The Prophylactic Placement of Hemoclips to Prevent Delayed Post-polypectomy Bleeding: An Unnecessary Practice? A Case Control Study

Background

With the recent, widespread availability of endoscopic hemoclips, it has become common clinical practice to apply hemoclips to some non-bleeding polypectomy sites “prophylactically” to prevent delayed post-polypectomy bleeding (PPB). Few published data support this practice, however.

Aim

The aim of this study was to compare rates of delayed PPB in matched patients who had polypectomies performed with and without the prophylactic placement of hemoclips.

Methods

We reviewed medical records of patients who had elective colonoscopy at our VA Medical Center between July 2008 and December 2009. We identified patients who had hemoclips applied prophylactically (cases) and compared their rate of delayed PPB within 30 days to that of patients who had polypectomy without hemoclipping (controls). Controls were matched 1:1 to cases based on age and on factors known to contribute to the risk of PPB including polyp size, morphology, technique of polyp removal, number of polyps removed, and use of anticoagulants.

Results

We identified 184 patients (cases) who underwent prophylactic hemoclipping and 184 well-matched controls. An average of 3.8 polyps per patient were removed in the case group compared to 3.3 polyps per patient in controls (p = 0.6). Delayed PPB occurred in three patients in the prophylactic hemoclip group and in one patient in the control group (1.6 vs. 0.5 %, p = 0.62).

Conclusions

We found no significant difference in the rate of delayed PPB between patients who had prophylactic hemoclipping of polypectomy sites and a well-matched control group of patients who had polypectomy without prophylactic hemoclipping. These data call into question the expensive practice of prophylactic hemoclipping.

     

Nomogram for the Prediction of Delayed Colorectal Post-Polypectomy Bleeding

Background: Delayed colorectal post-polypectomy bleeding (PPB) is a fairly common complication after polypectomy. The present study aimed to build a novel nomogram-based model of delayed PPB.Methods: A cohort of 2494 patients who had undergone colonoscopic polypectomy between January 2016 and April 2020 were consecutively enrolled. The patient demographics, polyp characteristics, laboratory factors, and pathological parameters were collected. The least absolute shrinkage and selection operator (LASSO) regression was applied for selecting potential variables. Multivariate logistic regression was used to develop the nomogram. A bootstrapping method was employed for internal validation. The performance of the nomogram was evaluated on the basis of its calibration, discrimination, and clinical usefulness.Results: Of 2494 patients undergoing colonoscopic polypectomy, 40 (1.6%) developed delayed PPB. The LASSO regression identified 6 variables (age, gender, polyp location, polyp morphology, antithrombotic medication use, and modality of polypectomy), and a predictive model was subsequently established. The area under the curve (AUC) of the predictive model and the internal validation were 0.838 (95% CI: 0.775-0.900) and 0.824 (95% CI: 0.759-0.889), respectively. The predictive model provided acceptable calibration, and a decision curve analysis (DCA) showed its clinical utility.Conclusion: This predictive model may enable clinicians to predict the risk of delayed PPB and optimize preoperative decision-making, for effective treatment.     

Heparin bridge therapy and post-polypectomy bleeding

AIM To identify risk factors for post-polypectomy bleeding(PPB), focusing on antithrombotic agents. METHODS This was a case-control study based on medical records at a single center. PPB was defined as bleeding that occurred 6 h to 10 d after colonoscopic polypectomy and required endoscopic hemostasis. As risk factors for PPB, patient-related factors including anticoagulants, antiplatelets and heparin bridge therapy as well as polyp- and procedure-related factors were evaluated. All colonoscopic hot polypectomies, endoscopic mucosal resections and endoscopic submucosal dissections performed between January 2011 and December 2014 were reviewed. RESULTS PPB occurred in 29(3.7%) of 788 polypectomies performed during the study period. Antiplatelet or anticoagulant agents were prescribed for 210(26.6%)patients and were ceased before polypectomy except for aspirin and cilostazol in 19 cases. Bridging therapy using intravenous unfractionated heparin was adopted for 73 patients. The univariate analysis revealed that anticoagulants, heparin bridge, and anticoagulants plus heparin bridge were significantly associated with PPB(P 0.0001) whereas antiplatelets and antiplatelets plus heparin were not. None of the other factors including age, gender, location, size, shape, number of resected polyps, prophylactic clipping and resection method were correlated with PPB. The multivariate analysis demonstrated that anticoagulants and anticoagulants plus heparin bridge therapy were significant risk factors for PPB(P 0.0001). Of the 29 PPB cases, 4 required transfusions and none required surgery. A thromboembolic event occurred in a patient who took anticoagulant. CONCLUSION Patients taking anticoagulants have an increased risk of PPB, even if the anticoagulants are interrupted before polypectomy. Heparin-bridge therapy might be responsible for the increased PPB in patients taking anticoagulants.     

