Microsoft



Name of journal: World Journal of GastroenterologyManuscript NO: 45772Manuscript type: META-ANALYSISEffect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysisAyoub F et al. Prophylactic clipping following endoscopic mucosal resectionFares Ayoub, Donevan R Westerveld, Justin J Forde, Christopher E Forsmark, Peter V Draganov, Dennis YangFares Ayoub, Donevan R Westerveld, Justin J Forde, Department of Medicine, University of Florida, Gainesville, FL 32608, United StatesChristopher E Forsmark, Peter V Draganov, Dennis Yang, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States ORCID number: Fares Ayoub (0000-0001-8559-5477); Donevan R Westerveld (0000-0003-0906-7466); Justin J Forde (0000-0002-4645-6455); Christopher E Forsmark (0000-0002-2508-1543); Peter V Draganov (0000-0002-3922-0882); Dennis Yang (0000-0003-3038-4669).Author contributions: Ayoub F and Westerveld DR performed the literature search, performed data collection, performed quality assessment, drafted and revised manuscript; Forde JJ performed quality assessment and revised manuscript; Ayoub F performed statistical analysis; Yang D designed study, evaluated included studies, drafted and revised manuscript; Draganov PV, Forsmark CE provided critical input and revised manuscript. Conflict-of-interest statement: The authors declare that no conflict of interest exists. There are no financial or other competing interests for principal investigators, patients included or any member of the trial.PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: source: Invited ManuscriptCorresponding author: Dennis Yang, MD, Assistant Professor, Doctor, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Gainesville, FL 32608, United States. dennis.yang@medicine.ufl.eduTelephone: +1-352-2739474Fax: +1-352-6279002 Received: January 24, 2019Peer-review started: January 24, 2019First decision: March 14, 2019Revised: March 22, 2019Accepted: May 2, 2019 Article in press: May 3, 2019Published online: May 14, 2019AbstractBACKGROUNDThe role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes.AIMto conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm. METHODSWe performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using a random-effects model.RESULTSThirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies ((I2 = 0%, P = 0.67).CONLUSIONProphylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy. Key words: Meta-analysis; Clipping; Endoscopic resection; Endoscopic mucosal resection? The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.Core tip: The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes. We conducted a meta-analysis that included 7794 polyps in 1701 cases of endoscopic mucosal resection (EMR) and found that prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.Ayoub F, Westerveld DR, Forde JJ, Forsmark CE, Draganov PV, Yang D. Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis. World J Gastroenterol 2019; 25(18): 2251-2263URL: : has been shown to decrease the risk of death from colorectal cancer through the early identification and removal of pre-malignant or early stage cancerous lesionsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1056/NEJMoa1100370","ISBN":"1533-4406 (Electronic) 0028-4793 (Linking)","ISSN":"0028-4793","PMID":"22356322","abstract":"BACKGROUND: In the National Polyp Study (NPS), colorectal cancer was prevented by colonoscopic removal of adenomatous polyps. We evaluated the long-term effect of colonoscopic polypectomy in a study on mortality from colorectal cancer. METHODS: We included in this analysis all patients prospectively referred for initial colonoscopy (between 1980 and 1990) at NPS clinical centers who had polyps (adenomas and nonadenomas). The National Death Index was used to identify deaths and to determine the cause of death; follow-up time was as long as 23 years. Mortality from colorectal cancer among patients with adenomas removed was compared with the expected incidence-based mortality from colorectal cancer in the general population, as estimated from the Surveillance Epidemiology and End Results (SEER) Program, and with the observed mortality from colorectal cancer among patients with nonadenomatous polyps (internal control group). RESULTS: Among 2602 patients who had adenomas removed during participation in the study, after a median of 15.8 years, 1246 patients had died from any cause and 12 had died from colorectal cancer. Given an estimated 25.4 expected deaths from colorectal cancer in the general population, the standardized incidence-based mortality ratio was 0.47 (95% confidence interval [CI], 0.26 to 0.80) with colonoscopic polypectomy, suggesting a 53% reduction in mortality. Mortality from colorectal cancer was similar among patients with adenomas and those with nonadenomatous polyps during the first 10 years after polypectomy (relative risk, 1.2; 95% CI, 0.1 to 10.6). CONCLUSIONS: These findings support the hypothesis that colonoscopic removal of adenomatous polyps prevents death from colorectal cancer. (Funded by the National Cancer Institute and others.).","author":[{"dropping-particle":"","family":"Zauber","given":"Ann G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Winawer","given":"Sidney J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"O'Brien","given":"Michael J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lansdorp-Vogelaar","given":"Iris","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ballegooijen","given":"Marjolein","non-dropping-particle":"van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hankey","given":"Benjamin F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shi","given":"Weiji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bond","given":"John H.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schapiro","given":"Melvin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Panish","given":"Joel F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stewart","given":"Edward T.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Waye","given":"Jerome D.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"New England Journal of Medicine","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2012","2","23"]]},"page":"687-696","publisher":" Massachusetts Medical Society ","title":"Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths","type":"article-journal","volume":"366"},"uris":[""]}],"mendeley":{"formattedCitation":"^[1]","plainTextFormattedCitation":"[1]","previouslyFormattedCitation":"^[1]"},"properties":{"noteIndex":0},"schema":""}[1]. Endoscopic resection (ER) is the preferred first-line treatment for most of these superficial neoplasms and is associated with lower costs, morbidity, and mortality when compared to surgeryADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.cgh.2015.08.037","ISBN":"1542-3565","ISSN":"15427714","PMID":"26364679","abstract":"Background & Aims: Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However, many patients still undergo surgery. Endoscopic treatment may be more cost effective. We compared the costs of endoscopic versus surgical management of large LSL. Methods: We performed a prospective, observational, multicenter study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events, and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, and findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis-related group codes, were used to estimate average cost per patient. Results: EMR was performed on 1489 lesions (mean size, 36 mm) in 1353 patients (mean age, 67 years; 52.1% male). Total costs involved in the endoscopic management of large LSL were US $6,316,593 and total inpatient hospitalization length of stay was 1180 days. The total cost predicted for the surgical management group was US $16,601,502, with a total inpatient hospitalization length of stay of 4986 days. Endoscopic management produced a potential total cost saving of US $10,284,909; the mean cost difference per patient was US $7602 (95% confidence interval, $8458-$9220; P < .001). Inpatient hospitalization length of stay was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94; P < .001). Conclusions: In a large multicenter study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. , Number: NCT01368289.","author":[{"dropping-particle":"","family":"Jayanna","given":"Mahesh","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Burgess","given":"Nicholas G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Singh","given":"Rajvinder","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hourigan","given":"Luke F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"Gregor J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zanati","given":"Simon A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moss","given":"Alan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lim","given":"James","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sonson","given":"Rebecca","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Williams","given":"Stephen J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bourke","given":"Michael J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Clinical Gastroenterology and Hepatology","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2016","2","1"]]},"page":"271-278","publisher":"W.B. Saunders","title":"Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions","type":"article-journal","volume":"14"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.gie.2014.04.015","ISBN":"1097-6779","ISSN":"10976779","PMID":"24916925","abstract":"Background: EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of R20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited. Objective: To compare actual endoscopic with predicted surgical mortality. Design: Prospective, observational, multicenter cohort study. Setting: Academic, high-volume, tertiary-care referral center. Patients: Consecutive patients referred for EMR. Intervention: EMR. Main Outcome Measurements: To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity. Results: Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P<.0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003). Limitations: Nonrandomized study. Conclusion: In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.","author":[{"dropping-particle":"","family":"Ahlenstiel","given":"Golo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hourigan","given":"Luke F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Brown","given":"Gregor","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zanati","given":"Simon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Williams","given":"Stephen J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Singh","given":"Rajvinder","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moss","given":"Alan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sonson","given":"Rebecca","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bourke","given":"Michael J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-2","issue":"4","issued":{"date-parts":[["2014","10","1"]]},"page":"668-676","publisher":"Elsevier","title":"Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon","type":"article-journal","volume":"80"},"uris":[""]}],"mendeley":{"formattedCitation":"^[2,3]","plainTextFormattedCitation":"[2,3]","previouslyFormattedCitation":"^[2,3]"},"properties":{"noteIndex":0},"schema":""}[2,3]. Most colonic polyps are less than 10 mm and can be safely and effectively resected with conventional snare polypectomy. Conversely, larger lateral spreading lesions (LSLs) or sessile polyps, particularly those ≥ 20 mm in size, are usually removed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). While ESD continues to gain traction as an alternative for lesions with suspected superficial invasion or subtypes of non-granular LSLsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1055/s-0034-1392882","ISSN":"14388812","PMID":"26317585","abstract":"The aim of this evidence-based and consensus-based Guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE), is to provide caregivers with a comprehensive review of the clinical indications for endoscopic submucosal dissection (ESD) for the treatment of gastrointestinal superficial lesions, as well as guidance on post-ESD management and on technical details. Details on pathology and the definitions applied (Appendix 2) and recommendations on training (Appendix 3) are also provided.","author":[{"dropping-particle":"","family":"Pimentel-Nunes","given":"Pedro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dinis-Ribeiro","given":"Mário","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ponchon","given":"Thierry","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Repici","given":"Alessandro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vieth","given":"Michael","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ceglie","given":"Antonella","non-dropping-particle":"De","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Amato","given":"Arnaldo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Berr","given":"Frieder","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bhandari","given":"Pradeep","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bialek","given":"Andrzej","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Conio","given":"Massimo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haringsma","given":"Jelle","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Langner","given":"Cord","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Meisner","given":"Soren","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Messmann","given":"Helmut","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Morino","given":"Mario","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Neuhaus","given":"Horst","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Piessevaux","given":"Hubert","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rugge","given":"Massimo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saunders","given":"Brian P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Robaszkiewicz","given":"Michel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Seewald","given":"Stefan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kashin","given":"Sergey","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dumonceau","given":"Jean Marc","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hassan","given":"Cesare","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Deprez","given":"Pierre H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy","id":"ITEM-1","issue":"9","issued":{"date-parts":[["2015","8","28"]]},"page":"829-854","title":"Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline","type":"article-journal","volume":"47"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1111/den.12456","ISBN":"0915-5635","ISSN":"14431661","PMID":"25652022","abstract":"Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence-based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas. ? 2015 The Authors. Digestive Endoscopy ? 2015 Japan Gastroenterological Endoscopy Society.","author":[{"dropping-particle":"","family":"Tanaka","given":"Shinji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kashida","given":"Hiroshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saito","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yahagi","given":"Naohisa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yamano","given":"Hiroo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saito","given":"Shoichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hisabe","given":"Takashi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yao","given":"Takashi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"Masahiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yoshida","given":"Masahiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kudo","given":"Shin Ei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tsuruta","given":"Osamu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sugihara","given":"Ken Ichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"Toshiaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saitoh","given":"Yusuke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Igarashi","given":"Masahiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Toyonaga","given":"Takashi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ajioka","given":"Yoichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ichinose","given":"Masao","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsui","given":"Toshiyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sugita","given":"Akira","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sugano","given":"Kentaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujimoto","given":"Kazuma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tajiri","given":"Hisao","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Digestive Endoscopy","id":"ITEM-2","issue":"4","issued":{"date-parts":[["2015","5"]]},"page":"417-434","title":"JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection","type":"article-journal","volume":"27"},"uris":[""]}],"mendeley":{"formattedCitation":"^[4,5]","plainTextFormattedCitation":"[4,5]","previouslyFormattedCitation":"^[4,5]"},"properties":{"noteIndex":0},"schema":""}[4,5], its definitive role in Western clinical practice is yet to be defined. Hence, wide-field EMR remains the preferred therapy for large non-cancerous colorectal lesions. Bleeding is the most common adverse event following ER of colorectal lesions. Bleeding can be immediate (during the procedure) or delayed (post-operatively), and has been estimated to occur in 1%-6% of casesADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/BF02052261","ISBN":"0012-3706 (Print)\\n0012-3706 (Linking)","ISSN":"00123706","PMID":"8253009","abstract":"Clinically significant hemorrhage following colonoscopic polypectomy may occur primarily as the polyp is removed or manifest itself days to weeks later secondary to clot dissolution. The rate of hemorrhage following colonoscopic polypectomy ranges widely from 0.3 to 6.1 percent, depending on whether the data are derived from studies using the number of patients or number of polypectomies. A retrospective study was performed in our institution to study 4,721 patients who underwent polypectomy between January 1987 and December 1991. Twenty (0.4 percent) of these patients required hospital admission because of 9 primary and 11 delayed hemorrhages. Fifty-four polyps were removed from these patients: 11 in the right colon, 7 in the transverse colon, 17 in the descending colon, and 19 in the sigmoid colon. Eight polyps were 2 cm or larger, 10 were pedunculated, and 44 were sessile. Six patients underwent cauterization or resnaring of the bleeding polyp site, one patient underwent subtotal colectomy, and the remainder of the patients stopped bleeding spontaneously. Factors that could be associated with the outcome of hemorrhage include patient age, size, location, number and morphology of polyps (i.e., sessile or thick stalk), and use of anticoagulants. An experienced endoscopist with knowledge of electrosurgical and technical principles may be the most important factor for prevention of postpolypectomy bleeding.","author":[{"dropping-particle":"","family":"Rosen","given":"Les","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bub","given":"David S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Reed","given":"James F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nastasee","given":"Susan A.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Diseases of the Colon & Rectum","id":"ITEM-1","issue":"12","issued":{"date-parts":[["1993"]]},"page":"1126-1131","title":"Hemorrhage following colonoscopic polypectomy","type":"article-journal","volume":"36"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1007/BF02054448","ISSN":"00123706","PMID":"8674375","abstract":"PURPOSE: This study was undertaken to evaluate the incidence, diagnostic methods, and treatment of hemorrhage occurring after colonoscopic polypectomy.\\n\\nMETHODS: A retrospective chart review was conducted of 12,058 patients who underwent colonoscopy at an academic referral center between January 1989 and July 1993. Of these, 6,365 patients required polypectomies or biopsies.