Randomized Controlled Trial Confirms Clipping Is Effective in Prevention of Right-Sided Colon Bleeding After EMR With Electrocautery

Randomized Controlled Trial Confirms Clipping Is Effective in Prevention of Right-Sided Colon Bleeding After EMR With Electrocautery

Douglas K. Rex, MD, MASGE, reviewing Gupta S, et al. Lancet Gastroenterol Hepatol 2021 Nov 18.

Previous randomized controlled trials (RCTs) have indicated that prophylactic clip closure is effective in preventing delayed hemorrhage after EMR of colonic lesions that are ≥20 mm in size, proximal to the splenic flexure, and removed by electrocautery. 

In a new RCT from a single Australian center, 231 patients with lesions proximal to the mid-transverse colon were randomized to clip closure versus no closure. In the clip group, 89 patients (75%) underwent closure. Twenty patients were excluded for deep mural injury type 2 or 3, and 8 were excluded for defects that were too large. In the control arm, clip closure was not performed in 96 patients (85%), of whom 16 had type 2 or 3 muscle injury that necessitated focal clip placement. 

In the intention-to-treat analysis, delayed bleeding was reduced from 10.6% to 3.4% by clipping. The number needed to treat to prevent 1 episode of delayed hemorrhage was 13.9. In the per-protocol analysis, the incidence of delayed hemorrhage decreased from 9.4% to 1.1%. 

There were no bleeds from the transverse colon in either arm. The largest reduction occurred in lesions 20 to 39 mm in size (13% to 0%). For location, the greatest benefit was seen in the cecum, where there was a reduction in bleeding from 19% to 5%.

Douglas K. Rex, MD, FASGE

COMMENT

This RCT provides important confirmation of the principle of closure of EMR defects after use of electrocautery and indicates strong support for a trend seen previously, that the benefit is greatest the farther the lesion is toward the cecum. We need new reliable closure methods for lesions larger than 4 to 5 cm in all dimensions.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

CITATION(S)

Gupta S, Sidhu M, Shahidi N, 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. Lancet Gastroenterol Hepatol 2021 Nov 18. (Epub ahead of print) (https://doi.org/10.1016/s2468-1253(21)00384-8)

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