Management of Anticoagulants and Antiplatelet Agents During Colonoscopy

Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.     

Endoscopic ultrasound (EUS) before gastric polyp resection: is it mandatory?

INTRODUCTION: Gastric polypectomy is associated with increased risk of bleeding. The use of endoscopic ultrasound (EUS) before polypectomy to decrease the rate of bleeding in such patients has not been studied. METHODS: All gastric polyps excised by snare polypectomy were evaluated. The primary outcome was the occurrence of immediate or delayed bleeding episodes. Postpolypectomy bleeding was correlated with the presence of blood vessels at the base of the polyp on EUS examination. Characteristics of both patients and polyps were analyzed as risk factors for postpolypectomy bleeding. RESULTS: One-hundred and two snare polypectomies were performed. Fifty-seven polyps (56%) had been evaluated by prior EUS. Bleeding occurred in 7 (7%) patients. Of these, 4 had not undergone EUS evaluation, whereas in 3 patients who had had a prepolypectomy EUS evaluation, none were found to harbor a visible blood vessel. Bleeding did not occur in any of the 8 patients in whom EUS suggested the presence of blood vessel. The size, location, type, and histology did not show any significance in predicting postpolypectomy bleeding. CONCLUSIONS: The risk of bleeding after endoscopic resection of gastric polyps was 7%. EUS evaluation before gastric polypectomy does not seem to contribute to the safety of such a procedure.     

Improving quality measures in colonoscopy and its therapeutic intervention

Colonoscopy with polypectomy has been shown to re-duce the risk of colon cancer. The critical element in the quality of colonoscopy in terms of polyp detection and removal continues to be the performance of the endoscopist, independent of patient-related factors. Im-proved results in terms of polyp detection and complete removal have implications regarding the development of screening and surveillance intervals and the reduction of interval cancers after negative colonoscopy. Advances in colonoscopy techniques such as high-definition colonos-copy, hood-assisted colonoscopy and dye-based chro-moendoscopy have improved the detection of small and flat-type colorectal polyps. Virtual chromoendoscopy has not proven to improve polyp detection but may be use-ful to predict polyp pathology. The majority of polyps can be removed endoscopically. Available polypectomy techniques include cold forceps polypectomy, cold snare polypectomy, conventional polypectomy, endoscopic mu-cosal resection and endoscopic submucosal dissection. The preferred choice depends on the polyp size and characteristics. Other useful techniques include colono-scopic hemostasis for acute colonic diverticular bleeding, endoscopic decompression using colonoscopic stenting, and transanal tube placement for colorectal obstruction. Here we review the current knowledge concerning the improvement of quality measures in colonoscopy and colonoscopy-related therapeutic interventions.     

Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy： A prospective randomized, multicenter study

AIM:To evaluate and compare the clinical outcomes of prophylactic submucosal saline-epinephrine injection and saline injection alone for large colon polyps by conventional polypectomy. METHODS:A prospective study was conducted from July 2003 to July 2004 at 11 tertiary endoscopic centers. Large colon polyps (> 10 mm in diameter) wererandomized to undergo endoscopic polypectomy with submucosal saline-epinephrine injection (epinephrine group) or normal saline injection (saline group). Endoscopic polypectomy was performed by the conventional snare method,and early (< 12 h) and late bleeding complications (12 h-30 d) were observed. RESULTS:A total of 561 polyps in 486 patients were resected by endoscopic polypectomy. Overall,bleeding complications occurred in 7.6% (37/486) of the patients,including 4.9% (12/244) in the epinephrine group,and 10.3% (25/242) in the saline group. Early and late postpolypectomy bleeding (PPB) occurred in 6.6% (32/486) and 1% (5/486) of the patients,respectively,including 4.5% (11/244),0.4% (1/244) in the epinephrine group,and 8.7% (21/242),1.7% (4/242) in the saline group. No significant differences in the rates of overall,early and late PPB were observed between the 2 groups. Multivariate stepwise logistic regression analysis revealed that large size (> 2 cm) and neoplastic polyps were independently and significantly associated with the presence of PPB. CONCLUSION:The prophylactic submucosal injection of diluted epinephrine does not appear to provide an additional advantage over the saline injection alone for the prevention of PPB.     

Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases

BACKGROUND: Anticoagulants and antiplatelet agents commonly are used to treat patients with cardiovascular and cerebrovascular diseases. Data on the safety of the use of these drugs before colonoscopic polypectomy are scanty. METHODS: An audit was conducted for a 2-year period of consecutive patients undergoing colonoscopy and polypectomy. Patient demographics, site and size of polyps, and the use of anticoagulants and antiplatelet agents were documented from a hospital on-line database. Bleeding episodes were classified as immediate or delayed and were graded as mild, moderate, or severe. Risk factors associated with postendoscopy bleeding were analyzed by multivariate logistic regression analysis. RESULTS: A total of 5593 cases were reviewed. Polypectomy was performed in 1657 patients. There were 37 cases of polypectomy-associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use, after adjustment for the effects of each of the other factors, was an independent risk factor for bleeding, with an odds ratio 13.37: 95% CI[4.10, 43.65]. Age; the location and size of polyp; and the use of aspirin, non-steroidal anti-inflammatory drugs, and other antiplatelet agents were not associated with a higher risk of polypectomy-associated bleeding. CONCLUSIONS: The use of antiplatelet agents during polypectomy was not associated with an increase in post-polypectomy bleeding. In contrast, treatment with warfarin should be discontinued, because this was associated with a significant increase in post-polypectomy bleeding.     

Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy

BACKGROUND: Residual adenoma is frequently found at the site of endoscopically resected large sessile adenomas on follow-up examination. We evaluated the efficacy of a thermal energy source, the argon plasma coagulator, to destroy visible residual adenoma after piecemeal resection of sessile polyps. METHODS: Seventy-seven piecemeal polypectomies with or without the use of argon plasma coagulator were analyzed retrospectively. All polyps were sessile, 20 mm or greater in size. The results from three groups of patients were compared. The study group was composed of patients who had visible residual adenoma after piecemeal polypectomy and had the base of the polypectomy site treated with the argon plasma coagulator. The first comparison group consisted of patients who underwent standard piecemeal polypectomy in whom the colonoscopist thought that all adenomatous tissue was removed and no further treatment was necessary. The second comparison group included patients in whom visible residual adenoma was left at the base after piecemeal resection of large adenomas. Follow-up colonoscopy was performed approximately 6 months after the initial procedure to check for recurrent/residual adenomatous tissue. RESULTS: The argon plasma coagulator was used after 30 piecemeal polypectomies in an attempt to eradicate visible residual adenomatous tissue; at follow-up, 50% of these cases had complete eradication of adenoma. The group in whom all visible tumor was removed by piecemeal polypectomy alone had an adenoma eradication rate of 54% on follow-up colonoscopy. In the patients in whom visible residual adenoma was left at the site the recurrence rate was 100% on the follow-up examination. Bleeding necessitating endoscopic therapy occurred once (3.3%) in the argon plasma coagulator group; there were four (12.5%) bleeding episodes and one (3.1%) confined retroperitoneal perforation in the complete piecemeal polypectomy group and no complications in the group in which polypectomy was incomplete. CONCLUSIONS: Argon plasma coagulator ablation of residual adenomatous tissue at the polypectomy base is safe and useful. It helps to complete the eradication of large sessile polyps when there is visible evidence of residual polyp.     

Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study.

BACKGROUND/AIMS: Polyps of the gastrointestinal tract are usually removed due to their link to bleeding, obstruction and malignancy. However, complications may occur following polypectomy. The aim of this study was to assess whether submucosal epinephrine injection before polypectomy could reduce the incidence of bleeding and perforation. METHODOLOGY: Between June 1997 and November 1999, patients with sessile polyps of the gastrointestinal tract found in our endoscopic unit were randomized to receive submucosal epinephrine injection (epinephrine group) or no injection (control group) before polypectomy. In the epinephrine group, epinephrine (1:10,000) was injected surrounding the stalk of the polyp until the mucosa was blanched and bulged. The patients were observed for complications in the following month. RESULTS: A total of 120 patients with 151 sessile polyps were enrolled in this study. In the epinephrine group, 75 polyps (n = 68) were randomized to receive epinephrine injection before polypectomy. In the control group, 76 polyps (n = 61) underwent polypectomy without epinephrine injection. In both groups, there was no significant difference in clinical features including the sizes of the polyps and their stalks, the location of polyps and the pathological diagnosis. There were a total of nine episodes of post-polypectomy hemorrhage, two in the epinephrine group and seven in the control group (2/75 vs. 7/76) (P = 0.07). One case in the epinephrine group experienced delayed bleeding (4 days later). Immediate hemorrhage occurred less in the epinephrine group than that in the control group (1/75 vs. 7/76, P = 0.03). There was one case of perforation in each group. CONCLUSIONS: Epinephrine injection prior to polypectomy is effective in preventing immediate bleeding.     