\\n\\nRESULTS: After these procedures, 13 patients (0.2 percent) developed lower gastrointestinal hemorrhage requiring hospitalization. All bleeding episodes occurred within 12 days of polypectomy or biopsy (mean = 8 days). Twelve patients (92 percent) underwent technetium-tagged red blood cell scintigraphy, which localized bleeding in four patients (31 percent). In the eight patients with normal scintigrams, hemorrhage did not recur, and no further evaluation was performed. Five patients (38 percent) underwent arteriography. Arteriogram was positive in two of four patients with positive scintigrams, and bleeding was controlled with selective vasopressin infusion. The fifth patient had arteriography without prior diagnostic studies because of massive hemorrhage; the bleeding site was identified and controlled with selective vasopressin infusion. Three patients had lower gastrointestinal endoscopy, with endoscopic identification of bleeding site in two patients, and endoscopic electrocautery controlled the bleeding in one patient. In the 13 patients with hemorrhage, cessation of bleeding occurred with intestinal rest and hydration in nine patients (69 percent), selective vasopressin infusion in three patients (23 percent), and endoscopic electrocautery in one patient (8 percent). Eight patients (62 percent) required blood transfusion with a mean of 4.8 units (excluding one patient on warfarin sodium who required 14 units of blood). No patient required surgical intervention.\\n\\nCONCLUSIONS: Incidence of hemorrhage after colonoscopic polypectomy or biopsy is low, and in our series, hemorrhage resolved without the need for surgical intervention. Management includes initial stabilization followed by diagnostic evaluation. Technetium-tagged red blood cell nuclear scintigraphy identifies ongoing bleeding and identifies patients in whom additional invasive procedures (arteriography lower gastrointestinal tract endoscopy) are warranted.","author":[{"dropping-particle":"","family":"Gibbs","given":"David H.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Opelka","given":"Frank G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Beck","given":"David E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hicks","given":"Terry C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Timmcke","given":"Alan E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gathright","given":"J. Byron","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Diseases of the Colon and Rectum","id":"ITEM-2","issue":"7","issued":{"date-parts":[["1996"]]},"page":"806-810","title":"Postpolypectomy colonic hemorrhage","type":"article-journal","volume":"39"},"uris":[""]}],"mendeley":{"formattedCitation":"^[6,7]","plainTextFormattedCitation":"[6,7]","previouslyFormattedCitation":"^[6,7]"},"properties":{"noteIndex":0},"schema":""}[6,7]. In the absence of coagulopathy, the risk of delayed polypectomy bleeding (DPB) is nearly negligible for the resection of small polyps < 10 mm. Conversely, the incidence of DPB increases with polyp sizeADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1055/s-2007-966959","ISBN":"2005915467","ISSN":"0013726X","PMID":"18253906","abstract":"Background and study aims: Postpolypectomy bleeding is a rare but serious adverse event. The aim of this study was to identify factors associated with the risk of severe delayed postpolypectomy bleeding. Patients and methods: This was a case-control study, comparing cases who developed hematochezia and required medical evaluation 6 hours to 14 days after colonoscopic polypectomy, and control patients who underwent polypectomy without delayed bleeding, and who were selected in approximately a 3 : 1 ratio. The following risk factors were specified a priori: resuming anticoagulation (within 1 week following polypectomy), aspirin use, hypertension, and polyp diameter. Results: Of the 4592 patients who underwent colonoscopy with polypectomy, 41 patients (0.9 %) developed delayed postpolypectomy bleeding (cases), and 132 patients were selected as controls. The mean age was 64.3 years for cases and 65.4 years for controls. Cases presented on average 6 days after polypectomy (range 1 - 14 days), and 48 % required blood transfusion (average 4.2 units, range 0 - 17). Two patients required surgery. Anticoagulation was resumed following polypectomy in 34 % of cases compared with 9 % of controls (OR 5.2; 95 % CI 2.2 - 12.5; P < 0.001). For every 1 mm increase in polyp diameter, the risk of hemorrhage increased by 9 % (OR 1.09; 95 % CI 1.0 - 1.2; P = 0.008). Hypertension (OR 1.1) and aspirin use (OR 1.1) did not increase the risk of postpolypectomy bleeding. In exploratory analysis, diabetes (OR 2.5) and coronary artery disease (OR 3.0) were associated with postpolypectomy hemorrhage, but the association was no longer statistically significant once adjusted for the use of anticoagulation. Conclusions: Resuming anticoagulation following polypectomy and polyp diameter were strongly associated with increased risk of severe delayed postpolypectomy bleeding.","author":[{"dropping-particle":"","family":"Sawhney","given":"M. S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Salfiti","given":"N.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nelson","given":"D. B.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lederle","given":"F. A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bond","given":"J. H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2008"]]},"page":"115-119","title":"Risk factors for severe delayed postpolypectomy bleeding","type":"article-journal","volume":"40"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1371/journal.pone.0108290","ISBN":"1932-6203 (Electronic)\\r1932-6203 (Linking)","ISSN":"19326203","PMID":"25271734","abstract":"BACKGROUND AND AIM: Delayed colonic postpolypectomy bleeding is the commonest serious complication after polypectomy. This study aimed to utilize massive sampling data of polypectomy to analyze risk factors for delayed postpolypectomy bleeding.\\n\\nPATIENTS AND METHODS: The endoscopic data of 5600 patients with 15553 polyps removed (2005 to 2013) were analyzed retrospectively through univariate analysis and multiple logistic regression analysis to evaluate the risk factors for delayed bleeding.\\n\\nRESULTS: Delayed postpolypectomy bleeding occurred in 99 polyps (0.6%). The rates of bleeding for different polypectomy methods including hot biopsy forcep, biopsy forcep, Argon Plasma Coagulation (APC), Endoscopy piecemeal mucosal resection (EPMR), Endoscopic Mucosal Resection (EMR), and snare polypectomy were 0.1%, 0.0%, 0.0%, 6.9%, 0.9% and 1.0%, respectively. The risk factors for delayed bleeding were the size of polyps over 10 mm (odds ratio [OR]?= 4.6, 95% CI, 2.9-7.2), pathology of colonic polyps (inflammatory/hyperplastic, OR = 1; adenomatous, OR = 1.4, 95% CI, 0.7-2.6; serrated, OR = 1.5, 95% CI, 0.2-11.9; juvenile, OR = 4.3, 95% CI, 1.8-11.0; Peutz-Jegher, OR = 3.3, 95% CI, 1.0-10.7), and immediate postpolypectomy bleeding (OR = 2.9, 95% CI, 1.4-5.9). In addition, although polypectomy method was not a risk factor, compared with hot biopsy forcep, snare polypectomy, EMR, and EPMR had increased risks of delayed bleeding, with ORs of 3.2 (0.4-23.3), 2.8 (0.4-21.7) and 5.1 (0.5-47.7), respectively.\\n\\nCONCLUSION: Polyp size over 10 mm, pathology of colonic polyps (especially juvenile, Peutz-Jegher), and immediate postpolypectomy bleeding were significant risk factors for delayed postpolypectomy bleeding.","author":[{"dropping-particle":"","family":"Zhang","given":"Qiang","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"An","given":"Sheng Li","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chen","given":"Zhen Yu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fu","given":"Feng Hua","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jiang","given":"Bo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zhi","given":"Fa Chao","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bai","given":"Yang","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gong","given":"Wei","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"PLoS ONE","id":"ITEM-2","issue":"10","issued":{"date-parts":[["2014"]]},"title":"Assessment of risk factors for delayed colonic post-polypectomy hemorrhage: A study of 15553 polypectomies from 2005 to 2013","type":"article","volume":"9"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1016/j.bpg.2016.09.009","ISSN":"15321916","PMID":"27931634","abstract":"Endoscopic resection (ER), including endoscopic polypectomy (EP), endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are used to remove superficial neoplasms from the colon. Snare resection is used for EP and EMR, whereas endoscopic knives are used to perform dissection in the submucosal space in ESD. 80–90% colonic polyps are <10?millimetres (mm) and are effectively managed by conventional EP. Increasingly cold snare polypectomy is preferred. Large laterally spreading lesions (LSLs) and sessile polyps ≥20?mm are primarily removed by EMR. ESD may be used when superficial invasive disease is suspected and for some LSLs, particularly non-granular subtypes. Resection of colonic lesions by ER is associated with a small but definite incidence of significant complications, most commonly bleeding and perforation. This review discusses complications of ER with a particular focus on their prevention, early recognition and management. In many cases, complications from all three procedures share similar mechanisms and management principles and these are described at the start of each section, followed by a description of specific aspects for individual procedures.","author":[{"dropping-particle":"","family":"Ma","given":"Michael X.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bourke","given":"Michael J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Best Practice and Research: Clinical Gastroenterology","id":"ITEM-3","issue":"5","issued":{"date-parts":[["2016"]]},"page":"749-767","title":"Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon","type":"article-journal","volume":"30"},"uris":[""]}],"mendeley":{"formattedCitation":"^[8–10]","plainTextFormattedCitation":"[8–10]","previouslyFormattedCitation":"^[8–10]"},"properties":{"noteIndex":0},"schema":""}[8-10]. Several studies have evaluated the effect of prophylactic clipping on DPB following ER, with mixed resultsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.gie.2012.10.024","ISBN":"1097-6779 (Electronic)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"23317580","abstract":"Background: Endoscopic resection of large colorectal lesions is associated with high complication rates. Objective: To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. Design: Retrospective study. Setting: Tertiary referral center. Patients and Interventions: Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. Main Outcome Measurements: Delayed hemorrhage, postpolypectomy syndrome, and perforation. Results: There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. Limitation: Retrospective design. Conclusions: Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted. ? 2013 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Liaquat","given":"Hammad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rohn","given":"Elizabeth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rex","given":"Douglas K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2013","3","1"]]},"page":"401-407","publisher":"Mosby","title":"Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: Experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions","type":"article-journal","volume":"77"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1093/jjco/hys131","ISBN":"0368-2811","ISSN":"03682811","PMID":"22914322","abstract":"OBJECTIVE: Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures.\\n\\nMETHODS: This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection.\\n\\nRESULTS: The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04).\\n\\nCONCLUSIONS: Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.","author":[{"dropping-particle":"","family":"Matsumoto","given":"Minori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fukunaga","given":"Shusei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saito","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsuda","given":"Takahisa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakajima","given":"Takeshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Taku","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tamai","given":"Naoto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kikuchi","given":"Tsuyoshi","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Japanese Journal of Clinical Oncology","id":"ITEM-2","issue":"11","issued":{"date-parts":[["2012","11","1"]]},"page":"1028-1034","publisher":"Oxford University Press","title":"Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors","type":"article-journal","volume":"42"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1016/j.gie.2015.04.005","ISBN":"0016-5107","ISSN":"10976779","PMID":"25975527","abstract":"Background Clip closure of large colorectal mucosal defects may reduce the rate of adverse events in a cost-effective manner. Objective To assess the adverse events and outcomes of clip closure of defects after endoscopic resection in patients with large colorectal tumors. Design Prospective, randomized, controlled study. Setting Single tertiary referral center. Patients and Interventions Patients with lesions measuring 1 to 4 cm who were scheduled for endoscopic resection between March 2012 and December 2014 were randomly assigned to a clip-closure group and a no-closure group. In the clip-closure group, the defect of the resection site was completely closed with an endoclip. In the no-closure group, the defect was left open. The following primary outcome measures were assessed: delayed postoperative bleeding, postpolypectomy coagulation syndrome, perforation, and abdominal pain. Secondary outcome measures of length of hospital stay, time required for procedure, and patient's satisfaction were also assessed. Results Patients and lesions had similar characteristics across both groups. For patients who underwent clip closure (n = 174), the rates of delayed postoperative bleeding (1.1% [2/174]) and postpolypectomy coagulation syndrome (0.6% [1/174]) were lower than those in the no-closure group (6.9% [12/174], P =.01 and 4.6% [8/174], P =.03). Two patients experienced perforation, 1 in each group. In the clip-closure group, 4 patients reported abdominal pain as opposed to 26 in the no-closure group (2.8% vs 16.7%, P <.01). The procedure took longer in the closure group (38.1 minutes vs 30.9 minutes, P =.04). The length of hospitalization was shorter in the closure group (3.1 days vs 4.7 days, P =.03). Total medical expense was similar between the 2 groups. Patients who underwent closure reported greater satisfaction. Limitation This was a single-center analysis. Conclusions Clip closure of endoscopic resection defects in patients with large colorectal tumors decreased the rate of procedure-related adverse events and did not increase the cost of hospitalization.","author":[{"dropping-particle":"","family":"Zhang","given":"Qi Sheng","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Han","given":"Bing","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Xu","given":"Jian Hua","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gao","given":"Peng","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shen","given":"Yu Cui","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-3","issue":"5","issued":{"date-parts":[["2015","11","1"]]},"page":"904-909","publisher":"Mosby","title":"Clip closure of defect after endoscopic resection in patients with larger colorectal tumors decreased the adverse events","type":"article-journal","volume":"82"},"uris":[""]}],"mendeley":{"formattedCitation":"^[11–13]","plainTextFormattedCitation":"[11–13]","previouslyFormattedCitation":"^[11–13]"},"properties":{"noteIndex":0},"schema":""}[11-13]. The inclusion of small polyps and different ER techniques (i.e., conventional polypectomy, EMR, ESD) significantly limits the interpretability of the data. The primary aim of this study was to conduct a meta-analysis on the effect of prophylactic clipping on DPB following EMR of colorectal lesions ≥ 20 mm. A secondary aim was to evaluate the effect of clipping on the incidence of adverse events following colorectal ER. MATERIALS AND METHODS Search strategy and study selectionWe identified studies through a literature search of two databases (MEDLINE through PubMed and the Cochrane Library) with the last search performed in January 2018. The PubMed search strategy was constructed by using the following string of search terms: (“clip” OR “clipping”) AND (“colon” OR “colorectal” OR “colonic”) AND (“endoscopic”). The search of the Cochrane library was conducted using similar search terms. A review of the reference list of included studies was performed to identify any relevant articles missed through the original search strategy. Titles and abstracts were screened by two investigators (F.A. and D.R.W) for relevance to the study. The full text of potentially eligible studies was subsequently reviewed by the two investigators (F.A and D.R.W). Disagreements were resolved by consensus or by consulting with a third investigator (D.Y).Inclusion and exclusion criteriaStudies eligible for inclusion were: (1) Prospective or retrospective, case-control, or cohort studies and clinical trials (2) studies reporting incidence of DPB following ER and (3) those that included outcomes on both patients with prophylactic clipping vs non-clipping after resection. Exclusion criteria were: (1) Case reports, (2) single arm retrospective or prospective case series, (3) studies not reporting incidence of DPB, (4) reviews, commentaries, surveys, (5) duplicate studies. Data extractionData from each eligible study were extracted using a standardized data extraction sheet. The extracted data included: (1) Study authors, (2) year of publication, (3) setting (location), (4) study period, (5) patient demographics (age, gender), (6) number of patients/lesions, (7) lesion characteristics (size, location, morphology), (8) type of ER (conventional polypectomy, EMR, ESD), (9) incidence of adverse events, including DPB and perforation, (10) follow-up period.Outcomes and definitionsThe aim of this study was to conduct a meta-analysis studying the effect of prophylactic clipping on DPB following EMR of colorectal lesions ≥ 20 mm. A secondary aim was to evaluate the effect of prophylactic clipping on the incidence of adverse events following colorectal ER. Prophylactic clipping was defined as endoscopic clipping performed with the aim of reducing the risk of delayed (post-operative) adverse events. DPB was defined as bleeding occurring post-operatively (upon conclusion of the ER and after scope withdrawal from the patient). Conventional polypectomy was defined as removal of a colorectal lesion with a forceps or snare without prior submucosal injection. In contrast, EMR was defined as resection achieved by first lifting the target lesion with a submucosal injection followed by snare polypectomy. ESD was defined as any resection in which submucosal dissection was performed. Assessment of methodologic qualityFor prospective trials, the quality of each study was assessed using the risk-of-bias tool as outlined in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0). The methodologic quality of retrospective studies was assessed using the Newcastle-Ottawa scaleADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s10654-010-9491-z","ISBN":"1065401094","ISSN":"03932990","PMID":"20652370","abstract":"<span style=\"color: rgb(85, 85, 85); font-family: Georgia, serif; font-size: 15px; font-style: italic; line-height: 22.5px; background-color: rgb(254, 252, 231);\">A STANG , \"Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses,\" Eur J Epidemiol, vol. 25, no. 9, pp. 603-605, 2010</span>","author":[{"dropping-particle":"","family":"Stang","given":"Andreas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"European Journal of Epidemiology","id":"ITEM-1","issue":"9","issued":{"date-parts":[["2010"]]},"page":"603-605","title":"Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses","type":"article","volume":"25"},"uris":[""]}],"mendeley":{"formattedCitation":"^[14]","plainTextFormattedCitation":"[14]","previouslyFormattedCitation":"^[15]"},"properties":{"noteIndex":0},"schema":""}[14]. The quality of all studies was assessed by 3 investigators (F.A, D.R.W, J.J.F). Funnel plots were generated to evaluate for any potential publication bias. Visual inspection of the funnel plot was used detect significant publication bias when less than 10 studies were available for meta-analysis as recommended by the Cochrane Handbook. Egger’s regression test was used when more than 10 studies were included in the meta-analysis.Statistical analysisWe obtained or calculated the proportions and 95%CI for each categorical variable and the mean or median for continuous data when possible. The pooled means and OR were calculated utilizing a random effects model. The random effects model was used regardless of underlying statistical testing of heterogeneity since it provides more conservative estimations of the pooled effects that are more likely to contain the true effect. The Cochran Q test and I2 were used to assess heterogeneity of included studies. I2 values of < 25%, 25%-50% and > 50% were considered to represent low, moderate and high heterogeneity, respectively. P values < 0.05 were considered significant and all tests were two tailed. The study was performed in accordance with the PRISMA recommendations for reporting systematic reviews and meta-analyses. Analysis was conducted using Stata, version 15 (Stata Corp, College Station, TX, United States) and RevMan 5.3 (The Cochrane Collaboration, Copenhagen).RESULTSSearch resultsFigure 1 depicts the study selection flow diagram. Overall, 255 studies were identified using our search strategy, of which 110 were duplicates. Of the remaining 145 studies, 120 were excluded after screening titles and abstracts. Full text review was then performed on 25 studies using the predefined inclusion and exclusion criteria, after which 13 studies were retained. Of the 13 studies, 7 were randomized control trials (RCTs)[13,15-21ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1155/2015/490272","ISBN":"2314-6133","ISSN":"23146141","PMID":"25722979","abstract":"BACKGROUNDS: The efficacy of clipping for preventing the delayed bleeding after the removal of colon polyps is still controversial. In order to clarify this efficacy, a randomized controlled study was performed.