Endoscopy 2014; 46(10): 910
DOI: 10.1055/s-0034-1378083
Letters to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Reply to Thoufeeq

Tae Ho Kim
,
Jeong-Seon Ji
,
Hwang Choi
Further Information

Publication History

Publication Date:
01 October 2014 (online)

We read the Letter by Dr. Thoufeeq with great interest and would like to respond to his concerns.

Unfortunately, we did not carry out cost analysis in our study. Luigiano et al. [1] reported that endoclip-assisted polypectomy is much more expensive than the endoloop-assisted procedure. In their paper, the cost of the technique with loops was € 86.2 per patient, whereas that of the technique with clips was € 297.3. However, the clip technique resulted in several patients avoiding colon resection and the associated increase in surgical risks and costs.

In our trial, patients taking anticoagulant or antiplatelet therapy for noncritical problems were instructed to discontinue the use of these drugs at least 5 days before the polypectomy [2]. They were instructed to restart their therapy on the day after the procedure if there was no hematochezia. Three of the nine patients who had immediate bleeding were undergoing antiplatelet or anticoagulant therapy prior to polypectomy. One patient from the endoloop group was taking antiplatelet medication. In the clip group, one patient was taking antiplatelet agents and the other was taking anticoagulant therapy. Actually, they discontinued the use of these drugs for 7 days before the polypectomy and restarted them on the day after the procedure.

Immediate bleeding from the stalks of pedunculated polyps can be prevented by application of endoloops, either before or after polypectomy [1] [3] [4]. The proper position for the electrocautery snare is around the upper half of the stalk. This position allows room to place an endoloop on the remnant stalk after conventional polypectomy when the stalk is sufficiently long. However, the endoloop is usually difficult to apply to the residual stalk after polypectomy. Matsushita et al. [5] reported they could not effectively apply endoloops to the remnant stalk. After conventional polypectomy, an endoloop was applied to the remnant stalk in five lesions for prevention of delayed bleeding or endoscopic hemostasis. In three of these lesions, the endoloop could not be applied effectively because of flattening and shortening of the remnant stalk. In one of the two lesions for which endoscopic hemostasis was attempted, bleeding could not be controlled with the endoloop. The authors therefore recommended placing the endoloop on the stalk before polypectomy.

We also do not recommend application of the endoloop after conventional polypectomy because the remnant stalk becomes too short, which increases the chance of a technical failure. In cases of a short remnant stalk with bleeding, other hemostatic techniques, such as injection of epinephrine, argon plasma coagulation, and application of hemoclips, should be used.

As mentioned in our paper, our results suggest that the application of a prophylactic clip is as safe and effective as an endoloop in the prevention of postpolypectomy bleeding in large pedunculated colonic polyps. Large scale, randomized, clinical trials are required to compare efficacy and cost effectiveness of the two groups.

 
  • References

  • 1 Luigiano C, Ferrara F, Ghersi S et al. Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome. Dig Dis Sci 2010; 55: 1726-1731
  • 2 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
  • 3 Fatima H, Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 2007; 17: 145-156
  • 4 Iishi H, Tatsuta M, Narahara H et al. Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc 1996; 44: 594-597
  • 5 Matsushita M, Hajiro K, Takakuwa H et al. Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps. Gastrointest Endosc 1998; 47: 496-499