Endoscopic snare resection of large colonic polyps: how far can we go?

BACKGROUND AND AIMS: Colonoscopic polypectomy is preventing colorectal cancer. Videoendoscopy and new perendoscopic hemostasis techniques make endoscopic polypectomy of large colonic polyps an alternative to the surgical approach. This study examined whether complete snare resection of giant colonic polyps is feasible and safe and for determining how often surgery is necessary due to invasive cancer detected histologically after polypectomy. PATIENTS AND METHODS: The study included 59 consecutive patients with 68 colonic polyps larger 30 mm in diameter. Snare polypectomy was performed after an endoscopic ultrasound with a miniprobe found no sign of invasive, or, depending on the appearance of the polyp, a bleeding prophylaxis had been carried out. Acute procedural or delayed bleeding was treated endoscopically. RESULTS: Of the 68 polyps 26, mostly pedunculated were resected en bloc (38%) and histologically ensured as completely resected; 42 polyps had to be resected by piecemeal technique (62%). Piecemeal resection was performed significantly more often in sessile polyps (38/41, 93%) than in pedunculated polyps (4/27, 15%, P<0.01). Follow-up colonoscopy after 3 months showed remaining adenomatous tissue of piecemeal-resected polyps in 12 cases (28%), which were 12 resected sessile polyps (29%) and no case of resected pedunculated polyp. To achieve complete resection of sessile polyps a second procedure was necessary significantly more often than for resection of pedunculated polyps (12 cases in sessile polyps, 18% vs. no case in pedunculated polyps). Remaining adenomatous tissue was removed in all 12 cases during the first follow-up colonoscopy after 3 months, confirmed by a biopsy 6 months after the initial procedure. Overall coexisting malignancy was found in only 7 polyps (12%). Due to high-risk factors only one of them underwent secondary surgical procedure. CONCLUSION: The present study shows that endoscopic snare resection of giant colonic polyps is a safe procedure, and that secondary operative measures for managing coexisting malignancy are rarely necessary.     

Risk of colonoscopic post-polypectomy bleeding in patients after the discontinuation of antithrombotic therapy

Background/AimsFew studies have examined the incidence of post-polypectomy bleeding (PPB) after discontinuation of antithrombotic therapies. Therefore, this study aimed to evaluate the incidence of PPB and thromboembolic events in patients whose antithrombotic agents were discontinued before colonoscopy.Materials and MethodsWe retrospectively selected all patients who underwent colon polypectomy at a community hospital. A total of 282 patients (540 polypectomies) discontinued antithrombotic agents (group 1), and 1,648 patients (2,827 polypectomies) did not take antithrombotic agents (group 2). The cessation periods before and after polypectomies were 4 and 3 days for warfarin, 5 and 3 days for anti-platelet agents, and 7 and 5 days of combination therapy, respectively. Main outcome measurements were the incidence of PPB and thromboembolic events.ResultsImmediate PPB rates were 3.9% (11/282) in group 1 and 4.6% (76/1648) in group 2 (adjusted odds ratio [OR], 0.85; 95% confidence interval [CI], 0.42–1.72; p=0.65). Delayed PPB rates were 1.4% (4/282) in group 1 and 1.1% (18/1648) in group 2 (adjusted OR, 1.24; 95% CI, 0.36–4.24; p=0.732). No thromboembolic events were observed in either group.ConclusionOur cessation periods were appropriate, and further shortening of these periods is possible.     