\\n\\nMETHODS: One hundred and fifty-six patients with colon neoplasms (288 lesions) were enrolled in the study. The patients were randomly divided into two groups: clipping or nonclipping groups using a sealed envelope method before the endoscopic resections. Eight specialists and nine residents were invited to perform this procedure. The risk factors and the rates of delayed bleeding after the endoscopic resections in each group were investigated.\\n\\nRESULTS: There were no significant differences in the bleeding rate between the clipping and nonclipping groups, while the length of the procedure was significantly longer and the cost was higher in the clipping group than in the nonclipping group. The rate of bleeding was significantly higher in cases with polyps 2 cm or larger and with a longer procedure time, while none of the other factors affected the bleeding rate.\\n\\nCONCLUSIONS: This randomized controlled study revealed no significant effect of prophylactic clipping for preventing delayed bleeding after the endoscopic resection of colon polyps.","author":[{"dropping-particle":"","family":"Dokoshi","given":"Tatsuya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujiya","given":"Mikihiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanaka","given":"Kazuyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakatani","given":"Aki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Inaba","given":"Yuhei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ueno","given":"Nobuhiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kashima","given":"Shin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Goto","given":"Takuma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sasajima","given":"Junpei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tominaga","given":"Motoya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ito","given":"Takahiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moriichi","given":"Kentaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanabe","given":"Hiroki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ikuta","given":"Katsuya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ohtake","given":"Takaaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kohgo","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BioMed Research International","id":"ITEM-1","issued":{"date-parts":[["2015","2","3"]]},"page":"1-6","publisher":"Hindawi","title":"A randomized study on the effectiveness of prophylactic clipping during endoscopic resection of colon polyps for the prevention of delayed bleeding","type":"article-journal","volume":"2015"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1111/den.12661","ISBN":"0915-5635","ISSN":"14431661","PMID":"27018874","author":[{"dropping-particle":"","family":"Matsumoto","given":"Mio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kato","given":"Mototsugu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oba","given":"Koji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abiko","given":"Satoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tsuda","given":"Momoko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Miyamoto","given":"Shuichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mizushima","given":"Takeshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Masayoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Omori","given":"Saori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Takahashi","given":"Masakazu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Shoko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mabe","given":"Katsuhiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakagawa","given":"Manabu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakagawa","given":"Soichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kudo","given":"Takahiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shimizu","given":"Yuichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Naoya","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Digestive Endoscopy","id":"ITEM-2","issue":"5","issued":{"date-parts":[["2016","7","1"]]},"page":"570-576","title":"Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding","type":"article-journal","volume":"28"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1055/s-2007-995604","ISBN":"1438-8812 (Electronic)\\r0013-726X (Linking)","ISSN":"1438-8812","PMID":"19085714","author":[{"dropping-particle":"","family":"Sakamoto","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Beppu","given":"K","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsumoto","given":"K","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shibuya","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Osada","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mori","given":"H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shimada","given":"Y","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Konno","given":"a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kurosawa","given":"a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nagahara","given":"a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Otaka","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ohkusa","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ogihara","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy","id":"ITEM-3","issue":"S 02","issued":{"date-parts":[["2008","9","1"]]},"page":"E97-8","publisher":"? Georg Thieme Verlag KG Stuttgart · New York","title":"\"Loop Clip\", a new closure device for large mucosal defects after EMR and ESD.","type":"article-journal","volume":"40 Suppl 2"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1007/s00464-014-3983-y","ISBN":"1432-2218 (Electronic)\\r0930-2794 (Linking)","ISSN":"14322218","PMID":"25480613","abstract":"BACKGROUND Comparative studies on wound surface treatments after endoscopic mucosal resection (EMR) of 10- to 20-mm colorectal polyps have not been reported. We conducted a prospective trial of postoperative hemorrhage prevention measures after EMR of such polyps. METHODS Of 138 patients (397 polyps) who had undergone EMR, 62 patients (148 polyps) with 10- to 20-mm colorectal polyps were enrolled. Using the sealed envelope method, the subjects were randomly assigned to either a snare cauterization (75 polyps) or clip closure group (73 polyps). The primary assessment item was the wound surface treatment time (from immediately after polyp resection to wound surface treatment completion). The secondary assessment items were the incidence of delayed bleeding, perforation incidence 1-7?days after EMR, and difference in medical costs between the groups (University Hospital Medical Information Network: No. 000013473). RESULTS The time required for wound surface treatment completion was 3.26?±?1.57?min in the snare cauterization group and 12.7?±?2.92?min in the clip closure group, thus demonstrating a significant difference (P?=?0.0001). Delayed bleeding was observed in two patients in the clip group, but was not observed in the snare cauterization group (P?=?0.098). The clip group required the use of 720 clips that cost \\523,410, US $5,163.50, or <euro>3,665.5. CONCLUSIONS After EMR of with 10- to 20-mm colorectal polyps, snare cauterization was superior to clip closure in terms of procedure time, and medical costs, and not inferior to clip closure in terms of the preventing effect of delayed bleeding.","author":[{"dropping-particle":"","family":"Mori","given":"Hirohito","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kobara","given":"Hideki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nishiyama","given":"Noriko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujihara","given":"Shintaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsunaga","given":"Tae","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ayaki","given":"Maki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chiyo","given":"Taiga","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Masaki","given":"Tsutomu","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-4","issue":"9","issued":{"date-parts":[["2015","9"]]},"page":"2818-2824","publisher":"Springer","title":"Simple and reliable treatment for post-EMR artificial ulcer floor with snare cauterization for 10- to 20-mm colorectal polyps: a randomized prospective study (with video)","type":"article-journal","volume":"29"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"10.1007/s00464-016-4763-7","ISBN":"0930-2794","ISSN":"14322218","PMID":"26895895","abstract":"Background: Most mucosal defects that occur with endoscopic submucosal dissection (ESD) can be closed completely using endoscopic clips. However, benefits of such closure in wound healing are unknown. A randomized controlled study evaluated the efficacy of closure with clips compared with no closure. Method: Twenty-eight patients who had undergone ESD were randomly divided into two groups: closure (n = 14) and non-closure groups (n = 14). In the closure group, the mucosal defect resulting from ESD was closed using endoscopic clips. Four weeks after ESD, defects in both groups were observed by colonoscopy. Efficacy was based on change in the area of the defect, percentage of complete healing in each group, and complications. Result: Data were analyzed for 26 of the 28 patients (13, closure group; 13, non-closure group). All tumors were resected en bloc by ESD without bleeding or perforation. In the closure group, the area of the defect just after ESD was 677 +/- 306 mm² (mean +/- SD) as determined by the size of the removed lesion and had decreased to 2.17 +/- 4.51 mm² at 4 weeks after ESD (reduction, 99.7 %), but in the non-closure group that area was 790 +/- 221 mm² and had decreased to 27.42 +/- 25.72 mm² at 4 weeks post-ESD (reduction, 96.2 %). The reduction rate was significantly higher in the closure than in the non-closure group (99.7 vs. 96.2 %, p = 0.010). Complete healing was 69.2 % in the closure group vs. 7.7 % in the non-closure group (p = 0.005). Multivariate analysis showed that closure of the mucosal defect (OR 24.029, 95 % CI 2.09-276.15, p = 0.011) was an independent factor associated with complete healing at 4 weeks after ESD. Delayed perforation or post-ESD bleeding was not observed in any participant. Conclusion: Use of endoscopic clips for closure of defects after ESD is safe and efficacious in accelerating wound healing. Trial registration: UMIN-CTR UMIN000009112 Copyright ? 2016, Springer Science+Business Media New York.","author":[{"dropping-particle":"","family":"Osada","given":"Taro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Naoto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ritsuno","given":"Hideaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Murakami","given":"Takashi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ueyama","given":"Hiroya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsumoto","given":"Kenshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shibuya","given":"Tomoyoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ogihara","given":"Tatsuo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"Sumio","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-5","issue":"10","issued":{"date-parts":[["2016","10","19"]]},"page":"4438-4444","publisher":"Springer US","title":"Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection","type":"article-journal","volume":"30"},"uris":[""]},{"id":"ITEM-6","itemData":{"DOI":"10.1067/mge.2003.193","ISBN":"0016-5107 (Print)\\r0016-5107","ISSN":"00165107","PMID":"12709699","abstract":"BACKGROUND: The most common major complication of colonoscopic polypectomy is postpolypectomy hemorrhage. Although several factors have been implicated in the occurrence of hemorrhage, accurate prediction of delayed bleeding remains difficult. This randomized controlled trial evaluated the efficacy of prophylactic clip application for prevention of delayed postpolypectomy bleeding. METHODS: Postpolypectomy ulcers created by colonoscopic removal of polyps (mean size 7.8 [4.0] mm) with the endoscopic mucosal resection technique were randomly assigned to prophylactic clip placement (n = 205) or no clip (n = 208). Baseline characteristics of the patients and polyps excised were comparable between the groups. Delayed bleeding was defined as the postprocedure passage of bloody stool or massive hematochezia. The site of delayed bleeding was identified at emergent colonoscopy. RESULTS: Delayed bleeding was identified from 2 ulcers in each group from 1 to 4 days after resection (mean 2.3 days). Delayed bleeding occurred from 0.98% of ulcers in the clip group and 0.96% in the non-clip group (p > 0.9999). No patient with delayed bleeding required transfusion or surgery. CONCLUSIONS: Prophylactic clip placement did not decrease the occurrence of delayed bleeding after colonoscopic polypectomy.","author":[{"dropping-particle":"","family":"Shioji","given":"Kazuhiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Suzuki","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kobayashi","given":"Masaaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakamura","given":"Atsuo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Azumaya","given":"Masaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Takeuchi","given":"Manabu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Baba","given":"Youichiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Honma","given":"Terasu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Narisawa","given":"Rintaro","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-6","issue":"6","issued":{"date-parts":[["2003","5","1"]]},"page":"691-694","publisher":"Mosby","title":"Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy","type":"article-journal","volume":"57"},"uris":[""]},{"id":"ITEM-7","itemData":{"DOI":"10.11280/gee.56.15","ISBN":"0387-1207","ISSN":"03871207","abstract":"To prevent post-operative hemorrhaging in patients who have undergone an endoscopic mucosal resection (EMR), it has not been definitively concluded that using a clip is the most effective method. We considered the benefits of hemostatic clips in this study. During the period from January 2010 to February 2012 we conducted a randomized controlled trial at our hospital among patients who had undergone an EMR. In this trial we examined the hemostatic effect of using a plication clip. Four patients (1.0%) in the clipped group (n = 211) and 9 patients (2.1%) in the non-clipped group (n = 216) had post-operative bleeding, with no statistical differences between groups. Patients who had diabetes, a I p polyp or who were using anticoagulant drugs were significantly more likely to experience related post-operative hemorrhaging in this study than those without those factors. Care should be taken with such patients. In conclusion, because a plication clip had little effect in preventing post-EMR bleeding its use is unnecessary, if only to reduce labor and other costs.","author":[{"dropping-particle":"","family":"Tominaga","given":"Naoyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanaka","given":"Yuichiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Higuchi","given":"Toru","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yamaguchi","given":"Daisuke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"Akira","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ogata","given":"Shinichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kajiwara","given":"Tetsuro","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastroenterological Endoscopy","id":"ITEM-7","issue":"1","issued":{"date-parts":[["2014"]]},"page":"15-20","publisher":"一般社団法人 日本消化器内視鏡学会","title":"The effect of hemostasis clipping post endoscopic mucosal resection of colorectal polyps","type":"article-journal","volume":"56"},"uris":[""]},{"id":"ITEM-8","itemData":{"DOI":"10.1016/j.gie.2015.04.005","ISBN":"0016-5107","ISSN":"10976779","PMID":"25975527","abstract":"Background Clip closure of large colorectal mucosal defects may reduce the rate of adverse events in a cost-effective manner. Objective To assess the adverse events and outcomes of clip closure of defects after endoscopic resection in patients with large colorectal tumors. Design Prospective, randomized, controlled study. Setting Single tertiary referral center. Patients and Interventions Patients with lesions measuring 1 to 4 cm who were scheduled for endoscopic resection between March 2012 and December 2014 were randomly assigned to a clip-closure group and a no-closure group. In the clip-closure group, the defect of the resection site was completely closed with an endoclip. In the no-closure group, the defect was left open. The following primary outcome measures were assessed: delayed postoperative bleeding, postpolypectomy coagulation syndrome, perforation, and abdominal pain. Secondary outcome measures of length of hospital stay, time required for procedure, and patient's satisfaction were also assessed. Results Patients and lesions had similar characteristics across both groups. For patients who underwent clip closure (n = 174), the rates of delayed postoperative bleeding (1.1% [2/174]) and postpolypectomy coagulation syndrome (0.6% [1/174]) were lower than those in the no-closure group (6.9% [12/174], P =.01 and 4.6% [8/174], P =.03). Two patients experienced perforation, 1 in each group. In the clip-closure group, 4 patients reported abdominal pain as opposed to 26 in the no-closure group (2.8% vs 16.7%, P <.01). The procedure took longer in the closure group (38.1 minutes vs 30.9 minutes, P =.04). The length of hospitalization was shorter in the closure group (3.1 days vs 4.7 days, P =.03). Total medical expense was similar between the 2 groups. Patients who underwent closure reported greater satisfaction. Limitation This was a single-center analysis. Conclusions Clip closure of endoscopic resection defects in patients with large colorectal tumors decreased the rate of procedure-related adverse events and did not increase the cost of hospitalization.","author":[{"dropping-particle":"","family":"Zhang","given":"Qi Sheng","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Han","given":"Bing","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Xu","given":"Jian Hua","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gao","given":"Peng","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shen","given":"Yu Cui","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-8","issue":"5","issued":{"date-parts":[["2015","11","1"]]},"page":"904-909","publisher":"Mosby","title":"Clip closure of defect after endoscopic resection in patients with larger colorectal tumors decreased the adverse events","type":"article-journal","volume":"82"},"uris":[""]}],"mendeley":{"formattedCitation":"^[13,15–21]","plainTextFormattedCitation":"[13,15–21]","previouslyFormattedCitation":"^[13,16–22]"},"properties":{"noteIndex":0},"schema":""}] and 6 were cohort studies (2 prospective, 4 