Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection

Figures & data

Figure 1. Zipper closure. Small or oval elongated lesions are clipped in a zipper fashion (30), starting in one corner and working clip by clip to the other corner. With every clip that is placed, the edges close to the clip are pulled a bit closer to each other, so the subsequent clips will easier reach the opposite wound margins.

Figure 2. Mechanism of action of TTS clip and Ovesco clip. (a). Endoscopic clipping of the mucosal layer with regular clips. (b). 3. The target tissue is sucked in the cap. The Twingrasper or Anchor devices (Ovesco Endoscopy AG, Tübingen, Germany) can be used to grab the target tissue and pull the margins into the cap, especially in case of tissue induration. 4–5. When the Ovesco clip is deployed, the clip teeth may slightly push the tissue out of the cap. If the margins of the lesion are not completely inside the cap, this may result in incomplete closure.

Figure 3. Approximating the peripheral wound edges prior to Zipper closure. Larger or round lesions, where the edges are further apart, can benefit from placing a clip in two opposite peripheries of the wound surface, making it more almond-shaped. After doing this, clipping can be continued between the clips in a zipper fashion.

Table 1. Overview of studies on prophylactic clipping.

Name, Year, N	Study design	Procedure	Polyp type	Polyp dimension	Polyp location	DB* (clip vs control)
Liaquat, 2010, 524 [38]	Retrospective study Tertiary Referral Center	EMR Resolution clip	Flat	≥20 mm Mean 31 mm (20–100 mm)	Colo-rectal 75% proximal of the splenic flexure	1.8% vs 9.7% (p = 0.001)
Albeniz, 2016, [50] 1255	Prospective multicentre study (23 centres)	EMR Clip unknown	Flat	≥20 mm	Colo rectal (51,3% proximal to SF)	1,4% vs 3,9% (p < 0.001)
Zhang, 2015, [47] 348	RCT, Tertiary Referral Center	EMR/ESD Combination EMR/ESD Resolution clip, QuickClip?	Flat	10–40 mm ≥20 mm: 37 vs 38%	Colo rectal 39 vs 29% proximal to the splenic flexure	1.1% vs 6.9% (p = 0.012)
Dokoshi, 2015, [46] 288	RCT, Tertiary Referral Center	EMR/Polypectomy Resolution HX-610-135 clips (Olympus Co., Ltd., Tokyo, Japan)	All types (86% flat)	≥20 mm	Colorectal 50% proximal to the splenic flexure	3.7% vs 3.0% (ns)
Feagins, 2014, [48] 184 clips, 184 matched controls	Case control, single centre	EMR/Polypectomy Clip unknown	All types (85% sessile)	≥20 mm: 8 vs 7%	Colo rectal, 48% right-sided.	1.6 vs. 0.5%, p = 0.62
Shioji, 2003, [45] 413	Prospective study Tertiary Referral Center	EMR/polypectomy HX5QR-1, Olympus	All types (68% flat)	Mean 7.8mm	Colorectal 43–47% proximal of the splenic flexure	0.98 vs 0.96 (p = 0.999)

These studies were performed on heterogeneous groups including all types of polyps from all sizes and locations in the colon. The higher up in the table a study is shown, the larger the subgroup of patients with high risk for DB in the study population was. The study outcomes show a corresponding increase in effect: there is a larger difference in DB rates between the clip groups en de control groups and p-values are closer to statistical significance higher up in the table. *DB: Delayed Bleeding.

Table 2. Clinical trials on prophylactic clipping after EMR.

#	Trial name	Trial number	Trial conducter
1	CLIPPER trial	NCT03309683	Dutch EMR Study Group, the Netherlands
2	-	NCT02765022	Fundacion Miguel Servet, Spain
3	CuRB study	NCT02196649	Westmead Endoscopy Unit, Australia
4	-	NCT01647581	Texas’ VA medical Centers, USA
5	CLIP study	NCT01936948	White River Junction VAMC, USA

The interim safety analysis of trial #4 was presented at the 2017 DDW in Washington, the US.(51) Results of trial #5 were recently presented on the DDW 2018 in Washington, the US. Results of trial #2 were recently presented on the ESGE 2019 in Prague, the Czech Republic.

Figure 4. (a). Prophylactic clip closure of resection field after piecemeal EMR. (b). Clip artifact in scar after EMR with HDWLE and Iscan.

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