Risk and cause of interval colorectal cancer after colonoscopic polypectomy

Background: To investigate the cause and risk of interval colorectal cancer (ICC) in patients undergoing surveillance colonoscopy within 5 years after colonoscopic polypectomy. Patients and Methods: We retrospectively analyzed data (endoscopy, pathology, demography) of patients who received surveillance colonoscopy within 5 years after colonoscopic polypectomy. Results: Among 1,794 patients undergoing surveillance colonoscopy within 5 years after colonoscopic polypectomy, 14 suffered from ICC. The mean follow-up time was 2.67 years and the incidence density of ICC was 2.9 cases per 1,000 person-years. 50% of ICCs were found in patients in whom adenomas had been incompletely removed by endoscopic therapy, 36% were missed cancers, and 14% were new cancers. Age >60 years (OR 2.97, 95% CI 2.31-3.82) was significantly associated with interval cancer on the surveillance colonoscopy as were advanced adenoma (OR 1.28, 95% CI 1.01-1.62), the presence of villous (HR 1.38, 95% CI 1.03-1.85) and high-grade dysplasia (OR 1.61, 95% CI 1.07-2.42). Conclusions: Among patients undergoing surveillance colonoscopy within 5 years after polypectomy, the incidence density of ICC was 2.9 cases per 1,000 person-years. The majority of interval cancers originated from incomplete resection of advanced adenomas and missed cancers, which can be prevented by improving endoscopic techniques and selecting an appropriate follow-up time interval.     

金属夹联合尼龙套圈在内镜带蒂大息肉摘除中的应用

背景：消化道出血是内镜息肉摘除术最常见的并发症。目的：观察金属夹联合尼龙套圈对内镜带蒂大息肉摘除术的效果和安全性。方法：选取2011年6月一2012年8月上海市第一人民医院分院89例带蒂大息肉患者,分为尼龙套圈组（A组）和金属夹联合尼龙圈套组（B组）,回顾性分析息肉形态、部位、大小以及并发症发生率。结果：A组和B组息肉形态均以山田Ⅳ型为主,主要位于乙状结肠,两组患者性别、年龄、息肉顶部、蒂部平均直径相比均无明显差异（P〉0．05）。A组和B组的术中出血发生率（12．8％对10．0％）、术后迟发性出血发生率（10．3％对4．0％）相比均无明显差异（P〉0．05）,经治疗后出血均停止。A组2例患者术后3个月息肉复发,B组手术创面愈合良好,无息肉残端残留。结论：金属夹联合尼龙套圈能有效预防内镜下带蒂大息肉切除术中和术后的出血。     

Aspirin does not increase bleeding complications after transbronchial biopsy

STUDY OBJECTIVES: The present study was performed to determine whether the risk of bleeding after transbronchial lung biopsy is increased in patients taking aspirin. DESIGN: Prospective cohort study. PATIENTS AND INTERVENTIONS: After excluding patients with other coagulation problems, 1,217 patients who had undergone transbronchial lung biopsy during a prospective 1.5-year study period were included in this study. The use of aspirin was not discontinued before the procedure. Two hundred eighty-five patients (23%) had consumed aspirin within 24 h of the procedure, and most of them (82%) used aspirin on a daily basis. Transbronchial biopsies were performed, and the bleeding incidence was compared between the groups. RESULTS: A total of 57 patients (4.7%) experienced procedure-related bleeding. Minor bleeding occurred in 5 of 285 patients (1.8%) taking aspirin and in 27 of 932 control patients (2.9%; not significant). Moderate bleeding was seen in 3 of 285 patients (1.1%) in the aspirin group and in 13 of 932 patients (1.4%) in the control group (not significant). Major bleeding occurred in only 9 patients, 2 of 285 (0.9%) in the aspirin group and 7 of 932 (0.8%) in the control group (not significant). All bleeding was controlled by endoscopic means, and there were no fatalities and no need for blood transfusions. CONCLUSIONS: We conclude that the risk of severe bleeding after transbronchial lung biopsy is small (ie, < 1%) and that the use of aspirin is not associated with any increased risk of bleeding.     

Look out before polypectomy in patients with diverticular disease �C a case of a large, inverted diverticulum of the colon resembling a pedunculated polyp

Diverticular disease of the colon may be responsible for abdominal symptoms requiring colonoscopy, which may reveal the presence of concomitant polyps. A polyp found during colonoscopy in patients with colonic diverticular disease may be removed by endoscopic polypectomy with electrosurgical snare, a procedure associated with an incidence of perforation of less than 0.05%. The risk of such a complication may be higher in the event of an inverted colonic diverticulum, which may be misinterpreted as a polypoid lesion at colonoscopy. To date, fewer than 20 cases of inverted colonic diverticula, diagnosed at colonoscopy or following air contrast barium enema, have been reported in the literature. The present report describes a 68-year-old woman who underwent a screening colonoscopy, which revealed a voluminous pedunculated polyp that was recognized to be an inverted giant colonic diverticulum before endoscopic polypectomy.     