retrospective)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.cgh.2016.03.021","ISBN":"1542-3565","ISSN":"15427714","PMID":"27033428","abstract":"Background & Aims After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. Methods We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. Results Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%–4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0–3), average-risk (score, 4–7), or high-risk (score, 8–10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70–0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. Conclusions The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8–10) had a 40% probability of delayed bleeding.","author":[{"dropping-particle":"","family":"Albéniz","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fraile","given":"María","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ibá?ez","given":"Berta","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Alonso-Aguirre","given":"Pedro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Ares","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Soto","given":"Santiago","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gargallo","given":"Carla Jerusalén","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ramos 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Tejada","given":"Alberto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Redondo","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guarner-Argente","given":"Carlos","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pin","given":"Noel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"León-Brito","given":"Helena","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pardeiro","given":"Remedios","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"López-Roses","given":"Leopoldo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodríguez-Téllez","given":"Manuel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jiménez","given":"Alejandra","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Alcalá","given":"Felipe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"García","given":"Orlando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"la 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Ros","given":"Javier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zú?iga Ripa","given":"Alba","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Concepción-Martín","given":"Mar","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Huelin-?lvarez","given":"Patricia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Colán-Hernández","given":"Juan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cubiella","given":"Joaquín","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Remedios","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bessa i Caserras","given":"Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"López-Viedma","given":"Bartolomé","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cobian","given":"Julyssa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"González-Haba","given":"Mariano","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Santiago","given":"José","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Cara","given":"Juan Gabriel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Valdivielso","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Clinical Gastroenterology and Hepatology","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2016","8","1"]]},"page":"1140-1147","publisher":"W.B. Saunders","title":"A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions","type":"article-journal","volume":"14"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1007/s00464-013-2807-9","ISBN":"0930-2794","ISSN":"09302794","PMID":"23404147","abstract":"BACKGROUND: Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.\\n\\nMETHODS: Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.\\n\\nRESULTS: A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.\\n\\nCONCLUSIONS: The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.","author":[{"dropping-particle":"","family":"Dior","given":"Marie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Coriat","given":"Romain","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarabichi","given":"Samer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Leblanc","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Polin","given":"Vanessa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perkins","given":"Géraldine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dhooge","given":"Marion","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Prat","given":"Frédéric","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chaussade","given":"Stanislas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-2","issue":"8","issued":{"date-parts":[["2013","8","13"]]},"page":"2775-2781","publisher":"Springer US","title":"Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?","type":"article-journal","volume":"27"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1055/s-0043-118743","ISSN":"2364-3722","PMID":"29201999","abstract":"<p>Background and study aims?Endoscopic submucosal dissection (ESD) is useful for en bloc resection of superficial colorectal neoplasms to ensure accurate histologic diagnoses. However, colorectal ESD is associated with a high frequency of adverse events (AEs). We aimed to investigate the effectiveness of prophylactic clip closure (PCC) of mucosal defects for AEs after colorectal ESD.</p>","author":[{"dropping-particle":"","family":"Harada","given":"Hideaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Suehiro","given":"Satoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Murakami","given":"Daisuke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakahara","given":"Ryotaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ujihara","given":"Tetsuro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shimizu","given":"Takanori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Miyama","given":"Yasunaga","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Katsuyama","given":"Yasushi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hayasaka","given":"Kenji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tounou","given":"Shigetaka","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy International Open","id":"ITEM-3","issue":"12","issued":{"date-parts":[["2017","12","21"]]},"page":"E1165-E1171","title":"Clinical impact of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection","type":"article-journal","volume":"05"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1016/j.gie.2006.11.035","ISBN":"0016-5107 (Print)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"17466205","abstract":"Background: Nonpolypoid (flat and depressed) colorectal lesions are increasingly recognized. Their endoscopic removal requires specialized EMR techniques, which are more complex to perform. Outcomes data on EMR of nonpolypoid neoplasms in the United States is needed. Objective: To determine the safety and efficacy of EMR in the resection of nonpolypoid colorectal neoplasms ≥1 cm. Design: Retrospective analysis. Setting: Veterans Affairs Palo Alto Health Care System. Patients: Over a 5-year period, patients who underwent EMR for nonpolypoid colorectal lesions ≥1 cm. Intervention: A standardized approach that included lesion assessment, classification, inject-and-cut EMR technique, reassessment, and treatment of residual tissue. Main Outcome Measurements: Complete resection, bleeding, perforation, development of advanced cancer, and death. Results: A total of 100 patients (125 lesions: 117 flat and 8 depressed) met inclusion criteria. Mean size was 16.7 ± 7 mm (range, 10-50 mm). Histology included 5 submucosal invasive cancers, 5 carcinomas in situ, and 91 adenomas. Thirty-eight patients (48 lesions) did not receive surveillance colonoscopy: 8 had surgery, 16 had hyperplastic pathology, and 14 did not undergo repeat examination. Surveillance colonoscopy was performed on 62 patients (77 lesions). Complete resection was achieved in 100% of these patients after 1 to 3 surveillance colonoscopies. All patients received follow-up (mean [standard deviation] = 4.5 ± 1.4 years); none developed colorectal cancer or metastasis. Limitations: Single endoscopist, retrospective study. Conclusions: A standardized EMR (inject-and-cut) technique is a safe and curative treatment option in nonpolypoid colorectal neoplasms (≥1 cm) in the United States. ? 2007 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Kaltenbach","given":"Tonya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Friedland","given":"Shai","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maheshwari","given":"Anamika","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ouyang","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"V.","family":"Rouse","given":"Robert","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wren","given":"Sherry","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Soetikno","given":"Roy","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-4","issue":"6","issued":{"date-parts":[["2007","5","1"]]},"page":"857-865","publisher":"Mosby","title":"Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions ≥1 cm (with video){A figure is presented}","type":"article-journal","volume":"65"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"10.1016/j.gie.2012.10.024","ISBN":"1097-6779 (Electronic)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"23317580","abstract":"Background: Endoscopic resection of large colorectal lesions is associated with high complication rates. Objective: To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. Design: Retrospective study. Setting: Tertiary referral center. Patients and Interventions: Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. Main Outcome Measurements: Delayed hemorrhage, postpolypectomy syndrome, and perforation. Results: There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. Limitation: Retrospective design. Conclusions: Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted. ? 2013 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Liaquat","given":"Hammad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rohn","given":"Elizabeth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rex","given":"Douglas K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-5","issue":"3","issued":{"date-parts":[["2013","3","1"]]},"page":"401-407","publisher":"Mosby","title":"Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: Experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions","type":"article-journal","volume":"77"},"uris":[""]},{"id":"ITEM-6","itemData":{"DOI":"10.1093/jjco/hys131","ISBN":"0368-2811","ISSN":"03682811","PMID":"22914322","abstract":"OBJECTIVE: Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures.\\n\\nMETHODS: This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection.\\n\\nRESULTS: The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04).\\n\\nCONCLUSIONS: Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.","author":[{"dropping-particle":"","family":"Matsumoto","given":"Minori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fukunaga","given":"Shusei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saito","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsuda","given":"Takahisa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakajima","given":"Takeshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Taku","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tamai","given":"Naoto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kikuchi","given":"Tsuyoshi","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Japanese Journal of Clinical Oncology","id":"ITEM-6","issue":"11","issued":{"date-parts":[["2012","11","1"]]},"page":"1028-1034","publisher":"Oxford University Press","title":"Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors","type":"article-journal","volume":"42"},"uris":[""]}],"mendeley":{"formattedCitation":"^{[11,12,22–25]}","plainTextFormattedCitation":"[11,12,22–25]","previouslyFormattedCitation":"^{[11,12,23–26]}"},"properties":{"noteIndex":0},"schema":""}[11,12,22-25]. Studies were published between 2003 and 2017. Nine studies were conducted in Asia, 2 in Europe, and 2 in the United States. These 13 studies were included in the meta-analysis evaluating the impact of prophylactic clipping on adverse events following colorectal ER. Of these, 4 studies with available data on specific parameters (lesion size, type of ER, clipping vs no clipping, incidence of DPB) were included in the analysis on the effects of prophylactic clipping on DPB after EMR of lesions ≥ 20 mm. Study characteristics are summarized in Table 1. Colorectal ER was performed in 7794 polyps, of which 3567 (45.8%) underwent prophylactic clipping. Out of the 13 studies identified, 7 studies excluded all pedunculated polyps whereas 1 study did not report details on polyp morphologyADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s00464-013-2807-9","ISBN":"0930-2794","ISSN":"09302794","PMID":"23404147","abstract":"BACKGROUND: Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.\\n\\nMETHODS: Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.\\n\\nRESULTS: A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.\\n\\nCONCLUSIONS: The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.","author":[{"dropping-particle":"","family":"Dior","given":"Marie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Coriat","given":"Romain","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarabichi","given":"Samer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Leblanc","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Polin","given":"Vanessa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perkins","given":"Géraldine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dhooge","given":"Marion","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Prat","given":"Frédéric","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chaussade","given":"Stanislas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2013","8","13"]]},"page":"2775-2781","publisher":"Springer US","title":"Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?","type":"article-journal","volume":"27"},"uris":[""]}],"mendeley":{"formattedCitation":"^[23]","plainTextFormattedCitation":"[23]","previouslyFormattedCitation":"^[24]"},"properties":{"noteIndex":0},"schema":""}[23]. Of the remaining six studies, 3772 out of 5225 polyps (72%) were reported as pedunculated. Eleven studies specified that the lesion located in the right colon (2695 out of 6309; 42.7%). Overall, 7 studies included data on EMR only, 3 studies reported outcomes on both EMR and conventional polypectomy, 2 on ESD alone, and 1 on both ESD and EMR. Most lesions (82%; 6377) were removed by EMR, followed by conventional polypectomy (14%; 1118), and ESD (4%; 299). While several studies reported the number of patients in each group (clipping vs non-clipping), a few studies only described the number of lesions in each armADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s00464-014-3983-y","ISBN":"1432-2218 (Electronic)\\r0930-2794 (Linking)","ISSN":"14322218","PMID":"25480613","abstract":"BACKGROUND Comparative studies on wound surface treatments after endoscopic mucosal resection (EMR) of 10- to 20-mm colorectal polyps have not been reported. We conducted a prospective trial of postoperative hemorrhage prevention measures after EMR of such polyps. METHODS Of 138 patients (397 polyps) who had undergone EMR, 62 patients (148 polyps) with 10- to 20-mm colorectal polyps were enrolled. Using the sealed envelope method, the subjects were randomly assigned to either a snare cauterization (75 polyps) or clip closure group (73 polyps). The primary assessment item was the wound surface treatment time (from immediately after polyp resection to wound surface treatment completion). The secondary assessment items were the incidence of delayed bleeding, perforation incidence 1-7?days after EMR, and difference in medical costs between the groups (University Hospital Medical Information Network: No. 000013473). RESULTS The time required for wound surface treatment completion was 3.26?±?1.57?min in the snare cauterization group and 12.7?±?2.92?min in the clip closure group, thus demonstrating a significant difference (P?=?0.0001). Delayed bleeding was observed in two patients in the clip group, but was not observed in the snare cauterization group (P?=?0.098). The clip group required the use of 720 clips that cost \\523,410, US $5,163.50, or <euro>3,665.5. CONCLUSIONS After EMR of with 10- to 20-mm colorectal polyps, snare cauterization was superior to clip closure in terms of procedure time, and medical costs, and not inferior to clip closure in terms of the preventing effect of delayed bleeding.","author":[{"dropping-particle":"","family":"Mori","given":"Hirohito","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kobara","given":"Hideki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nishiyama","given":"Noriko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujihara","given":"Shintaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsunaga","given":"Tae","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ayaki","given":"Maki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chiyo","given":"Taiga","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Masaki","given":"Tsutomu","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-1","issue":"9","issued":{"date-parts":[["2015","9"]]},"page":"2818-2824","publisher":"Springer","title":"Simple and reliable treatment for post-EMR artificial ulcer floor with snare cauterization for 10- to 20-mm colorectal polyps: a randomized prospective study (with video)","type":"article-journal","volume":"29"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1155/2015/490272","ISBN":"2314-6133","ISSN":"23146141","PMID":"25722979","abstract":"BACKGROUNDS: The efficacy of clipping for preventing the delayed bleeding after the removal of colon polyps is still controversial. In order to clarify this efficacy, a randomized controlled study was performed.\\n\\nMETHODS: One hundred and fifty-six patients with colon neoplasms (288 lesions) were enrolled in the study. The patients were randomly divided into two groups: clipping or nonclipping groups using a sealed envelope method before the endoscopic resections. Eight specialists and nine residents were invited to perform this procedure. The risk factors and the rates of delayed bleeding after the endoscopic resections in each group were investigated.\\n\\nRESULTS: There were no significant differences in the bleeding rate between the clipping and nonclipping groups, while the length of the procedure was significantly longer and the cost was higher in the clipping group than in the nonclipping group. The rate of bleeding was significantly higher in cases with polyps 2 cm or larger and with a longer procedure time, while none of the other factors affected the bleeding rate.