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Predicting Complete Closure of EMR Sites

Douglas K. Rex, MD, MASGE, reviewing Ortiz O, et al. Endoscopy 2020 Dec 8.

Clip closure of endoscopic mucosal resection (EMR) defects ≥20 mm located proximal to the splenic flexure and removed by electrocautery is associated with a reduction in delayed hemorrhage. In two large studies, complete closure of the defect was associated with substantially lower risk compared to partial or no closure. 

In one of the large multicenter trials proving that closure reduces bleeding risk, factors associated with complete closure were examined. Complete clip closure, defined as no visible mucosal defect and clips placed less than 1 cm apart, was achieved in 68% of 494 lesions. Another 18% had partial closure, and 13% had no closure. 

Smaller lesion size was strongly associated with clip closure. Complete closure was achieved in 80% of 20- to 29-mm polyps, 70% of 30- to 39-mm polyps, and 42% of lesions ≥40 mm. In multivariable analysis, complete closure was also associated with better endoscopic access, complete submucosal lifting, en bloc resection, and serrated histology. Closure was not associated with the use of coagulation current versus Endo Cut to perform the resection, the type of injectate used (saline vs viscous), sessile versus flat morphology, endoscopist EMR volume, intraprocedural bleeding, or polyp location.

Douglas K. Rex, MD, FASGE

COMMENT

When prophylactic clip closure is performed, complete closure should be the goal. However, the factors described here that are associated with complete closure are largely nonmodifiable. In my experience, the dominant features that predict success in achieving complete closure are lesion size and the quality of endoscopic access. Now that closure is a proven concept, new approaches that are easy, less expensive, and effective to apply, such as new styles of clips, larger clips, and suturing studies, should be pursued.

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)

Ortiz O, Rex DK, Ian G, et al. Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps. Endoscopy 2020 Dec 8. (Epub ahead of print) (https://doi.org/10.1055/a-1332-6727)

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