Prophylactic clipping to prevent clinically significant bleeding following endoscopic mucosal resection (EMR) of colorectal lesions is not cost-effective, and not known to be highly effective for all lesions, researchers say.
Professor Michael Bourke, Director of Gastrointestinal Endoscopy at Westmead Hospital and Professor of Medicine at the University of Sydney, said there was not much data on how widespread the practice was in Australia, but anecdotally “it seems to be relatively common.”
“Clipping for the sake of clipping is not economically justified,” he told the limbic. “Nor does it add any measurable safety benefit.”
Professor Bourke was the lead author in a study published in the Endoscopy journal, which set out to evaluate the cost-effectiveness of a prophylactic clipping strategy for the prevention of clinically significant post-endoscopic bleeding (CSPEB).
“Prevention of EMR-related adverse events is of paramount importance, as expanding colorectal cancer screening programs are likely to detect more LSLs and endoscopic rather than surgical resection is becoming the preferred therapeutic modality,” the authors wrote.
“CSPEB is the most relevant EMR-related adverse event, as it is associated with significant morbidity and resource consumption.”
The rate of CSPEB is 7% overall and is significantly higher in the proximal colon (9 %) than in the distal colon (3 %), and has also been associated with significant morbidity and substantial resource utilisation.
“Effective, readily applicable, and safe prevention of CSPEB has not been realised,” the authors wrote. “Because of the low bleeding rate of conventional polypectomy, few studies have been able to achieve sufficient power to report statistically meaningful results for any prophylactic intervention.”
The authors concluded that a prophylactic clipping strategy to prevent CSPEB was six times more expensive compared with non-intervention and did not offset the cost of treating CSPEB.
“Even a selective clipping strategy in the proximal colon was found to be cost-ineffective,” they concluded.
“For prophylactic clipping to be cost-effective, the cost of clips would need to be significantly reduced. At this stage it appears that the routine application of clips to prevent CSPEB is not economically justified.”
The says an adequately powered randomised control trial targeting high-risk patients, though challenging to perform, would provide greater understanding of this issue.
However, Professor Bourke said clipping did have a place in EMR outside a prophylactic capacity. He said it should be reserved for larger lesions (greater than 20mm) located in the proximal colon, or where patients were at significant risk of post-procedure bleeding.
And as he said some 90% of polyps were 10mm or less, there was even less reason to clip prophylactically.
“There is no proven way to prevent post-procedural bleeding but we are working on it,” he said.