\\n\\nCONCLUSIONS: This randomized controlled study revealed no significant effect of prophylactic clipping for preventing delayed bleeding after the endoscopic resection of colon polyps.","author":[{"dropping-particle":"","family":"Dokoshi","given":"Tatsuya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujiya","given":"Mikihiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanaka","given":"Kazuyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakatani","given":"Aki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Inaba","given":"Yuhei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ueno","given":"Nobuhiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kashima","given":"Shin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Goto","given":"Takuma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sasajima","given":"Junpei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tominaga","given":"Motoya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ito","given":"Takahiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moriichi","given":"Kentaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanabe","given":"Hiroki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ikuta","given":"Katsuya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ohtake","given":"Takaaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kohgo","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BioMed Research International","id":"ITEM-2","issued":{"date-parts":[["2015","2","3"]]},"page":"1-6","publisher":"Hindawi","title":"A randomized study on the effectiveness of prophylactic clipping during endoscopic resection of colon polyps for the prevention of delayed bleeding","type":"article-journal","volume":"2015"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1016/j.gie.2006.11.035","ISBN":"0016-5107 (Print)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"17466205","abstract":"Background: Nonpolypoid (flat and depressed) colorectal lesions are increasingly recognized. Their endoscopic removal requires specialized EMR techniques, which are more complex to perform. Outcomes data on EMR of nonpolypoid neoplasms in the United States is needed. Objective: To determine the safety and efficacy of EMR in the resection of nonpolypoid colorectal neoplasms ≥1 cm. Design: Retrospective analysis. Setting: Veterans Affairs Palo Alto Health Care System. Patients: Over a 5-year period, patients who underwent EMR for nonpolypoid colorectal lesions ≥1 cm. Intervention: A standardized approach that included lesion assessment, classification, inject-and-cut EMR technique, reassessment, and treatment of residual tissue. Main Outcome Measurements: Complete resection, bleeding, perforation, development of advanced cancer, and death. Results: A total of 100 patients (125 lesions: 117 flat and 8 depressed) met inclusion criteria. Mean size was 16.7 ± 7 mm (range, 10-50 mm). Histology included 5 submucosal invasive cancers, 5 carcinomas in situ, and 91 adenomas. Thirty-eight patients (48 lesions) did not receive surveillance colonoscopy: 8 had surgery, 16 had hyperplastic pathology, and 14 did not undergo repeat examination. Surveillance colonoscopy was performed on 62 patients (77 lesions). Complete resection was achieved in 100% of these patients after 1 to 3 surveillance colonoscopies. All patients received follow-up (mean [standard deviation] = 4.5 ± 1.4 years); none developed colorectal cancer or metastasis. Limitations: Single endoscopist, retrospective study. Conclusions: A standardized EMR (inject-and-cut) technique is a safe and curative treatment option in nonpolypoid colorectal neoplasms (≥1 cm) in the United States. ? 2007 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Kaltenbach","given":"Tonya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Friedland","given":"Shai","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maheshwari","given":"Anamika","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ouyang","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"V.","family":"Rouse","given":"Robert","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wren","given":"Sherry","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Soetikno","given":"Roy","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-3","issue":"6","issued":{"date-parts":[["2007","5","1"]]},"page":"857-865","publisher":"Mosby","title":"Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions ≥1 cm (with video){A figure is presented}","type":"article-journal","volume":"65"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1007/s00464-013-2807-9","ISBN":"0930-2794","ISSN":"09302794","PMID":"23404147","abstract":"BACKGROUND: Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.\\n\\nMETHODS: Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.\\n\\nRESULTS: A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.\\n\\nCONCLUSIONS: The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.","author":[{"dropping-particle":"","family":"Dior","given":"Marie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Coriat","given":"Romain","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarabichi","given":"Samer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Leblanc","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Polin","given":"Vanessa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perkins","given":"Géraldine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dhooge","given":"Marion","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Prat","given":"Frédéric","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chaussade","given":"Stanislas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-4","issue":"8","issued":{"date-parts":[["2013","8","13"]]},"page":"2775-2781","publisher":"Springer US","title":"Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?","type":"article-journal","volume":"27"},"uris":[""]},{"id":"ITEM-5","itemData":{"DOI":"10.1016/j.gie.2012.10.024","ISBN":"1097-6779 (Electronic)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"23317580","abstract":"Background: Endoscopic resection of large colorectal lesions is associated with high complication rates. Objective: To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. Design: Retrospective study. Setting: Tertiary referral center. Patients and Interventions: Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. Main Outcome Measurements: Delayed hemorrhage, postpolypectomy syndrome, and perforation. Results: There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. Limitation: Retrospective design. Conclusions: Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted. ? 2013 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Liaquat","given":"Hammad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rohn","given":"Elizabeth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rex","given":"Douglas K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-5","issue":"3","issued":{"date-parts":[["2013","3","1"]]},"page":"401-407","publisher":"Mosby","title":"Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: Experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions","type":"article-journal","volume":"77"},"uris":[""]},{"id":"ITEM-6","itemData":{"DOI":"10.1093/jjco/hys131","ISBN":"0368-2811","ISSN":"03682811","PMID":"22914322","abstract":"OBJECTIVE: Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures.\\n\\nMETHODS: This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection.\\n\\nRESULTS: The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04).\\n\\nCONCLUSIONS: Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.","author":[{"dropping-particle":"","family":"Matsumoto","given":"Minori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fukunaga","given":"Shusei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saito","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsuda","given":"Takahisa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakajima","given":"Takeshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Taku","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tamai","given":"Naoto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kikuchi","given":"Tsuyoshi","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Japanese Journal of Clinical Oncology","id":"ITEM-6","issue":"11","issued":{"date-parts":[["2012","11","1"]]},"page":"1028-1034","publisher":"Oxford University Press","title":"Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors","type":"article-journal","volume":"42"},"uris":[""]},{"id":"ITEM-7","itemData":{"DOI":"10.1016/j.cgh.2016.03.021","ISBN":"1542-3565","ISSN":"15427714","PMID":"27033428","abstract":"Background & Aims After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. Methods We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. Results Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%–4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0–3), average-risk (score, 4–7), or high-risk (score, 8–10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70–0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. Conclusions The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8–10) had a 40% probability of delayed bleeding.","author":[{"dropping-particle":"","family":"Albéniz","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fraile","given":"María","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ibá?ez","given":"Berta","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Alonso-Aguirre","given":"Pedro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Ares","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Soto","given":"Santiago","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gargallo","given":"Carla Jerusalén","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ramos Zabala","given":"Felipe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"?lvarez","given":"Marco Antonio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodríguez-Sánchez","given":"Joaquín","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Múgica","given":"Fernando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nogales","given":"?scar","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Herreros de Tejada","given":"Alberto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Redondo","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guarner-Argente","given":"Carlos","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pin","given":"Noel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"León-Brito","given":"Helena","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pardeiro","given":"Remedios","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"López-Roses","given":"Leopoldo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodríguez-Téllez","given":"Manuel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jiménez","given":"Alejandra","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Alcalá","given":"Felipe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"García","given":"Orlando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"la Pe?a","given":"Joaquín","non-dropping-particle":"de","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Akiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Alberca de las Parras","given":"Fernando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pellisé","given":"María","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rivero","given":"Liseth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saperas","given":"Esteban","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pérez-Roldán","given":"Francisco","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pueyo Royo","given":"Antonio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eguaras Ros","given":"Javier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zú?iga Ripa","given":"Alba","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Concepción-Martín","given":"Mar","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Huelin-?lvarez","given":"Patricia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Colán-Hernández","given":"Juan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cubiella","given":"Joaquín","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Remedios","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bessa i Caserras","given":"Xavier","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"López-Viedma","given":"Bartolomé","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cobian","given":"Julyssa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"González-Haba","given":"Mariano","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Santiago","given":"José","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Cara","given":"Juan Gabriel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Valdivielso","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Clinical Gastroenterology and Hepatology","id":"ITEM-7","issue":"8","issued":{"date-parts":[["2016","8","1"]]},"page":"1140-1147","publisher":"W.B. Saunders","title":"A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions","type":"article-journal","volume":"14"},"uris":[""]},{"id":"ITEM-8","itemData":{"DOI":"10.1055/s-0043-118743","ISSN":"2364-3722","PMID":"29201999","abstract":"<p>Background and study aims?Endoscopic submucosal dissection (ESD) is useful for en bloc resection of superficial colorectal neoplasms to ensure accurate histologic diagnoses. However, colorectal ESD is associated with a high frequency of adverse events (AEs). We aimed to investigate the effectiveness of prophylactic clip closure (PCC) of mucosal defects for AEs after colorectal ESD.</p>","author":[{"dropping-particle":"","family":"Harada","given":"Hideaki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Suehiro","given":"Satoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Murakami","given":"Daisuke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakahara","given":"Ryotaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ujihara","given":"Tetsuro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shimizu","given":"Takanori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Miyama","given":"Yasunaga","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Katsuyama","given":"Yasushi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hayasaka","given":"Kenji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tounou","given":"Shigetaka","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy International Open","id":"ITEM-8","issue":"12","issued":{"date-parts":[["2017","12","21"]]},"page":"E1165-E1171","title":"Clinical impact of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection","type":"article-journal","volume":"05"},"uris":[""]}],"mendeley":{"formattedCitation":"^{[11,12,15,18,22–25]}","plainTextFormattedCitation":"[11,12,15,18,22–25]","previouslyFormattedCitation":"^{[11,12,16,19,23–26]}"},"properties":{"noteIndex":0},"schema":""}[11,12,15,18,22-25]; hence, the number of lesions was used in the analysis.Quality assessmentThe risk of bias in the 6 nonrandomized studies was evaluated according to the Newcastle-Ottawa assessment scale (Supplementary Table 1). The average quality score was 8 out of the highest possible score of 9. Five of the 6 included cohort studies were of high methodological quality (score 8-9/9), and 1 was of low quality (score 4-5/9). The risk of bias for the 7 RCTs is shown in Supplementary Table 2. Blinding of participants and personnel was not performed in any of the included RCTs. Methods for random sequence generation and allocation concealment were described by 5 studies. All RCTs were found to have adequate assessment of incomplete outcomes and avoided selective reporting. Meta-analysis resultsEffect of prophylactic clipping on DPB following EMR of colorectal lesions ≥ 20 mm: Of the 13 studies on colorectal ER, data from 4 studies were available to evaluate the incidence of DPB after EMR of lesions ≥ 20 mmADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.cgh.2016.03.021","ISBN":"1542-3565","ISSN":"15427714","PMID":"27033428","abstract":"Background & Aims After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. Methods We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. Results Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%–4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0–3), average-risk (score, 4–7), or high-risk (score, 8–10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70–0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. Conclusions The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8–10) had a 40% probability of delayed bleeding.","author":[{"dropping-particle":"","family":"Albéniz","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fraile","given":"María","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ibá?ez","given":"Berta","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Alonso-Aguirre","given":"Pedro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Ares","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Soto","given":"Santiago","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gargallo","given":"Carla Jerusalén","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ramos Zabala","given":"Felipe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"?lvarez","given":"Marco Antonio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodríguez-Sánchez","given":"Joaquín","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Múgica","given":"Fernando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nogales","given":"?scar","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Herreros de Tejada","given":"Alberto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Redondo","given":"Eduardo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guarner-Argente","given":"Carlos","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pin","given":"Noel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"León-Brito","given":"Helena","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pardeiro","given":"Remedios","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"López-Roses","given":"Leopoldo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodríguez-Téllez","given":"Manuel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jiménez","given":"Alejandra","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martínez-Alcalá","given":"Felipe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"García","given":"Orlando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"la Pe?a","given":"Joaquín","non-dropping-particle":"de","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Akiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Alberca de las Parras","given":"Fernando","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pellisé","given":"María","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rivero","given":"Liseth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saperas","given":"Esteban","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pérez-Roldán","given":"Francisco","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pueyo Royo","given":"Antonio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eguaras 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Hepatology","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2016","8","1"]]},"page":"1140-1147","publisher":"W.B. Saunders","title":"A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions","type":"article-journal","volume":"14"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1007/s00464-013-2807-9","ISBN":"0930-2794","ISSN":"09302794","PMID":"23404147","abstract":"BACKGROUND: Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.\\n\\nMETHODS: Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.\\n\\nRESULTS: A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.\\n\\nCONCLUSIONS: The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.","author":[{"dropping-particle":"","family":"Dior","given":"Marie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Coriat","given":"Romain","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tarabichi","given":"Samer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Leblanc","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Polin","given":"Vanessa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Perkins","given":"Géraldine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dhooge","given":"Marion","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Prat","given":"Frédéric","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chaussade","given":"Stanislas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Surgical Endoscopy and Other Interventional Techniques","id":"ITEM-2","issue":"8","issued":{"date-parts":[["2013","8","13"]]},"page":"2775-2781","publisher":"Springer US","title":"Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?","type":"article-journal","volume":"27"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1016/j.gie.2012.10.024","ISBN":"1097-6779 (Electronic)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"23317580","abstract":"Background: Endoscopic resection of large colorectal lesions is associated with high complication rates. Objective: To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. Design: Retrospective study. Setting: Tertiary referral center. Patients and Interventions: Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. Main Outcome Measurements: Delayed hemorrhage, postpolypectomy syndrome, and perforation. Results: There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. Limitation: Retrospective design. Conclusions: Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted. ? 