Endoscopic characteristics influencing postpolypectomy bleeding in 1147 consecutive pedunculated colonic polyps: a multicenter retrospective study

Published:April 12, 2021DOI:https://doi.org/10.1016/j.gie.2021.03.996

      Background and Aims

      Postpolypectomy bleeding is the most common adverse event with pedunculated polyps. We clarified the endoscopic characteristics influencing postpolypectomy bleeding for pedunculated colonic polyps.

      Methods

      We reviewed clinical data for 1147 pedunculated colonic polyps removed by polypectomy in 5 Japanese institutions. Pedunculated polyps were defined as polyps with a stalk length ≥5 mm. Analyzed clinical data were age, sex, polyp location/size, stalk length/width, prophylactic clipping or endoloop before polypectomy, injecting the stalk, closing the polypectomy site, antithrombotic agent use, and endoscopist experience. Postpolypectomy bleeding was classified as immediate bleeding or delayed bleeding.

      Results

      Immediate and delayed bleeding was observed in 8.5% (97/1147) and 2% (23/1147) of polypectomies, respectively. Comparing immediate bleeding with nonbleeding, multivariate analysis showed that stalk width ≥6 mm (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.4) was a significant risk factor for immediate bleeding. For polyp size ≥15 mm, prophylactic endoloop use (OR, .17; 95% CI, .04-.72) was a significant inhibiting factor. Comparing delayed bleeding with nonbleeding, multivariate analysis showed that prophylactic clipping before polypectomy (OR, 4.2; 95% CI, 1.3-13) and injecting the stalk (OR, 4.0; 95% CI, 1.4-12) were significant risk factors for delayed bleeding.

      Conclusions

      The increased risk for delayed bleeding with injecting the stalk and prophylactic clipping before polypectomy suggests that simple resection with coagulation mode is a suitable strategy in endoscopic resection of pedunculated polyps. Moreover, prophylactic endoloop use was highly likely to inhibit immediate bleeding with polyp size ≥15 mm.

      Abbreviations:

      CI (confidence interval), OR (odds ratio), RCT (randomized controlled trial)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Winawer S.J.
        • Zauber A.G.
        • Ho M.N.
        • et al.
        Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
        N Engl J Med. 1993; 329: 1977-1981
        • Zauber A.G.
        • Winawer S.J.
        • O'Brien M.J.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • Provenzale D.
        • Jasperson K.
        • Ahnen D.J.
        • et al.
        Colorectal cancer screening, version 1.2015.
        J Natl Compr Canc Netw. 2015; 13 (quiz 68): 959-968
        • Kudo S.
        • Kashida H.
        • Tamura T.
        • et al.
        Colonoscopic diagnosis and management of nonpolypoid early colorectal cancer.
        World J Surg. 2000; 24: 1081-1090
        • 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
        • Rey J.F.
        • Marek T.A.
        Endo-loop in the prevention of the post-polypectomy bleeding: preliminary results.
        Gastrointest Endosc. 1997; 46: 387-389
        • Ji J.S.
        • Lee S.W.
        • Kim T.H.
        • et al.
        Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study.
        Endoscopy. 2014; 46: 598-604
        • Park Y.
        • Jeon T.J.
        • Park J.Y.
        • et al.
        Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps.
        J Gastroenterol Hepatol. 2015; 30: 1499-1506
        • 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
        • Soh J.S.
        • Seo M.
        • Kim K.J.
        Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding.
        BMC Gastroenterol. 2020; 20: 68
        • Gweon T.G.
        • Lee K.M.
        • Lee S.W.
        • et al.
        Effect of prophylactic clip application for the prevention of postpolypectomy bleeding of large pedunculated colonic polyps: a randomized controlled trial.
        Gastrointest Endosc. 2021; 94: 148-154
        • Tanaka S.
        • Kashida H.
        • Saito Y.
        • et al.
        JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection.
        Dig Endosc. 2015; 27: 417-434
        • Fujimoto K.
        • Fujishiro M.
        • Kato M.
        • et al.
        Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment.
        Dig Endosc. 2014; 26: 1-14
        • Watabe H.
        • Yamaji Y.
        • Okamoto M.
        • et al.
        Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors.
        Gastrointest Endosc. 2006; 64: 73-78
        • Choung B.S.
        • Kim S.H.
        • Ahn D.S.
        • et al.
        Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study.
        J Clin Gastroenterol. 2014; 48: 784-789
        • Rosen L.
        • Bub D.S.
        • Reed 3rd, J.F.
        • et al.
        Hemorrhage following colonoscopic polypectomy.
        Dis Colon Rectum. 1993; 36: 1126-1131
        • Liaquat H.
        • Rohn E.
        • Rex D.K.
        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: 401-407
        • Shioji K.
        • Suzuki Y.
        • Kobayashi M.
        • et al.
        Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy.
        Gastrointest Endosc. 2003; 57: 691-694
        • Matsumoto M.
        • Fukunaga S.
        • Saito Y.
        • et al.
        Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors.
        Jpn J Clin Oncol. 2012; 42: 1028-1034
        • Quintanilla E.
        • Castro J.L.
        • Rabago L.R.
        • et al.
        Is the use of prophylactic hemoclips in the endoscopic resection of large pedunculated polyps useful? A prospective and randomized study.
        J Interv Gastroenterol. 2012; 2: 99-104
        • 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
        • Kwon M.J.
        • Kim Y.S.
        • Bae S.I.
        • et al.
        Risk factors for delayed post-polypectomy bleeding.
        Intest Res. 2015; 13: 160-165
        • Dokoshi T.
        • Fujiya M.
        • Tanaka K.
        • et al.
        A randomized study on the effectiveness of prophylactic clipping during endoscopic resection of colon polyps for the prevention of delayed bleeding.
        Biomed Res Int. Epub 2015 Feb 3;
        • Rutter M.D.
        • Nickerson C.
        • Rees C.J.
        • et al.
        Risk factors for adverse events related to polypectomy in the English Bowel Cancer Screening Programme.
        Endoscopy. 2014; 46: 90-97
        • Fisher D.A.
        • Maple J.T.
        • Sharaf R.N.
        • et al.
        • ASGE Standards of Practice Committee
        Complications of colonoscopy.
        Gastrointest Endosc. 2011; 74: 745-752
        • Hsieh Y.H.
        • Lin H.J.
        • Tseng G.Y.
        • et al.
        Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study.
        Hepatogastroenterology. 2001; 48: 1379-1382
        • Park C.H.
        • Jung Y.S.
        • Nam E.
        • et al.
        Comparison of efficacy of prophylactic endoscopic therapies for postpolypectomy bleeding in the colorectum: a systematic review and network meta-analysis.
        Am J Gastroenterol. 2016; 111: 1230-1243
        • Shirai M.
        • Nakamura T.
        • Matsuura A.
        • et al.
        Safer colonoscopic polypectomy with local submucosal injection of hypertonic saline-epinephrine solution.
        Am J Gastroenterol. 1994; 89: 334-338
        • Tada Y.
        • Ohta Y.
        • Dohi T.
        • et al.
        Measurement of tissue water content of rat kidneys using bioelectrical impedance technique.
        Jpn J Artif Organs. 1993; 22: 999-1003
        • Uraoka T.
        • Ramberan H.
        • Matsuda T.
        • et al.
        Cold polypectomy techniques for diminutive polyps in the colorectum.
        Dig Endosc. 2014; 26: 98-103
        • Repici A.
        • Hassan C.
        • Vitetta E.
        • et al.
        Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study.
        Endoscopy. 2012; 44: 27-31
        • Kaltenbach T.
        • Anderson J.C.
        • Burke C.A.
        • et al.
        Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2020; 158: 1095-1129