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Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials

      Background and Aims

      After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm.

      Methods

      We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses.

      Results

      From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of .31 (95% confidence interval [CI], .17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of .78 (95% CI, .17-3.54) and .67 (95% CI, .20-2.22), respectively.

      Conclusions

      Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon.

      Graphical abstract

      Abbreviations:

      AE (adverse event), CI (confidence interval), CSPEB (clinically significant post-EMR bleeding), GRADE (Grading of Recommendations Assessment, Development and Evaluation), IPD (individual patient data), LNPCP (large nonpedunculated colorectal polyp), OR (odds ratio), PPS (postpolypectomy syndrome), PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses), RCT (randomized controlled trial), RR (relative risk), UHU (unplanned healthcare utilization)
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      Linked Article

      • Prevention of clinically significant post-EMR bleeding: To clip or not to clip?
        Gastrointestinal EndoscopyVol. 96Issue 5
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          Endoscopic mucosal resection (EMR) is the existing standard of care for the management of large nonpedunculated colon polyps (LNPCPs), having a high safety and cost profile compared with other resection techniques such as endoscopic submucosal dissection and surgery.1 Adverse events (AEs) related to EMR include post-EMR bleeding, perforation, and postpolypectomy syndrome. Clinically significant post-EMR bleeding (CSPEB) occurs in 5% to 7.2% of cases and is more common in the right side of the colon.
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