2013 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Liaquat","given":"Hammad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rohn","given":"Elizabeth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rex","given":"Douglas K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-3","issue":"3","issued":{"date-parts":[["2013","3","1"]]},"page":"401-407","publisher":"Mosby","title":"Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: Experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions","type":"article-journal","volume":"77"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.11280/gee.56.15","ISBN":"0387-1207","ISSN":"03871207","abstract":"To prevent post-operative hemorrhaging in patients who have undergone an endoscopic mucosal resection (EMR), it has not been definitively concluded that using a clip is the most effective method. We considered the benefits of hemostatic clips in this study. During the period from January 2010 to February 2012 we conducted a randomized controlled trial at our hospital among patients who had undergone an EMR. In this trial we examined the hemostatic effect of using a plication clip. Four patients (1.0%) in the clipped group (n = 211) and 9 patients (2.1%) in the non-clipped group (n = 216) had post-operative bleeding, with no statistical differences between groups. Patients who had diabetes, a I p polyp or who were using anticoagulant drugs were significantly more likely to experience related post-operative hemorrhaging in this study than those without those factors. Care should be taken with such patients. In conclusion, because a plication clip had little effect in preventing post-EMR bleeding its use is unnecessary, if only to reduce labor and other costs.","author":[{"dropping-particle":"","family":"Tominaga","given":"Naoyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanaka","given":"Yuichiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Higuchi","given":"Toru","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yamaguchi","given":"Daisuke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"Akira","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ogata","given":"Shinichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kajiwara","given":"Tetsuro","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastroenterological Endoscopy","id":"ITEM-4","issue":"1","issued":{"date-parts":[["2014"]]},"page":"15-20","publisher":"一般社団法人 日本消化器内視鏡学会","title":"The effect of hemostasis clipping post endoscopic mucosal resection of colorectal polyps","type":"article-journal","volume":"56"},"uris":[""]}],"mendeley":{"formattedCitation":"^[11,21–23]","plainTextFormattedCitation":"[11,21–23]","previouslyFormattedCitation":"^[11,22–24]"},"properties":{"noteIndex":0},"schema":""}[11,21-23]. In all, clipping was performed in 592 (34.8%) cases of the 1701 EMRs of lesions ≥ 20 mm. Clipping was associated with a lower incidence of DPB (8 out of 592; 1.4%) when compared to no clipping (58 out of 1109; 5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001). There was little heterogeneity among the included studies (I2 = 0%, P = 0.67) (Figure 2A). There was no evidence of substantial publication bias based on visual inspection of the funnel plot (Figure 2B).Effect of prophylactic clipping on the incidence of adverse events following colorectal ER: DPB, the incidence of DPB was reported in all 13 studies included in the meta-analysis. The overall pooled incidence of DPB was 2.1% (160 out of 7794 lesions) (Table 2). DPB was reported in 46 (1.3%) cases with prophylactic clipping as compared to 114 (2.7%) in the non-clipping arm (pooled OR: 0.50; 95%CI: 0.25-0.91, P = 0.02) (Figure 3A). A sensitivity analysis was performed by using patient instead of lesion numbers when available and this did not alter the overall pooled outcome (pooled OR 0.49; 95%CI: 0.27-0.89, P = 0.02). There was significant heterogeneity among the included studies (I2 = 50%, P = 0.03). When only RCTs were included in the analysis, compared with no clipping, the pooled OR for DPB with clipping was 0.77 (95%CI: 0.36-1.65, P = 0.51), suggesting no significant difference between the two groups (Figure 3A). However, there was moderate heterogeneity among these RCT results (I2 = 42%, P = 0.12). In all, there was no evidence of substantial publication bias based on the visual inspection of the funnel plot and Egger’s regression test (P = 0.57) (Figure 3B).Perforation following Colorectal ER. Eight studies evaluated the rate of perforation following ER. No cases of perforation were reported in six studies, whereas the remaining two observed a total of 2 cases of perforation in each group (clipping vs non-clipping). Hence, the overall pooled rate for perforation was 0.19% (4 out of 2031 lesions), with no significant difference between the two groups (pooled OR: 1.05; 95%CI: 0.15-7.48, P = 0.96).Subgroup analysesLesion Size ≥ 20 mm: Eight studies with available data on outcomes for lesions ≥ 20 mm included 910 cases with clipping and 1445 without clipping following ER (EMR or ESD). The overall pooled rate of DPB was 3.8% for lesions ≥ 20 mm. Prophylactic clipping of lesions ≥ 20 mm was associated with a lower rate of DPB when compared to no clipping (1.8% vs 5.1%) (pooled OR: 0.33, 95%CI: 0.18-0.62, P < 0.001), with no significant heterogeneity among the available studies (I2 = 10%, P = 0.36) (Figure 4). Polyp morphology (pedunculated) and right-colon location: Out of the 13 studies included in the meta-analysis, only two studies specified outcomes on DBP for pedunculated polypsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.11280/gee.56.15","ISBN":"0387-1207","ISSN":"03871207","abstract":"To prevent post-operative hemorrhaging in patients who have undergone an endoscopic mucosal resection (EMR), it has not been definitively concluded that using a clip is the most effective method. We considered the benefits of hemostatic clips in this study. During the period from January 2010 to February 2012 we conducted a randomized controlled trial at our hospital among patients who had undergone an EMR. In this trial we examined the hemostatic effect of using a plication clip. Four patients (1.0%) in the clipped group (n = 211) and 9 patients (2.1%) in the non-clipped group (n = 216) had post-operative bleeding, with no statistical differences between groups. Patients who had diabetes, a I p polyp or who were using anticoagulant drugs were significantly more likely to experience related post-operative hemorrhaging in this study than those without those factors. Care should be taken with such patients. In conclusion, because a plication clip had little effect in preventing post-EMR bleeding its use is unnecessary, if only to reduce labor and other costs.","author":[{"dropping-particle":"","family":"Tominaga","given":"Naoyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanaka","given":"Yuichiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Higuchi","given":"Toru","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yamaguchi","given":"Daisuke","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watanabe","given":"Akira","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ogata","given":"Shinichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kajiwara","given":"Tetsuro","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastroenterological Endoscopy","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2014"]]},"page":"15-20","publisher":"一般社団法人 日本消化器内視鏡学会","title":"The effect of hemostasis clipping post endoscopic mucosal resection of colorectal polyps","type":"article-journal","volume":"56"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1111/den.12661","ISBN":"0915-5635","ISSN":"14431661","PMID":"27018874","author":[{"dropping-particle":"","family":"Matsumoto","given":"Mio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kato","given":"Mototsugu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oba","given":"Koji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abiko","given":"Satoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tsuda","given":"Momoko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Miyamoto","given":"Shuichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mizushima","given":"Takeshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Masayoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Omori","given":"Saori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Takahashi","given":"Masakazu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Shoko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mabe","given":"Katsuhiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakagawa","given":"Manabu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakagawa","given":"Soichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kudo","given":"Takahiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shimizu","given":"Yuichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Naoya","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Digestive Endoscopy","id":"ITEM-2","issue":"5","issued":{"date-parts":[["2016","7","1"]]},"page":"570-576","title":"Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding","type":"article-journal","volume":"28"},"uris":[""]}],"mendeley":{"formattedCitation":"^[16,21]","plainTextFormattedCitation":"[16,21]","previouslyFormattedCitation":"^[17,22]"},"properties":{"noteIndex":0},"schema":""}[16,21]. The pooled incidence for DPB in pedunculated polyps from these two studies did not show a difference between clipping (1.1%) vs no clipping (1.1%) (pooled OR: 0.77, 95%CI: 0.17-3.46, P = 0.73). Only 1 study specified the incidence of DPB in right-sided colonic lesions. The authors did not report a significant difference in the rate of DPB between the two groups (1.3% with clipping vs 6% without clipping; OR: 2.28, 95%CI: 0.79-6.58, P = 0.13)ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/den.12661","ISBN":"0915-5635","ISSN":"14431661","PMID":"27018874","author":[{"dropping-particle":"","family":"Matsumoto","given":"Mio","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kato","given":"Mototsugu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oba","given":"Koji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abiko","given":"Satoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tsuda","given":"Momoko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Miyamoto","given":"Shuichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mizushima","given":"Takeshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Masayoshi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Omori","given":"Saori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Takahashi","given":"Masakazu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ono","given":"Shoko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mabe","given":"Katsuhiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakagawa","given":"Manabu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nakagawa","given":"Soichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kudo","given":"Takahiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shimizu","given":"Yuichi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakamoto","given":"Naoya","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Digestive Endoscopy","id":"ITEM-1","issue":"5","issued":{"date-parts":[["2016","7","1"]]},"page":"570-576","title":"Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding","type":"article-journal","volume":"28"},"uris":[""]}],"mendeley":{"formattedCitation":"^[16]","plainTextFormattedCitation":"[16]","previouslyFormattedCitation":"^[17]"},"properties":{"noteIndex":0},"schema":""}[16]. DISCUSSIONDPB is the most common adverse event following ER of colorectal lesions. Prophylactic clipping has been suggested as a strategy for the prevention of DPB, although prior data has been marred by conflicting findings. The results from this meta-analysis suggests that endoscopic clipping may be associated with a lower occurrence of DPB after colorectal EMR of lesions ≥ 20 mm in size. Nishizawa et alADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1177/2050640616687837","ISSN":"20506414","PMID":"29026600","abstract":"BACKGROUND AND AIM The efficacy of clipping for preventing delayed bleeding after colorectal endoscopic resection is still controversial. To assess the efficacy of prophylactic clipping, we conducted a meta-analysis of randomized controlled trials. METHODS We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified seven eligible randomized trials from the database search, and compared the effect of clipping versus non-clipping with respect to delayed bleeding and perforation. Data from eligible studies were combined to calculate pooled odds ratios (ORs). RESULTS Postoperative bleeding was observed in 41 of 1526 cases (2.7%) without clipping and in 32 of 1533 cases (2.1%) with clipping (OR 0.76, 95% CI: 0.39-1.47, p?=?0.414). There was no significant heterogeneity among the trial results (I-Square?=?26.7%, p?=?0.22). In the subgroup analysis based on small tumor size (<20?mm) and large tumor size (≥20?mm), there were no significant differences. Compared with non-clipping, the pooled OR of developing perforation with clipping was 1.00 (95% CI: 0.14-7.25), indicating no significant difference between the two groups. CONCLUSIONS Prophylactic clipping did not decrease the occurrence of delayed bleeding after colorectal endoscopic resection. Clipping could be of interest in patients with a high risk of bleeding (anticoagulation) or large lesions, but with the available trials data to prove this are scarce.","author":[{"dropping-particle":"","family":"Nishizawa","given":"Toshihiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Suzuki","given":"Hidekazu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Goto","given":"Osamu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ogata","given":"Haruhiko","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kanai","given":"Takanori","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Yahagi","given":"Naohisa","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"United European Gastroenterology Journal","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2017","10"]]},"page":"859-867","publisher":"SAGE Publications","title":"Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies","type":"article-journal","volume":"5"},"uris":[""]}],"mendeley":{"formattedCitation":"^[26]","plainTextFormattedCitation":"[26]","previouslyFormattedCitation":"^[27]"},"properties":{"noteIndex":0},"schema":""}[26] recently reported the results of their meta-analysis on the effect of prophylactic clipping after colorectal ER. A total of 7 RCTs with 3059 cases were included. In their study, the rate of DPB was similar between cases with clipping (2.1%) vs no clipping (2.7%) (OR 0.76; 95%CI: 0.39-1.47; P = 0.414). Similarly, when only RCTs were included in our meta-analysis, clipping did not affect the rate of DPB when compared to no clipping after ER (OR 0.77; 95%CI: 0.36-1.65, P = 0.51). However, it is important to highlight that nearly all of the cases included in these RCTs (2847 out of 3059; 93%) involved polyps < 20 mm in size. DPB is a rare occurrence following ER of small colorectal lesions. Indeed, most if not all of these lesions can be safely and completely excised with conventional cold snare polypectomy with no risk for DPBADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/j.1463-1318.2011.02696.x","ISBN":"1462-8910","ISSN":"14628910","PMID":"21689363","abstract":"AIM: Polypectomy techniques in the removal of polyps in the 3-8 mm size range are inconsistent. The aim of our study was to compare cold (CSP) with hot snare polypectomy (HSP) in the occurrence of postpolypectomy bleeding in small colonic polyps 3-8 mm in size. METHOD: In all, 414 consecutive patients with small colorectal polyps 3-8 mm in size were prospectively randomized into the CSP group and the HSP group. RESULTS: There was no early or late postpolypectomy bleeding in either group. Intraprocedural bleeding was significantly more frequent in the CSP group than the HSP group (CSP, 19/208; HSP, 2/206; P<0.001) but resolved spontaneously without any intervention in both groups. CONCLUSION: The data show that the CSP technique is safe, effective and quicker than HSP for patients and it could be considered the ideal procedure for small polyp removal.","author":[{"dropping-particle":"","family":"Paspatis","given":"G. A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tribonias","given":"G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Konstantinidis","given":"K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Theodoropoulou","given":"A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vardas","given":"E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Voudoukis","given":"E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Manolaraki","given":"M. M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chainaki","given":"I.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chlouverakis","given":"G.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Colorectal Disease","id":"ITEM-1","issue":"10","issued":{"date-parts":[["2011"]]},"title":"A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps","type":"article-journal","volume":"13"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.3748/wjg.v22.i23.5436","ISSN":"22192840","PMID":"27340361","abstract":"AIM: To compare previously reported randomized controlled studies (RCTs) of cold and hot polypectomy, we systematically reviewed and clarify the utility of cold polypectomy over hot with respect to efficacy and adverse events. METHODS: A meta-analysis was conducted to evaluate the predominance of cold and hot polypectomy for removing colon polyps. Published articles and abstracts from worldwide conferences were searched using the keywords \"cold polypectomy\". RCTs that compared either or both the effects or adverse events of cold polypectomy with those of hot polypectomy were collected. The patients' demographics, endoscopic procedures, No. of examined lesions, lesion size, macroscopic and histologic findings, rates of incomplete resection, bleeding amount, perforation, and length of procedure were extracted from each study. A forest plot analysis was used to verify the relative strength of the effects and adverse events of each procedure. A funnel plot was generated to assess the possibility of publication bias. RESULTS: Ultimately, six RCTs were selected. No significant differences were noted in the average lesion size (less than 10 mm) between the cold and hot polypectomy groups in each study. Further, the rates of complete resection and adverse events, including delayed bleeding, did not differ markedly between cold and hot polypectomy. The average procedural time in the cold polypectomy group was significantly shorter than in the hot polypectomy group. CONCLUSION: Cold polypectomy is a time-saving procedure for removing small polyps with markedly similar curability and safety to hot polypectomy.","author":[{"dropping-particle":"","family":"Fujiya","given":"Mikihiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sato","given":"Hiroki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ueno","given":"Nobuhiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sakatani","given":"Aki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tanaka","given":"Kazuyuki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Dokoshi","given":"Tatsuya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujibayashi","given":"Shugo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nomura","given":"Yoshiki","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kashima","given":"Shin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gotoh","given":"Takuma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sasajima","given":"Junpei","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moriichi","given":"Kentaro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Watari","given":"Jiro","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kohgo","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"World Journal of Gastroenterology","id":"ITEM-2","issue":"23","issued":{"date-parts":[["2016"]]},"page":"5436-5444","title":"Efficacy and adverse events of cold vs hot polypectomy: A meta-analysis","type":"article-journal","volume":"22"},"uris":[""]}],"mendeley":{"formattedCitation":"^[27,28]","plainTextFormattedCitation":"[27,28]","previouslyFormattedCitation":"^[28,29]"},"properties":{"noteIndex":0},"schema":""}[27,28]. Hence, it is not surprising that prophylactic clipping did not impact the rate of postoperative bleeding in patients included in those trials. It is well known that the incidence of DPB is directly associated with lesion size, and has been more frequently reported after the resection of lesions ≥ 20 mmADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/gut.24.5.376","ISSN":"00175749","PMID":"6601604","abstract":"The diagnostic and therapeutic benefits of colonoscopy are well known but most large-scale surveys, especially those involving multiple centres, may underestimate the range and incidence of complications. The detailed records of 5000 colonoscopies in a specialist unit have been analysed and conclusions drawn which may help to make the procedure safer. The incidence of haemorrhage was 1% and bowel perforation 0.1%. All the major haemorrhages occurred during polypectomies over 2 cm in size. Secondary haemorrhage was an unpredictable occurrence, one to 14 days later. Three deaths followed colonoscopy: one cardiorespiratory death was related to oversedation; a second was due to mismanaged ischaemic colitis developing two days after traumatic instrumentation, and the third was due to peritonitis. Minor complications included thrombophlebitis, abdominal distension, and vasovagal episodes. Because of experience during the first half of the series and also due to improvements in instrumentation, the complication rate of the later part of the series was halved. Recommendations include the avoidance of oversedation, review of previous barium enema films so as to be aware of large polyps which are more likely to bleed, and the recognition of situations where perforation or septicaemia is likely to occur.","author":[{"dropping-particle":"","family":"Macrae","given":"F. A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tan","given":"K. G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Williams","given":"C. B.