Reply to Matsushita

We thank Dr Matsushita and his colleagues for their interest in our report. We agree that common mucosal defects remaining after small polypectomy or endoscopic mucosal resection do not necessarily need to be closed. Matsushita points out that in the study by Shioji, clipping does not decrease the occurrence of delayed bleeding. However the number of small safety polypectomy procedures carried out in the study (mean size 7.8 mm, n = 413) was too low for a meaningful statistical analysis to be performed. Determining the efficacy of the prophylactic clip method will require analysis of many more endoscopic treatment cases, including those in high-risk groups.

Recently, the National Cancer Center Hospital (Tokyo) reported that patients treated endoscopically for large colorectal tumors (diameter > 20 mm) without placement of a prophylactic clip showed a significantly higher incidence of delayed bleeding than in those patients with a clip [1]. Although the majority of perforations are small enough to close with immediate clipping, some cases require surgical treatment due to unsuccessful closure.

Matsushita expressed anxiety about the closure of residual tumors. It is true that any lesion resected incompletely during piecemeal resection must not be closed. However, our educated opinion is that most lesions undergoing endoscopic treatment were resected completely with appropriate methods.

Matsushita also had concerns about the technical difficulty of endoscopic submucosal dissection (ESD). Some improved methods or devices, including ours [2], that are in development, should enable ESD to be carried out safely and easily. ”Loop clip”, a closure device for large mucosal defects and perforations, could be a useful tool when it is applied in appropriate cases.

Competing interests: None

References

• 1 Fukunaga S, Saito Y, Matsuda T. et al . Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors.  Gastrointest Endosc. 2008;  67 AB309
• 2 Sakamoto N, Osada T, Shibuya T. et al . The facilitation of a new traction device (S-O clip) assisting endoscopic submucosal dissection for superficial colorectal neoplasms.  Endoscopy. 2008;  DOI: DOI 10.1055/S-2007-995603