PROPHYLACTIC CLIP PLACEMENT DURING POLYPECTOMY DOES NOT REDUCE THE RISK OF DELAYED BLEEDING: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

Background: Delayed gastrointestinal bleeding is a known complication of snare polypectomy during colonoscopy. Published data on prophylactic clip placement are scarce with conflicting results. Aim: To determine the effect of prophylactic clip placement on delayed post polypectomy bleeding. Methods: Three independent reviewers conducted a search of MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings using the following MeSH search terms: “polyp”, “bleeding”, “colonoscopy” and “clips”. Randomized and non-randomized studies that compared prophylactic clip placement with no clip placement were included. Pooled estimates of delayed post polypectomy bleeding, perforation and overall complications were analyzed by calculating odds ratio (OR) along with 95% confidence interval (CI). Random and fixed effects models were used as appropriate. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. Results: Initial search revealed 418 studies; of which 26 studies were reviewed. Eleven studies (including 4 randomized controlled trials) met the inclusion/exclusion criteria. The final analysis included 10,910 polypectomies in 13,308 patients. The rate of delayed post polypectomy bleeding was 1.27% with prophylactic clips placement vs. 0.97% without placement of clips (OR = 0.94; 95% CI: 0.4-2.24; p = 0.9; I2 71%). With inclusion of high quality studies (Newcastle-Ottawa scale score >6), there was a significant difference in delayed post polypectomy bleeding with clip placement (1.24% vs 3.26%; OR, 0.46, 95% CI: 0.21-1.00, p= 0.05; I2= 35%). The rate of perforation was 0.16% with prophylactic clip placement vs. 0.017% without placement of clips (OR = 1.45; 95% CI: 0.26-8.09; p = 0.7; I2 0%). Subgroup analysis showed that clip placement decreased risk of bleeding in polyps larger than 2 cm (2.2% vs. 7.98%, OR 0.25; 95% CI 0.12-0.51, p 6), there was a significant difference in delayed post polypectomy bleeding with clip placement (1.24% vs 3.26%; OR, 0.46, 95% CI: 0.21-1.00, p= 0.05; I2= 35%). The rate of perforation was 0.16% with prophylactic clip placement vs. 0.017% without placement of clips (OR = 1.45; 95% CI: 0.26-8.09; p = 0.7; I2 0%). Subgroup analysis showed that clip placement decreased risk of bleeding in polyps larger than 2 cm (2.2% vs. 7.98%, OR 0.25; 95% CI 0.12-0.51, p 2 cm and if they were removed with endoscopic mucosal resection and pure coagulation current.