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gut","id":"ITEM-1","issue":"5","issued":{"date-parts":[["1983"]]},"page":"376-383","title":"Towards safer colonoscopy: A report on the complications of 5000 diagnostic or therapeutic colonoscopies","type":"article-journal","volume":"24"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1067/mge.2000.105773","ISBN":"0016-5107","ISSN":"00165107","PMID":"10840301","abstract":"Background: Postpolypectomy hemorrhage may warrant intensive care monitoring, transfusions and surgery. We sought factors predicting significant bleeding requiring blood transfusion and the benefits of critical care monitoring. Methods: Patients with postpolypectomy bleeding between April 1989 and November 1996 were identified from a comprehensive GI bleeding database. Data included age, gender, medical history, medications, polyp characteristics, and polypectomy technique. Outcomes assessed included bleeding cessation, transfusion requirements, recurrent bleeding, length of stay, and death. Results: There were 83 patients with a median age of 73 years (range 18 to 88 years; 56 men, 27 women). Comorbid conditions were common (71.1% cardiovascular, 43.4% musculoskeletal, 14.5% hematologic, 6.0% renal). Within 3 days of presentation, 32.5% had taken aspirin, 10.8% nonsteroidal anti-inflammatory drugs, 12.0% warfarin, and 12.0% corticosteroids; and within I day, 10.8% intravenous heparin, 7.2% subcutaneous heparin, and 7.2% dipyridamole. Fifty-seven percent of patients were hemodynamically stable. Sessile cecal polyps greater than 2 cm in diameter bled more commonly. The median number of units transfused was equal between critical care and noncritical care patients. Using age in the logistic regression model, no other variable was predictive of transfusion. Eighty patients (96.4%) received endoscopic therapy, 1 required embolization and 2 hemicolectomy. There was no significant difference in outcomes for patients managed in an intensive care unit versus a general medical floor. Conclusions: Postpolypectomy bleeding appears to have a predictable presentation and outcome. Advanced age seems to be predictive of transfusion requirement. Patient monitoring in an intensive care setting is not absolutely necessary.","author":[{"dropping-particle":"","family":"Sorbi","given":"Darius","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Norton","given":"Ian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Conio","given":"Massimo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Balm","given":"Rita","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zinsmeister","given":"Alan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gostout","given":"Christopher J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-2","issue":"6","issued":{"date-parts":[["2000"]]},"page":"690-696","title":"Postpolypectomy lower GI bleeding: Descriptive analysis","type":"article-journal","volume":"51"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1055/s-2007-966959","ISBN":"2005915467","ISSN":"0013726X","PMID":"18253906","abstract":"Background and study aims: Postpolypectomy bleeding is a rare but serious adverse event. The aim of this study was to identify factors associated with the risk of severe delayed postpolypectomy bleeding. Patients and methods: This was a case-control study, comparing cases who developed hematochezia and required medical evaluation 6 hours to 14 days after colonoscopic polypectomy, and control patients who underwent polypectomy without delayed bleeding, and who were selected in approximately a 3 : 1 ratio. The following risk factors were specified a priori: resuming anticoagulation (within 1 week following polypectomy), aspirin use, hypertension, and polyp diameter. Results: Of the 4592 patients who underwent colonoscopy with polypectomy, 41 patients (0.9 %) developed delayed postpolypectomy bleeding (cases), and 132 patients were selected as controls. The mean age was 64.3 years for cases and 65.4 years for controls. Cases presented on average 6 days after polypectomy (range 1 - 14 days), and 48 % required blood transfusion (average 4.2 units, range 0 - 17). Two patients required surgery. Anticoagulation was resumed following polypectomy in 34 % of cases compared with 9 % of controls (OR 5.2; 95 % CI 2.2 - 12.5; P < 0.001). For every 1 mm increase in polyp diameter, the risk of hemorrhage increased by 9 % (OR 1.09; 95 % CI 1.0 - 1.2; P = 0.008). Hypertension (OR 1.1) and aspirin use (OR 1.1) did not increase the risk of postpolypectomy bleeding. In exploratory analysis, diabetes (OR 2.5) and coronary artery disease (OR 3.0) were associated with postpolypectomy hemorrhage, but the association was no longer statistically significant once adjusted for the use of anticoagulation. Conclusions: Resuming anticoagulation following polypectomy and polyp diameter were strongly associated with increased risk of severe delayed postpolypectomy bleeding.","author":[{"dropping-particle":"","family":"Sawhney","given":"M. S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Salfiti","given":"N.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nelson","given":"D. B.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lederle","given":"F. A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bond","given":"J. H.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy","id":"ITEM-3","issue":"2","issued":{"date-parts":[["2008"]]},"page":"115-119","title":"Risk factors for severe delayed postpolypectomy bleeding","type":"article-journal","volume":"40"},"uris":[""]}],"mendeley":{"formattedCitation":"^[8,29,30]","plainTextFormattedCitation":"[8,29,30]","previouslyFormattedCitation":"^[8,30,31]"},"properties":{"noteIndex":0},"schema":""}[8,29,30]. Nonetheless, the study by Nishizawa et al[26] did not report a difference in postoperative bleeding for lesions ≥ 20 mm with clipping vs no clipping (pooled OR 0.78; 95%CI: 0.23-2.68). The small number of cases with lesions ≥ 20 mm included in their study (97 with clipping and 115 without clipping) may have underpowered their analysis to detect any meaningful differences. In contrast, in effort to specifically evaluate the risk of DPB in lesions of clinically significant size, we included a total of 2355 polyps ≥ 20 mm in size. Our results demonstrated that clipping following the ER of lesions ≥ 20 mm was associated with a reduction in the risk of DPB when compared to no clipping (1.8% vs 5.1%, pooled OR: 0.33, 95%CI: 0.18-0.62, P < 0.001), with little heterogeneity among the studies (I2 = 10%, P = 0.36). Furthermore, given that colorectal lesions ≥ 20 mm are primarily removed with EMR, we specifically evaluated the risk of DPB in this group. Similarly, our meta-analysis demonstrated that clipping after EMR of lesions ≥ 20 mm significantly reduced the risk of bleeding when compared to no clipping (1.4% vs 5.2%; pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001). When compared to conventional polypectomy, EMR, particularly when performed for the removal of larger lesions, inherently results in an extended residual mucosal defectADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.gie.2015.05.001","ISBN":"0016-5107","ISSN":"10976779","PMID":"26077453","abstract":"The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, by using a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the \"related articles\" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched for publications in English through September 2014 by using the keywords \"endoscopic lesion removal,\" \"endoscopic resection,\" \"endoscopic mucosal resection,\" and \"EMR.\" Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.","author":[{"dropping-particle":"","family":"Hwang","given":"Joo Ha","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Konda","given":"Vani","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abu Dayyeh","given":"Barham K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chauhan","given":"Shailendra S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Enestvedt","given":"Brintha K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fujii-Lau","given":"Larissa L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Komanduri","given":"Sri","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maple","given":"John T.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Murad","given":"Faris M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pannala","given":"Rahul","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Thosani","given":"Nirav C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Banerjee","given":"Subhas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2015"]]},"page":"215-226","title":"Endoscopic mucosal resection","type":"article-journal","volume":"82"},"uris":[""]}],"mendeley":{"formattedCitation":"^[31]","plainTextFormattedCitation":"[31]","previouslyFormattedCitation":"^[32]"},"properties":{"noteIndex":0},"schema":""}[31]. Prophylactic clip closure of the defect reduces exposure of the submucosal tissue to the colonic luminal milieu, which may in turn reduce the risk of DPB and other adverse events, including abdominal pain and post-polypectomy syndromeADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.gie.2015.04.005","ISBN":"0016-5107","ISSN":"10976779","PMID":"25975527","abstract":"Background Clip closure of large colorectal mucosal defects may reduce the rate of adverse events in a cost-effective manner. Objective To assess the adverse events and outcomes of clip closure of defects after endoscopic resection in patients with large colorectal tumors. Design Prospective, randomized, controlled study. Setting Single tertiary referral center. Patients and Interventions Patients with lesions measuring 1 to 4 cm who were scheduled for endoscopic resection between March 2012 and December 2014 were randomly assigned to a clip-closure group and a no-closure group. In the clip-closure group, the defect of the resection site was completely closed with an endoclip. In the no-closure group, the defect was left open. The following primary outcome measures were assessed: delayed postoperative bleeding, postpolypectomy coagulation syndrome, perforation, and abdominal pain. Secondary outcome measures of length of hospital stay, time required for procedure, and patient's satisfaction were also assessed. Results Patients and lesions had similar characteristics across both groups. For patients who underwent clip closure (n = 174), the rates of delayed postoperative bleeding (1.1% [2/174]) and postpolypectomy coagulation syndrome (0.6% [1/174]) were lower than those in the no-closure group (6.9% [12/174], P =.01 and 4.6% [8/174], P =.03). Two patients experienced perforation, 1 in each group. In the clip-closure group, 4 patients reported abdominal pain as opposed to 26 in the no-closure group (2.8% vs 16.7%, P <.01). The procedure took longer in the closure group (38.1 minutes vs 30.9 minutes, P =.04). The length of hospitalization was shorter in the closure group (3.1 days vs 4.7 days, P =.03). Total medical expense was similar between the 2 groups. Patients who underwent closure reported greater satisfaction. Limitation This was a single-center analysis. Conclusions Clip closure of endoscopic resection defects in patients with large colorectal tumors decreased the rate of procedure-related adverse events and did not increase the cost of hospitalization.","author":[{"dropping-particle":"","family":"Zhang","given":"Qi Sheng","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Han","given":"Bing","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Xu","given":"Jian Hua","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gao","given":"Peng","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shen","given":"Yu Cui","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-1","issue":"5","issued":{"date-parts":[["2015","11","1"]]},"page":"904-909","publisher":"Mosby","title":"Clip closure of defect after endoscopic resection in patients with larger colorectal tumors decreased the adverse events","type":"article-journal","volume":"82"},"uris":[""]}],"mendeley":{"formattedCitation":"^[13]","plainTextFormattedCitation":"[13]","previouslyFormattedCitation":"^[13]"},"properties":{"noteIndex":0},"schema":""}[13]. Several issues remain to be addressed before this practice can be fully advocated. It is important to note that prophylactic clipping is not without its limitations. From a health economics standpoint, a prophylactic clipping strategy may not be cost effective and justifiable for all colorectal lesions removed by EMRADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1055/s-0042-105558","ISSN":"14388812","PMID":"27110693","abstract":"BACKGROUND AND STUDY AIMS: Clinically significant bleeding (CSPEB) is the most common adverse event following endoscopic mucosal resection (EMR) of large sessile and laterally spreading colorectal lesions (LSLs), and is associated with morbidity and resource utilization. CSPEB occurs more frequently with proximal LSLs. Prophylactic clipping of the post-EMR defect may be beneficial in CSPEB prevention. The aim of this study was to determine the cost-effectiveness of a prophylactic clipping strategy. We hypothesized that prophylactic clipping in the proximal colon was cost-effective. PATIENTS AND METHODS: An economic model was applied to outcomes from the Australian Colonic Endoscopic Mucosal Resection (ACE) Study. Clip distances of 3, 5, 8, and 10 mm were analyzed. The cost of treating CSPEB was determined from an independent costing agency. The funds needed to spend (FNS) was the cost incurred in order to prevent one episode of CSPEB. A break-even analysis was performed to determine cost equivalence of the costs of clipping and CSPEB. RESULTS: Outcomes of 1717 LSLs (mean size 35.8 mm; 52.6 % proximal colon) that underwent EMR were analyzed. The overall rate of CSPEB was 6.4 % (proximal 8.9 %; distal 3.7 %). Endoscopic management was required in 45 % of CSPEB episodes. With a clip distance of 3 mm, the expected cost of prophylactic clipping was € 1106 per lesion compared with € 157 per lesion for the expected cost of CSPEB without clipping. At 100 % clipping efficacy, the FNS was € 14 826 (proximal and distal lesions € 9309 and € 29 540, respectively). A clip price of € 10.35 was required for the cost of clipping to offset the cost of CSPEB. CONCLUSIONS: A prophylactic clipping strategy is not cost-effective and at present cannot be justified for all lesions or selectively for lesions in the proximal colon.","author":[{"dropping-particle":"","family":"Bahin","given":"Farzan F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rasouli","given":"Khalid N.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Williams","given":"Stephen J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lee","given":"Eric Y.T.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bourke","given":"Michael J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Endoscopy","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2016","4","25"]]},"page":"754-761","publisher":"? Georg Thieme Verlag KG","title":"Prophylactic clipping for the prevention of bleeding following wide-field endoscopic mucosal resection of laterally spreading colorectal lesions: An economic modeling study","type":"article-journal","volume":"48"},"uris":[""]}],"mendeley":{"formattedCitation":"^[32]","plainTextFormattedCitation":"[32]","previouslyFormattedCitation":"^[33]"},"properties":{"noteIndex":0},"schema":""}[32]. Certainly, the added cost of clips and lengthier procedure should be weighed against the potential incremental expenditures associated with DPB (i.e., emergency room visits, readmissions, need for transfusions, repeat therapeutic interventions). Given the above limitations, a strategy of clipping targeted to patient and/or lesion characteristics would likely prove most efficient. Patient characteristics that may warrant prophylactic clipping may include those requiring resumption of anti-coagulant or anti-thrombotic therapy following resection, those with a high comorbidity burden who may not hemodynamically tolerate significant hemorrhage or patients with low likelihood of post-procedural follow up and access to careADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"","accessed":{"date-parts":[["2018","3","2"]]},"id":"ITEM-1","issued":{"date-parts":[["0"]]},"title":"2013 March (Vol. 77) GIE Author Interview Series- Douglas K. Rex - YouTube","type":"webpage"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.gie.2012.10.024","ISBN":"1097-6779 (Electronic)\\r0016-5107 (Linking)","ISSN":"00165107","PMID":"23317580","abstract":"Background: Endoscopic resection of large colorectal lesions is associated with high complication rates. Objective: To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. Design: Retrospective study. Setting: Tertiary referral center. Patients and Interventions: Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. Main Outcome Measurements: Delayed hemorrhage, postpolypectomy syndrome, and perforation. Results: There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. Limitation: Retrospective design. Conclusions: Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted. ? 2013 American Society for Gastrointestinal Endoscopy.","author":[{"dropping-particle":"","family":"Liaquat","given":"Hammad","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rohn","given":"Elizabeth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rex","given":"Douglas K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Gastrointestinal Endoscopy","id":"ITEM-2","issue":"3","issued":{"date-parts":[["2013","3","1"]]},"page":"401-407","publisher":"Mosby","title":"Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: Experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions","type":"article-journal","volume":"77"},"uris":[""]}],"mendeley":{"formattedCitation":"^[11,33]","plainTextFormattedCitation":"[11,33]","previouslyFormattedCitation":"^[11,34]"},"properties":{"noteIndex":0},"schema":""}[11,33]. Lesion characteristics that may benefit from clipping may include those that are larger than 20 mm, pedunculated, located in the right colon or a combination of the aforementioned factors. Future well-designed RCTs are needed to further define the role of prophylactic clipping in the prevention of DPB in select lesions, specifically after EMR of large colonic lesions. This study has several strengths. Given that DPB often occurs following ER of larger lesions, we specifically evaluated the efficacy of prophylactic clipping with respect to lesion size. Furthermore, many studies on prophylactic closure for DPB do not differentiate between the types of endoscopic intervention (i.e., EMR vs ESD), which significantly limits the interpretability of the results as both of these approaches are technically distinct and carry inherently different risks for post-procedural adverse eventsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1177/2050640615585470","ISSN":"20506414","PMID":"26966519","abstract":"BACKGROUND AND AIMS This systematic review and meta-analysis compares the safety and effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of flat and sessile colorectal lesions >20 mm preoperatively assessed as noninvasive. METHODS We reviewed the literature published between January 2000 and March 2014. Pooled estimates of the proportion of patients with en bloc, R0 resection, complications, recurrence, and need for further treatment were compared in a meta-analysis using fixed and random effects. RESULTS A total of 11 studies and 4678 patients were included. The en bloc resection rate was 89.9% for ESD vs 34.9% for EMR patients (RR 1.93 p < 0.001). The R0 resection rate was 79.6% for ESD vs 36.2% for EMR patients (RR 2.01 p < 0.001). The rate of perforation was 4.9% for the ESD group and 0.9% for EMR (RR 3.19, p < 0.001), while the rate of bleeding was 1.9% for ESD and 2.9% for EMR (RR 0.68, p = 0.070). Therefore, the overall need for further surgery, including surgery for oncologic reasons and surgery for complications, was 7.8% for ESD and 3.0% for EMR (RR 2.40, p < 0.001). CONCLUSIONS ESD achieves a higher rate of en bloc and R0 resection compared to EMR, at the cost of a higher risk of complications. This, added to an increased need for surgery for oncologic reasons for a plausible tendency to extend indication for endoscopic excision, increases the risk of further surgery after ESD.","author":[{"dropping-particle":"","family":"Arezzo","given":"Alberto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Passera","given":"Roberto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Marchese","given":"Nicola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Galloro","given":"Giuseppe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Manta","given":"Raffaele","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cirocchi","given":"Roberto","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"United European Gastroenterology Journal","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2016"]]},"page":"18-29","title":"Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions","type":"article-journal","volume":"4"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/j.critrevonc.2016.06.008","ISSN":"18790461","PMID":"27370173","abstract":"Aim To assess the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for the treatment of colorectal lesions. Methods A literature search was conducted from January 2000 to May 2015. The main outcomes were: recurrence after “en bloc” and “piecemeal” resection; procedure related adverse events; the EMR endoscopic success rate and the completely eradicated resection rate (R0) after ESD. Results A total of 66 studies were included in the analysis. The total number of lesions was 17950 (EMR: 11.873; ESD: 6077). Recurrence rate was higher in the EMR than ESD group (765/7303l vs. 50/3910 OR 8.19, 95% CI 6.2–10.9 p?