduced the risk of bleeding in the cecum by 14.7%.

Significant risk factors for post-EMR bleeding included absence of clipping and bleeding occurring in the cecum. The timing of post-procedure bleeding for the control group and the clip group did not differ. Post-EMR bleeding was higher in the study participants who were on anticoagulants compared with participants who were not. Risk of post-EMR bleeding in this subgroup of participants on anticoagulants was further reduced by clipping.

What did the study data show about lesion size and clip efficacy?

The investigators demonstrated the benefit of complete closure of large EMR defects, especially those in the right colon. They concluded that the benefit of clip closure is greatest for EMR defects that are 20 to 39 mm in size and among defects located within cecum. In patients with defects of that size, complete clip closure was achieved in 86% and partial closure was achieved in 12%. No patients in whom complete or partial closure was achieved experienced post-EMR bleeding.

Overall, the ability to achieve complete or partial closure decreased as lesion size increased beyond 39 mm. As closure technique improves and as new devices to facilitate closure are used, we believe that endoscopists can achieve adequate closure rates in patients with larger lesions, especially in patients with high-risk conditions. The level of risk reduction achieved in these patients with lesions beyond 39 mm should be similar to that seen in patients with lesions of 20 to 39 mm.

What impact do you expect the use of prophylactic clip closure have on procedure cost?

Table: Summary of outcomes of multiple published prospective randomized control trials

Prophylactic use of a greater number of clips for high-quality closure can increase procedural costs. However, the accumulated high-level evidence demonstrates that the use of this approach to achieve complete closure of large defects may reduce the number of hospital admissions and the need for subsequent interventions, thus reducing overall costs associated with the removal of large colorectal lesions in the right colon.

The table summarizes outcomes of multiple published prospective randomized control trials examining the use of clip closure in EMR.

For more information

Gupta S, et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: A single-centre, randomised controlled trial. The Lancet. Gastroenterology & Hepatology. 2022;2:152.

Mohapatra S, et al. Prevention of bleeding after EMR of colorectal lesions: When and how? The Lancet. Gastroenterology & Hepatology. 2022;2:109.

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