Should colorectal endoscopic submucosal dissection defects be closed just because we can?

We read with interest the paper by Farha et al. [1], entitled “A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study.” The study reports a 93 % technical success rate for defect closure using a new through-the-scope (TTS) closure system. The delayed bleeding rate was 1.2 %, and the authors have suggested closure reduces this rate.

Although the novelty of this system is attractive, several of the results must be questioned. Only 54 % of the defects could be closed by suturing alone in this retrospective study. The intention-to-treat analysis in a recent large randomized trial demonstrated that classic clips, which are less expensive, particularly in Europe, and easier to use, allowed complete closure in 68 % of cases [2]. The median size of the defect in that study was 30 mm, which is similar to this trial. Simple tricks, like anchoring the clips [3], may further increase the closure rate.

Moreover, the need for closure should also be questioned. Defect closure has been shown to reduce right colonic bleeding after large endoscopic mucosal resections (EMRs) in three high level randomized controlled trials [2] [4] [5]. There is however a lack of strong scientific evidence supporting the closure of colorectal endoscopic submucosal dissection (ESD) defects, and the available retrospective data are conflicting. The differences in risk factors for delayed bleeding after ESD and EMR (i. e. rectum [6] and right colonic locations, respectively) indicate that the two procedures must be considered to be distinct from each other in terms of post-procedure bleeding. Therefore, results for EMRs may not be directly applicable to ESDs.

Several new devices, gels, and powders have recently been introduced to prevent delayed bleeding after colorectal ESD because this is a fast growing market in the West; however, there is no strong evidence to support their daily use at this time. Given the potential costs and environmental impact of these new devices, high quality randomized trials are urgently needed to assess their efficacy and ensure that they do not merely reassure the physician.

Publication History

Article published online:
27 September 2023

• References

• 1 Farha J, Ramberan H, Aihara H. et al. A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study. Endoscopy 2023; DOI: 10.1055/a-1970-5528.
• 2 Pohl H, Grimm IS, Moyer MT. et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; 157: 977-984.e3
• 3 Héroin L, Pioche M, Lafeuille P. et al. Clip-anchoring technique: a fast, cheap, and efficient way to close a gastric peroral endoscopic pyloromyotomy tunnel. Endoscopy 2022; 54: E590-E591
• 4 Albéniz E, Álvarez MA, Espinós JC. et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 2019; 157: 1213-1221.e4
• 5 Gupta S, Sidhu M, Shahidi N. et al. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7: 152-160
• 6 Seo M, Song EM, Cho JW. et al. A risk-scoring model for the prediction of delayed bleeding after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2019; 89: 990-998.e2