<?0.0001). EMR-en bloc resection was achieved in 6793/10803 lesions (62.8%) while ESD-en bloc resection was obtained in 5500/6077 lesions (90.5%) (OR 0.18, p?<?0.0001, 95% CI 0.16–0.2). Perforation occurred more frequently in ESD than in EMR group (p?<?0.0001, OR 0.19, 95% CI 0.15–0.24). Conclusions Endoscopic resection of large colorectal lesions is safe and effective. Compared with EMR, ESD results in higher “en bloc” resection rate and lower local recurrence rate, however ESD has high procedure-related complication rates.","author":[{"dropping-particle":"","family":"Ceglie","given":"Antonella","non-dropping-particle":"De","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hassan","given":"Cesare","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mangiavillano","given":"Benedetto","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matsuda","given":"Takahisa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saito","given":"Yutaka","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ridola","given":"Lorenzo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bhandari","given":"Pradeep","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Boeri","given":"Federica","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Conio","given":"Massimo","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Critical Reviews in Oncology/Hematology","id":"ITEM-2","issued":{"date-parts":[["2016"]]},"page":"138-155","title":"Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review","type":"article","volume":"104"},"uris":[""]}],"mendeley":{"formattedCitation":"^[34,35]","plainTextFormattedCitation":"[34,35]","previouslyFormattedCitation":"^[35,36]"},"properties":{"noteIndex":0},"schema":""}[34,35]. In this meta-analysis, we demonstrate that prophylactic clipping reduces the risk of DPB in arguably the most clinically significant group: lesions ≥ 20 mm removed with EMR. These observations have direct clinical implications as vast majority of these lesions in the West are approached with EMR. We also acknowledge the limitations of this study. All available studies reporting the effect of clipping on DPB were included in this meta-analysis in efforts to capture sufficient cases for subgroup analyses. The inclusion of cohort studies, in addition to RCTs, potentially introduces selection bias. Nonetheless, the overall quality of the included cohort studies was satisfactory based on the Newcastle-Ottawa scale and there was little heterogeneity among the studies. Furthermore, given that the main aim of the study was to evaluate DPB in lesions ≥ 20 mm following EMR, only a few studies were available, and thereby these results should be interpreted with caution and underscores the need of additional well-designed trials. Secondly, the lack of data on polyp morphology, location in the colon, and management of anti-coagulant/anti-thrombotic medications prior to ER in many of the included studies limited our ability to perform additional sub-analyses or draw any meaningful conclusions on these important subgroups. In summary, this meta-analysis suggests that prophylactic clipping may reduce DPB after ER of colorectal lesions. Clip closure was associated with a significant reduction in the incidence of DPB in lesions ≥ 20 mm following EMR. Future trials are needed to further identify risk factors for DPB and help implement a cost-effective preventive strategy.Article Highlights Research backgroundThe role of prophylactic clipping in the prevention of delayed polypectomy bleeding (DPB) is unclear.Research motivationPrevious meta-analyses included a variety of polyp resection methods and all polyp sizes, our analysis used a more focused approach.Research objectivesTo assess the effect of prophylactic clip placement on DPB after endoscopic mucosal resection (EMR) of colorectal lesions 20mm or larger.Research methodsWe performed a systematic search of Medline through PubMed and the Cochrane Library database for studies investigating the effect of prophylactic clipping on DPB following EMR of colorectal lesions. We used the PRISMA protocol for our analysis and assessed the quality of included articles using the Newcastle-Ottawa scale. We used RevMan version 5 for the statistical analysis, using the random-effects model (DeSimonian-Laird method).Research resultsA total of 7794 polyps in 13 studies were analyzed, including 1701 cases of EMR of lesions ≥ 20 mm. We found that prophylactic clipping following EMR of lesions ≥ 20 mm was associated with a lower rate of DPB (1.4%) compared to no clipping (5.2%).Research conclusionsPlacement of clips prophylactically following EMR of colorectal lesions ≥ 20 mm may reduce rates of DPB and its associated morbidity and should be considered by practicing endoscopists in select patients.Research perspectivesFuture prospective studies on the effect of clipping for DPB after EMR should focus on lesions ≥ 20 mm since those represent the highest risk. Cost analyses must also be conducted to implement the most cost-effective strategies for DPB prevention.REFERENCES1 Zauber AG, Winawer SJ, O'Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Hankey BF, Shi W, Bond JH, Schapiro M, Panish JF, Stewart ET, Waye JD. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696 [PMID: 22356322 DOI: 10.1056/NEJMoa1100370]2 Jayanna M, Burgess NG, Singh R, Hourigan LF, Brown GJ, Zanati SA, Moss A, Lim J, Sonson R, Williams SJ, Bourke MJ. Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions. Clin Gastroenterol Hepatol 2016; 14: 271-278; e1-2 [PMID: 26364679 DOI: 10.1016/j.cgh.2015.08.037]3 Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh R, Moss A, Sonson R, Bourke MJ; Australian Colonic Endoscopic Mucosal Resection (ACE) Study Group. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80: 668-676 [PMID: 24916925 DOI: 10.1016/j.gie.2014.04.015]4 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A, Amato A, Berr F, Bhandari P, Bialek A, Conio M, Haringsma J, Langner C, Meisner S, Messmann H, Morino M, Neuhaus H, Piessevaux H, Rugge M, Saunders BP, Robaszkiewicz M, Seewald S, Kashin S, Dumonceau JM, Hassan C, Deprez PH. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854 [PMID: 26317585 DOI: 10.1055/s-0034-1392882]5 Tanaka S, Kashida H, Saito Y, Yahagi N, Yamano H, Saito S, Hisabe T, Yao T, Watanabe M, Yoshida M, Kudo SE, Tsuruta O, Sugihara K, Watanabe T, Saitoh Y, Igarashi M, Toyonaga T, Ajioka Y, Ichinose M, Matsui T, Sugita A, Sugano K, Fujimoto K, Tajiri H. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434 [PMID: 25652022 DOI: 10.1111/den.12456]6 Rosen L, Bub DS, Reed JF 3rd, Nastasee SA. Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum 1993; 36: 1126-1131 [PMID: 8253009 DOI: 10.1007/BF02052261]7 Gibbs DH, Opelka FG, Beck DE, Hicks TC, Timmcke AE, Gathright JB Jr. Postpolypectomy colonic hemorrhage. Dis Colon Rectum 1996; 39: 806-810 [PMID: 8674375 DOI: 10.1007/BF02054448]8 Sawhney MS, Salfiti N, Nelson DB, Lederle FA, Bond JH. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 2008; 40: 115-119 [PMID: 18253906 DOI: 10.1055/s-2007-966959]9 Zhang Q, An Sl, Chen Zy, Fu FH, Jiang B, Zhi Fc, Bai Y, Gong W. Assessment of risk factors for delayed colonic post-polypectomy hemorrhage: a study of 15553 polypectomies from 2005 to 2013. PLoS One 2014; 9: e108290 [PMID: 25271734 DOI: 10.1371/journal.pone.0108290]10 Ma MX, Bourke MJ. Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon. Best Pract Res Clin Gastroenterol 2016; 30: 749-767 [PMID: 27931634 DOI: 10.1016/j.bpg.2016.09.009]11 Liaquat H, Rohn E, Rex DK. 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 [PMID: 23317580 DOI: 10.1016/j.gie.2012.10.024]12 Matsumoto M, Fukunaga S, Saito Y, Matsuda T, Nakajima T, Sakamoto T, Tamai N, Kikuchi T. Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors. Jpn J Clin Oncol 2012; 42: 1028-1034 [PMID: 22914322 DOI: 10.1093/jjco/hys131]13 Zhang QS, Han B, Xu JH, Gao P, Shen YC. Clip closure of defect after endoscopic resection in patients with larger colorectal tumors decreased the adverse events. Gastrointest Endosc 2015; 82: 904-909 [PMID: 25975527 DOI: 10.1016/j.gie.2015.04.005]14 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25: 603-605 [PMID: 20652370 DOI: 10.1007/s10654-010-9491-z]15 Dokoshi T, Fujiya M, Tanaka K, Sakatani A, Inaba Y, Ueno N, Kashima S, Goto T, Sasajima J, Tominaga M, Ito T, Moriichi K, Tanabe H, Ikuta K, Ohtake T, Kohgo Y. A randomized study on the effectiveness of prophylactic clipping during endoscopic resection of colon polyps for the prevention of delayed bleeding. Biomed Res Int 2015; 2015: 490272 [PMID: 25722979 DOI: 10.1155/2015/490272]16 Matsumoto M, Kato M, Oba K, Abiko S, Tsuda M, Miyamoto S, Mizushima T, Ono M, Omori S, Takahashi M, Ono S, Mabe K, Nakagawa M, Nakagawa S, Kudo T, Shimizu Y, Sakamoto N. Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding. Dig Endosc 2016; 28: 570-576 [PMID: 27018874 DOI: 10.1111/den.12661]17 Sakamoto N, Beppu K, Matsumoto K, Shibuya T, Osada T, Mori H, Shimada Y, Konno A, Kurosawa A, Nagahara A, Otaka M, Ohkusa T, Ogihara T, Watanabe S. "Loop Clip", a new closure device for large mucosal defects after EMR and ESD. Endoscopy 2008; 40 Suppl 2: E97-E98 [PMID: 19085714 DOI: 10.1055/s-2007-995604]18 Mori H, Kobara H, Nishiyama N, Fujihara S, Matsunaga T, Ayaki M, Chiyo T, Masaki T. Simple and reliable treatment for post-EMR artificial ulcer floor with snare cauterization for 10- to 20-mm colorectal polyps: a randomized prospective study (with video). Surg Endosc 2015; 29: 2818-2824 [PMID: 25480613 DOI: 10.1007/s00464-014-3983-y]19 Osada T, Sakamoto N, Ritsuno H, Murakami T, Ueyama H, Matsumoto K, Shibuya T, Ogihara T, Watanabe S. Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection. Surg Endosc 2016; 30: 4438-4444 [PMID: 26895895 DOI: 10.1007/s00464-016-4763-7]20 Shioji K, Suzuki Y, Kobayashi M, Nakamura A, Azumaya M, Takeuchi M, Baba Y, Honma T, Narisawa R. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003; 57: 691-694 [PMID: 12709699 DOI: 10.1067/mge.2003.193]21 Tominaga N, Tanaka Y, Higuchi T, Yamaguchi D, Watanabe A, Ogata S, Kajiwara T. The effect of hemostasis clipping post endoscopic mucosal resection of colorectal polyps. Gastroenterol Endosc 2014; 56: 15–20 [DOI: 10.11280/gee.56.15]22 Albéniz E, Fraile M, Ibá?ez B, Alonso-Aguirre P, Martínez-Ares D, Soto S, Gargallo CJ, Ramos Zabala F, ?lvarez MA, Rodríguez-Sánchez J, Múgica F, Nogales ?, Herreros de Tejada A, Redondo E, Pin N, León-Brito H, Pardeiro R, López-Roses L, Rodríguez-Téllez M, Jiménez A, Martínez-Alcalá F, García O, de la Pe?a J, Ono A, Alberca de Las Parras F, Pellisé M, Rivero L, Saperas E, Pérez-Roldán F, Pueyo Royo A, Eguaras Ros J, Zú?iga Ripa A, Concepción-Martín M, Huelin-?lvarez P, Colán-Hernández J, Cubiella J, Remedios D, Bessa I Caserras X, López-Viedma B, Cobian J, González-Haba M, Santiago J, Martínez-Cara JG, Valdivielso E, Guarner-Argente C; Endoscopic Mucosal Resection Endoscopic Spanish Society Group. A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions. Clin Gastroenterol Hepatol 2016; 14: 1140-1147 [PMID: 27033428 DOI: 10.1016/j.cgh.2016.03.021]23 Dior M, Coriat R, Tarabichi S, Leblanc S, Polin V, Perkins G, Dhooge M, Prat F, Chaussade S. Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management? Surg Endosc 2013; 27: 2775-2781 [PMID: 23404147 DOI: 10.1007/s00464-013-2807-9]24 Harada H, Suehiro S, Murakami D, Nakahara R, Ujihara T, Shimizu T, Miyama Y, Katsuyama Y, Hayasaka K, Tounou S. Clinical impact of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection. Endosc Int Open 2017; 5: E1165-E1171 [PMID: 29201999 DOI: 10.1055/s-0043-118743]25 Kaltenbach T, Friedland S, Maheshwari A, Ouyang D, Rouse RV, Wren S, Soetikno R. Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions or = 1 cm (with video). Gastrointest Endosc 2007; 65: 857-865 [PMID: 17466205 DOI: 10.1016/j.gie.2006.11.035]26 Nishizawa T, Suzuki H, Goto O, Ogata H, Kanai T, Yahagi N. Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies. United European Gastroenterol J 2017; 5: 859-867 [PMID: 29026600 DOI: 10.1177/2050640616687837]27 Paspatis GA, Tribonias G, Konstantinidis K, Theodoropoulou A, Vardas E, Voudoukis E, Manolaraki MM, Chainaki I, Chlouverakis G. A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps. Colorectal Dis 2011; 13: e345-e348 [PMID: 21689363 DOI: 10.1111/j.1463-1318.2011.02696.x]28 Fujiya M, Sato H, Ueno N, Sakatani A, Tanaka K, Dokoshi T, Fujibayashi S, Nomura Y, Kashima S, Gotoh T, Sasajima J, Moriichi K, Watari J, Kohgo Y. Efficacy and adverse events of cold vs hot polypectomy: A meta-analysis. World J Gastroenterol 2016; 22: 5436-5444 [PMID: 27340361 DOI: 10.3748/wjg.v22.i23.5436]29 Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-383 [PMID: 6601604 DOI: 10.1136/gut.24.5.376]30 Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 2000; 51: 690-696 [PMID: 10840301 DOI: 10.1067/mge.2000.105773]31 ASGE Technology Committee., Hwang JH, Konda V, Abu Dayyeh BK, Chauhan SS, Enestvedt BK, Fujii-Lau LL, Komanduri S, Maple JT, Murad FM, Pannala R, Thosani NC, Banerjee S. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226 [PMID: 26077453 DOI: 10.1016/j.gie.2015.05.001]32 Bahin FF, Rasouli KN, Williams SJ, Lee EY, Bourke MJ. Prophylactic clipping for the prevention of bleeding following wide-field endoscopic mucosal resection of laterally spreading colorectal lesions: an economic modeling study. Endoscopy 2016; 48: 754-761 [PMID: 27110693 DOI: 10.1055/s-0042-105558]33 2013 March (Vol. 77) GIE Author Interview Series-Douglas K. Rex-YouTube [Internet]. [cited 2018 Mar 2]; Available from: Arezzo A, Passera R, Marchese N, Galloro G, Manta R, Cirocchi R. Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United European Gastroenterol J 2016; 4: 18-29 [PMID: 26966519 DOI: 10.1177/2050640615585470]35 De Ceglie A, Hassan C, Mangiavillano B, Matsuda T, Saito Y, Ridola L, Bhandari P, Boeri F, Conio M. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review. Crit Rev Oncol Hematol 2016; 104: 138-155 [PMID: 27370173 DOI: 10.1016/j.critrevonc.2016.06.008]P-Reviewer: Bustamante-Balen M, Chiu CC S-Editor: Cui LJL-Editor: A E-Editor: Zhang YLSpecialty?type: Gastroenterology and hepatology Country?of?origin: United StatesPeer-review?report?classificationGrade?A?(Excellent): 0Grade?B?(Very?good): B, BGrade?C?(Good): 0Grade?D?(Fair): 0Grade?E?(Poor): 0 Table 1 Study characteristicsStudyStudy designCountryEndoscopic Resection (n)InterventionAge, mean ± SDGender (M/F)Patients (n)Lesions (n)Lesion Size in mm, mean ± SDPedunculated (n)Right colon (n)CPEMRESDShioji et al[20], 2003RCTJapan-----413----Clip64 ± 9118/381562057.8 ± 3.96797Non-Clip63 ± 12130/371672087.8 ± 4.16590Kaltenbach et al[25], 2007CohortUnited States-----125----Clip68 ± 9100/0Not reported4916.7 ± 7Excluded49Non-clip760Dior et al[23], 2012CohortFrance------139----Clip66 (23-90)176/62Not reported75Not reportedNot reported63Non-clip64Liaquat et al[11], 2012CohortUnited States------472----Clip67.1 ± 10.9250/213Not reported22531 (20-100)1Excluded273Non-clip247Matsumoto et al[12], 2012CohortJapan403----Clip63 ± 12140/135Not reported17427.1 ± 9.6ExcludedNot reportedNon-clip229Mori et al[18], 2014RCTJapan------148----ClipNot reportedNot reportedNot reported7315.3 ± 2.84249Non-clip7515.5 ± 2.602410Tominaga et al[21], 2014RCTJapan------801----Clip67 (22-88)1151/602113857.7 (5-30)122979Non-clip66.6 (15-94)1148/682164168.5 (5-35)1245114Dokoshi et al[15], 2015RCTJapan54234----Clip67.1 ± 82109/45Not reported154< 10 mm: 98, 10-20 mm: 48, > 20 mm: 84173Non-clip67.8 ± 11299/35134< 10 mm: 86, 10-20mm: 48, > 20 mm: 6Zhang et al[13], 2015RCTChina----28662Clip67.9 ± 12.6112/6217417410-20 mm: 111, 20-40 mm: 63Excluded22Non-clip64.2 ± 9.8107/6717417410-20 mm: 107, 20-40 mm: 6727Albéniz et al[22], 2016CohortSpain----1056----Clip67.9 ± 10.9770/444Not reported28130.5 ± 11.8ExcludedNot reportedNon-clip775Matsumoto et al[16], 2016RCTJapan10642300----Clip65 (25-87)534/2187521636< 5 mm: 388, > 5 mm: 12481467823Non-clip66 (25-88)513/2347471728< 5 mm: 447, > 5 mm: 12811595845Osada et al[19], 2016RCTJapan--------26Clip68.8 ± 8.79/41313677.2 ± 3063ExcludedNot reportedNon-clip66.2 ± 10.47/61313790 ± 2203Harada et al[24], 2017CohortJapan--------211Clip70.7 ± 9.2124/87Not reported123< 30 mm: 65, 30-60 mm: 58, > 60 mm: 21450Non-Clip88< 30 mm: 23, 30-60 mm: 53, > 60 mm: 121Range; 2Standard error; 3Area in mm2. RCT: Randomized controlled trial; CP: Conventional polypectomy; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.Table 2 Incidence of delayed polypectomy bleeding and perforation following endoscopic resectionAuthor/YearEndoscopic resection (n)InterventionPolypsDPBPerforationCPEMRESDShioji et al[20], 2003-----413----Clip20520No clip20820Kaltenbach et al[25], 2007-----125-----Clip4900No clip7600Dior et al[23], 2012------139------Clip750Not reportedNo clip643Not reportedLiaquat et al[11], 2012------472-----Clip22541No clip247241Matsumoto et al[12], 2012403------Clip1743Not reportedNo clip22914Not reportedMori et al[18], 2014------148-------Clip7320No clip7500Tominaga et al[21], 2014-------801-------Clip3854Not reportedNo clip4169Not reportedDokoshi et al[15], 201554234-------Clip15440No clip13430Zhang et al[13], 2015------28662Clip17421No clip174121Albéniz et al[22], 2016------1056------Clip2814Not reportedNo clip77530Not reportedMatsumoto et al[16], 201610642300------Clip163618Not reportedNo clip172815Not reportedOsada et al[19], 2016------------26Clip1300No clip1300Harada et al[24], 2017------------211Clip12330No clip8820CP: Conventional polypectomy; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection. Figure 1 PRISMA flow diagram. Figure 2 Forrest plot of the included studies evaluating the rate of delayed polypectomy bleeding after colorectal endoscopic mucosal resection of lesions ≥ 20 mm (A) and studies evaluating the rate of delayed polypectomy bleeding after colorectal endoscopic mucosal resection of lesions ≥ 20 mm (B). Figure 3 Forrest plots on the effect of prophylactic clipping on delayed polypectomy bleeding following colorectal endoscopic resection stratified by study type (A) and the included studies comparing the rate of delayed polypectomy bleeding between clipping vs no clipping (B). Figure 4 Forrest plot of the included studies evaluating the rate of delayed polypectomy bleeding for lesions ≥ 20 mm. ................
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