Prophylactic clipping after colorectal endoscopic submucosal dissection does not reduce delayed bleeding rates: a multicenter propensity-score matched analysis

Aims Clinically significant delayed bleeding (CSDB) is the most common complication following colorectal endoscopic submucosal dissection (ESD). The Limoges Bleeding Score was recently developed to identify patients at risk of CSDB after colorectal ESD. The effectiveness of prophylactic clipping to prevent bleeding remains a subject of ongoing debate. This study aimed to evaluate the real-world efficacy of complete clip closure in preventing CSDB after colorectal ESD.

Methods We conducted a retrospective analysis of prospectively collected data from ten centers between 2019 and 2022. Pre- and periprocedural data were collected prospectively, while post-procedural data, including the evaluation of CSDB, were collected retrospectively. All epithelial colorectal lesions treated with ESD were included. We excluded JNET III lesions and non-en bloc resections. Patients were divided into closure and non-closure groups, which were compared before and after propensity-score matching (PSM) based on the Limoges Bleeding Score risk factors (age>75 years, lesion size>50 mm, ASA III-IV, rectal location, and use of anticoagulant/antiplatelet agents). We further analyzed post-ESD CSDB in subgroups of patients on anticoagulants and those at high risk of bleeding (5 to 8 points according to the Limoges score).

Results A total of 3,142 patients were included, with 1,199 in the closure group and 1,943 in the non-closure group. Overall, 216 patients (7%) developed CSDB after ESD without significant differences between the two groups (7.2% in the closure group vs 6.7% in the non-closure group; p=0.06). Multivariate analysis identified the following predictive factors for CSDB: age≥75 years [Odds Ratio (OR) 1.38, 95%CI 1.01-1.87)], ASA III-IV status (OR 1.6, 95%CI 1.15-2.23), and use of antithrombotic agents (anticoagulants: OR 2.27, 95%CI 1.58-3.27; antiplatelets: OR 1.9, 95%CI 1.35-2.69), while a lesion size<50 mm was associated with lower CSDB rates (OR 0.49, 95%CI 0.36-0.68). PSM based on Limoges Bleeding Score risk factors created 944 matched pairs. The CSDB rates were not significantly different between the groups also after PSM (closure group: 7.73% vs non-closure group: 5.72%; p=0.098). Subgroup analysis of patients on anticoagulants (164 in the closure group vs 246 in the non-closure group) and those identified as high-risk by the Limoges score (180 in the closure group vs 524 in the non-closure group) found no significant differences in CSDB between the groups (p=0.39 and p=0.73, respectively).

Conclusions In our study population, prophylactic clipping following colorectal ESD did not significantly reduce the incidence of CSDB. This finding remained consistent even after PSM analysis and when the analysis was restricted to high-risk populations. Considering the technical challenges associated with complete clip closure, it may be best reserved for selected clinical scenarios [1] [2] [3] [4] [5].

Publication History

Article published online:
27 March 2025

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