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DOI: 10.1055/s-0039-1681735
FACTORS ASSOCIATED WITH DIFFICULTY IN PROPHYLACTIC CLIP CLOSURE AFTER ENDOSCOPIC MUCOSAL RESECTION OF LARGE COLORECTAL POLYPS
Publication History
Publication Date:
18 March 2019 (online)
Aims:
Evaluate factors associated with inability to achieve prophylactic complete clip closure of the mucosal defect after endoscopic mucosal resection (EMR) of large ≥20 mm non-pedunculated colorectal polyps.
Methods:
This is a post-hoc analysis of a multicenter, randomized trial (CLIP study – NCT01936948) and included all patients that were randomized to the clip arm. Main outcome was complete versus incomplete closure (partial or no closure). The defect was considered completely closed when there was no remaining visible mucosal defect and clips were less than 1 cm apart. Factors associated with clip closure were evaluated in multivariate analysis.
Results:
458 patients (age 65, 58% men) with 494 large polyps were included. Complete clip closure of the resection defect was possible for 338 polyps (68.4%) and was not achieved for 156 (31.6%) polyps; 90 (18.2%) had partial and 66 (13.4%) no closure. Inability to completely close the resection defect was associated with polyp size, adenomatous vs. serrated histology, difficulties of establishing polyp access, incomplete submucosal lifting, and piecemeal resection (Table). Other factors evaluated such as patient characteristics, polyp location, polyp morphology according to Paris, type of submucosal injectate, cautery setting, or ablation of the resection margin were not associated with clip closure.
Complete closure N = 338 polyps N = 313 patients |
No complete closure. N = 156 polyps N = 145 patients |
Adjusted OR (95% CI) |
p (adjusted) |
|
Characteristics Size. *Median (IQR) *Mean (SD) Histology *Serrated, n (%) *Adenomatous, n (%) |
25 (20,31) 28.5 (12.9) 92 (86.8) 246 (63.4) |
35 (25.5). 38.4 (16.6) 14 (13.2) 142 (36.6) |
0.95 (0.93 – 0.97) (per mm increase) 1.00 0.37 (0.19 – 0.73) |
< 0.001 0.04 |
Access difficulty *Easy or moderate n (%) *Severe, n (%) |
323 (70.7) 15 (40.5) |
134 (29.3) 22 (59.5) |
1.00 0.26 (0.11 – 0.58) |
0.001 |
Mucosal-Lifting *Complete, n (%) *Incomplete, n (%) |
290 (73.8) 45 (46.4) |
103 (26.2) 52 (53.6) |
1.00 0.45 (0.26 – 0.78) |
0.05 |
Piecemeal resection *No, n (%) *Yes, n (%) |
46 (95.8) 292 (65.5) |
2 (4.2) 154 (34.5) |
1.00 0.13 (0.03 – 0.61) |
0.010 |
Conclusions:
In this multicenter study incomplete closure of the mucosal defect after EMR of large colorectal polyps was associated with polyp and procedure characteristics that reflect more difficult resections. Expertise in clipping of such lesions and investigation in improving clipping technique is needed to maximize clip closure and minimize bleeding risk of EMR.