A Large Juvenile Polyp Successfully Treated by Endoscopic Polypectomy with a Detachable Snare

Abstract: A 43-year-old man was referred to our hospital because of a three week history of intermittent hematochezia. Barium enema study and colonoscopy revealed a large pedunculated polyp measuring 35 mm in diameter in the descending colon. Endoscopic polypectomy was performed using a detachable snare as an auxiliary device to ensure hemostasis. The detachable snare was considered useful in performing endoscopic polypectomy for this pedunculated polyp which had a particularly thick stalk. Furthermore, we consider this device to potentially play an important role in widening the indications for endoscopic polypectomy.     

Clips for the prevention and treatment of postpolypectomy bleeding (hemoclips in polypectomy).

INTRODUCTION: The most accurate method for the prevention and treatment of complications after polypectomy has not been well defined. The prophylactic use of hemoclips may reduce the risk of bleeding, mainly in pedunculated big polyps. OBJECTIVE: To evaluate the accuracy of hemoclips in the prophylaxis and treatment of bleeding after endoscopic polypectomy. MATERIAL AND METHODS: Retrospective study of 223 consecutive endoscopic polypectomies performed in our Endoscopy Unit between january and october 2001. Hemoclips were routinely used only for large polyps (15 to 40 mm); all of them were located in the colon except one, a gastric polyp. RESULTS: From a total of 223 polypectomies (215 patients), hemoclips were used for 34 (15.2%), in 30 of them just before and in 4 just after polypectomy. When used prophylactically no complication was observed, except one mild bleeding episode (3.3%) that stopped with the placing of a second hemoclip. The therapeutic clipping (4 polypectomies) induced immediate haemostasis in all cases. CONCLUSIONS: The prophylactic use of hemoclips is associated with a very low risk of bleeding after endoscopic resection of big polyps. Therapeutic clipping is an effective measure for polypectomy-related bleeding.     

Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study

OBJECTIVES: The aims of this prospective study were to document the incidence of colon immediate postpolypectomy bleeding (IPPB) according to grade, and to identify potential risk factors of IPPB in patients who have received complete colonoscopy and polypectomy because of a colorectal polyp. METHODS: This was a prospective, cross-sectional study of 5,152 patients treated at 11 tertiary medical centers between July 2003 and July 2004. Patient-related, polyp-related, and procedure-related variables were evaluated as potential risk factors for IPPB. IPPB was defined as a bleeding occurring during the procedure and was graded as G1-G4. Risk factors associated with IPPB were analyzed by univariate and multivariate logistic regression analysis. RESULTS: A total of 9,336 colonic polyps were removed in 5,152 patients, and 262 (2.8%) colorectal polyps in 215 patients presented with IPPB. Polyp-based multivariate analysis revealed that old age (>or=65 yr), comorbid cardiovascular or chronic renal disease, anticoagulant use, polyp size greater than 1 cm, gross morphology of polyps such as pedunculated polyp or laterally spreading tumor, poorer bowel preparation, cutting mode of the electrosurgical current, and the inadvertent cutting of a polyp before current application were significant risk factors for IPPB. CONCLUSION: Nine factors have been found to be associated with IPPB and polypectomy should be undertaken with caution under these conditions.     

Current standards and new developments of colorectal polyp management and resection techniques

Introduction: Colonoscopy and endoscopic removal of precancerous polyps play an important role in colorectal cancer (CRC) prevention. Improved endoscopes and quality standards have led to an increasing polyp and adenoma detection rate. Optimal polyp resection techniques and management strategies are key for an effective colonoscopy practice.

Areas covered: Strategies for how to improve diminutive polyp (polyps up to 5 mm in size) management are discussed because of their high prevalence. Systematic removal of diminutive polyps leads to increasing costs of colonoscopy practice, while the effect on colorectal cancer prevention might be negligible. Furthermore, polypectomy recommendations for mid-size and large polyps are provided. For all larger polyps larger, complete and safe resection is mandatory to avoid post colonoscopy cancers. The focus for managing such larger polyps is to use new techniques (i.e. cold snares) and to attempt complete removal and to reduce post-polypectomy complications.

Expert commentary: The resect-and-discard strategy is a promising management strategy for diminutive polyps. However, modification of this approach might be required in order to make widespread adoption feasible. Cold snare polypectomy is a promising new approach for small polyp resection. For resection of large polyps adequate treatment recommendations with regard to endoscopic mucosal resection and complication prevention are provided.