Linda A. Feagins
SAN DIEGO — Prophylactic placement of hemoclips following the removal of large colon polyps did not decrease the risk for post-polypectomy bleeding, which questions the common practice of using hemoclips during polypectomy, according to the results of a prospective, randomized study presented at Digestive Disease Week.
“We started thinking about this study back in 2011,” Linda A. Feagins, MD, AGAF, FACG, director of the inflammatory bowel diseases clinic at VA North Texas Health Care System, told Healio Gastroenterology and Liver Disease. “I had conducted a study before this where we were looking at the safety of continuing thienopyridines for patients when they were undergoing polypectomy and when we did that study, we had used a lot of prophylactic hemoclipping for our patients on those drugs. With no data to support it, just because we were concerned that they might bleed more being on anti-coagulants. However, when we analyzed the data in the end, of the five patients who had bled in that study, four of them had been prophylactically hemoclipped and so it didn’t seem to make any difference.”
Feagins said there have been other studies that have demonstrated mixed results regarding hemoclips, suggesting they are ineffective for polyps less than 1 cm in size, but may be effective for polyps larger in size.
The researchers aimed to analyze whether the use of prophylactic hemoclips after the removal of larger polyps ( 1cm in size) would result in a reduction of clinically important delayed post-polypectomy bleeding.
Additionally, the researchers aimed to determine if there were any subgroups that may benefit from hemoclipping.
“Going into the study, we felt that it was going to be a win-win no matter what the answer was,” Feagins said in an interview. “Whether the hemoclips were preventative of bleeding or not, we wanted to be able to use them for everyone to help reduce the risk of post-polypectomy bleeding, but on the other hand, if they weren’t useful, it’s very important because they cost between $150 and $200 per hemoclip and some folks will use three or four hemoclips to close a post-polypectomy defect. That's a lot of cost savings right there if they don’t do anything, you’re spending $450 to $600 for no reason.”
Feagins and colleagues conducted a randomized, prospective equivalence study of patients scheduled for elective colonoscopy across four Veterans Affairs medical centers. Researchers withdrew patients if their polyp was not greater than or equal to 1 cm.
They then randomly assigned patients 1:1 to either hemoclip or no hemoclip and then followed up via phone at 7 and 30 days.
Clinically important delayed bleeding within 30 days of polypectomy served as the primary endpoint.
Five-hundred thirty patients (age, 64.5 years; 69.8% white) received hemoclip and 520 patients (age, 64 years; 72.1% white) did not.
The most common antiplatelet and antithrombotic medications patients reported using were aspirin (48.3%, hemoclip; 46.3%, no hemoclip), NSAIDs (12.6%, hemoclip; 12.7%, no hemoclip) and warfarin (6.8%, hemoclip; 6.7%, no hemoclip).
More than half of the patients in both the hemoclip (69%) and non-hemoclip (70%) had sessile polyps. Almost all (97%) patients in both groups had their polyps removed using a hot snare.
Using a per protocol analysis, there was a small but insignificant difference (2.3%, hemoclip; 2.9%, no hemoclip) in important post-polypectomy bleeding. Additionally, similar results were found using an intent-to-treat analysis (2.2%, hemoclip; 2.7%, no hemoclip).
A multiple logistic regression analysis also found that the use of hemoclips did not predict delayed post-polypectomy bleeding (adjusted OR = 0.79; 95% CI, 0.36-1.71).
“We didn’t see any benefit and we even did a subgroup analysis for patients with polyps 2 cm or bigger and we didn’t see a benefit there,” she said.
Feagins acknowledged that there will still likely be some debate in the specialty surrounding the use of hemoclips, but that the introduction of guidelines could help.
“The one thing we don’t have at this point is guidelines on the use of hemoclips,” she said. “Hopefully from these data, and other work to come out, we will be able to come up with guidelines on who should receive hemoclips and who shouldn’t.” – by Ryan McDonald
Feagins LA, et al. Abstract 83. Presented at: Digestive Disease Week 2019; May 18-21; San Diego, California.
Disclosure: Feagins reports no relevant financial disclosures.