Clip or loop? Which modality can we call “A stitch in time saves nine”?

The article by Ji et al. was read with interest [1]. It is reassuring to note that clip application is as good as the endoloop in reducing the risk of postpolypectomy bleeds. Placement of prophylactic endoscopic clips after polypectomy has been found to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy [2].

The authors mention that three patients who had immediate bleeding were on either anticoagulant or antiplatelet therapy prior to colonoscopy. They mentioned that these therapies were stopped at least 5 days before endoscopy. Current guidelines suggest that this should be done 7 – 10 days prior to colonoscopy [3] [4]. Do the authors retrospectively feel that they should have stopped these medications sooner?

The advantages of the clip over the endoloop are ease of use, shorter procedure, and clear identification of the device at angiography, should this become necessary. It would be interesting to know whether a cost analysis was conducted as part of the study, or read comments from the authors regarding the costs of the two modalities.

Previous studies have demonstrated the benefits of endoloop placement both pre- and postpolypectomy [5] [6] along with clip application, but no study has compared the outcomes of these different timings. It would be interesting to read the authors’ views about the timing of device placement.

• References

• 1 Ji JS, Lee SW, Kim TH et al. Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study. Endoscopy 2014; 46: 598-604
• 2 Parikh ND, Zanocco K, Keswani RN et al. A cost-efficacy decision analysis of prophylactic clip placement after endoscopic removal of large polyps. Clin Gastroenterol Hepatol 2013; 11: 1319-1324
• 3 Anderson MA, Ben-Menachem T, Gan SI et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
• 4 Veitch AM, Baglin TP, Gershlick AH et al. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008; 57: 1322-1329
• 5 Kouklakis G, Mpoumponaris A, Gatopoulou A et al. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 2009; 23: 2732-2737
• 6 Mizukami T, Hiroyuki I, Hibi T. Anchor clip technique helps in easy prevention of post-polypectomy hemorrhage of large colonic polyps. Dig Endosc 2010; 22: 366-369