Prospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Mar 16, 2017; 9(3): 133-138
Published online Mar 16, 2017. doi: 10.4253/wjge.v9.i3.133
Clipping prevents perforation in large, flat polyps
Daniel Luba, Mona Raphael, Dayna Zimmerman, Joseph Luba, Jon Detka, James DiSario
Daniel Luba, James DiSario, Monterey Bay Gastroenterology Consultants, Monterey, CA 93940, United States
Mona Raphael, Saint George’s University School of Medicine, Saint George, Grenada
Dayna Zimmerman, Drexel University College of Medicine, Philadelphia, PA 19102, United States
Joseph Luba, Vanderbilt University, Nashville, TN 37203, United States
Jon Detka, California State University Monterey Bay, Monterey, CA 93955, United States
Author contributions: Luba D and DiSario J designed research, performed research; Luba D contributed new technique to remove and clip polyps; Luba D, Raphael M, Zimmerman D, Luba J, Detka J and DiSario J analyzed data, wrote paper.
Institutional review board statement: The study was reviewed and approved by the Community Hospital of the Monterey Peninsula (Monterey, CA, United States) Institutional Review Board.
Informed consent statement: All study participants provided written consent prior to study enrollment.
Conflict-of-interest statement: The authors of this manuscript have no conflicts of interest to disclose.
Data sharing statement: There is no additional data available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Daniel Luba, MD, Monterey Bay Gastroenterology Consultants, 23 Upper Ragsdale Dr, Monterey, CA 93940, United States. dluba@montereygi.com
Telephone: +1-831-3753577 Fax: +1-831-3751478
Received: July 24, 2016
Peer-review started: July 25, 2016
First decision: September 7, 2016
Revised: October 12, 2016
Accepted: December 13, 2016
Article in press: December 14, 2016
Published online: March 16, 2017
Processing time: 233 Days and 14 Hours
Abstract
AIM

To determine if prophylactic clipping of post-polypectomy endoscopic mucosal resection (EMR) mucosal defects of large, flat, right sided polyps prevents perforations.

METHODS

IRB approved review of all colonoscopies, and prospective data collection of grasp and snare EMR performed by 2 endoscopists between January 1, 2010 and March 31, 2014 in a community ambulatory endoscopy center. The study consisted of two phases. In the first phase, all right-sided, flat polyps greater than or equal to 1.2 cm in size were removed using the grasp and snare technique. Clipping was done at the discretion of the endoscopist. In the second phase, all mucosal defects were closed using resolution clips. Phase 2 of the study was powered to detect a statistically significant difference in perforation rate with 148 EMRs, if less than or equal to 2 perforations occurred.

RESULTS

In phase 1 of the study, 2121 colonoscopies were performed. Seventy-five patients had 95 large polyps removed. There were 4 perforations in 95 polypectomies (4.2%). The perforations occurred in polyps ranging in size from 1.5 cm to 2.5 cm. In phase 2, there were 2464 colonoscopies performed. One hundred and sixteen patients had 151 large polyps removed, and all mucosal defects were clipped. There were no perforations (P = 0.0016). There were no post-polypectomy hemorrhages in either phase. An average of 2.15 clips were required to close the mucosal defects. The median time to perform the polypectomy and clipping was 13 min, and the median procedure duration was 40 min. Five percent of all patients undergoing colonoscopy in our community based, ambulatory endoscopy center had flat, right sided polyps greater than or equal to 1.2 cm in size.

CONCLUSION

Prophylactic clipping of the mucosal resection defect of large, right-sided, flat polyps reduces the incidence of perforation.

Keywords: Flat polyps; Complications; Perforation; Polypectomy; Prevalence; Clipping; Endoscopic mucosal resection

Core tip: Large, flat, right sided polyps are being recognized with increasing frequency, and have become one of the more technically challenging aspects of colonoscopy. In a prospective study of over 4500 consecutive colonoscopies performed in a community, ambulatory endoscopy center, the prevalence of these polyps was 5%. We showed that it was safe to remove these polyps in the outpatient setting, and that clipping the mucosal defect prevented perforations. An average of 2 clips were required to close the defects, and the average polypectomy time was 13 min. It is not necessary to perform these procedures in a hospital setting.