Jessica Yu, MD, MS
Ann Arbor, Michigan
Babu P. Mohan, MD1, Ravishankar Asokkumar, MRCP2, Jessica X. Yu, MD, MS3, Tonya Kaltenbach, MD, MS, FACG4, Roy Soetikno, MD, MS5
1University of Arizona / Banner University Medical Center, Tucson, AZ; 2Singapore General Hospital, Singapore, Singapore; 3University of Michigan, Ann Arbor, MI; 4University of California San Francisco, Veterans Affairs San Francisco Healthcare System, San Francisco, CA; 5Advanced GI Endoscopy, Los Altos, CA
Introduction: Published data on the risk of delayed bleeding (DB) after endoscopic resection of large colorectal lesions (≥1cm) are conflicting. Prior systematic analyses were underpowered. We systematically reviewed the current data, focusing on randomized studies, to compare the risk of DB with and without clipping, and to determine its cost-effectiveness. We hypothesized that prophylactic clipping is the preferred strategy.
Methods: We conducted a systematic search in PubMed and the Cochrane library to identify RCTs that compared the DB outcomes of prophylactic clipping vs. no clipping after resection of large polyps. We estimated pooled odds ratios (ORs with 95% CIs). Using the 2016 CMS reimbursement rates for procedure and hospitalization and price of clips estimated from the VHA system, we created a decision tree to model the cost: the initial procedure was estimated to be the cost of a colonoscopy with EMR and three clip placement or no clip. We assumed that some patients who had DB required repeat colonoscopy. Our primary outcome is the total cost. We sought to determine the cost of clips that would make the strategies equal.
Results: Six studies, which included 2002 patients with 3736 polyps in the clipping arm and 1996 patients with 3717 polyps in the no clipping arm met eligibility criteria for the meta-analysis. Prophylactic clipping of large polyps had a reduced risk of DB compared to those without clipping: OR 0.60 (95%CI:0.38–0.92) with the random effects and OR 0.59 (95%CI:0.39–0.89) with the fixed effects models. There was no significant heterogeneity (I2=7%, p=0.37). The pooled risks of bleeding with clipping was 2.3% (95%CI:0.8–6.1%) and 3.6% (95%CI:1.2–10.3%) without clipping. In the meta-regression analysis, there was no significant difference based on antithrombotic use (p=0.57) or lesion size (p=0.79). Using a base case of 3 clips placed in the clipping arm (cost = $522), we found that the strategy of prophylactic clipping cost $1517.91 compared to $1179.69 for no clipping. The prophylactic clipping strategy cost $11,274 for each rebleed prevented. The two strategies however became equivalent in cost if the total cost of clipping is lower than $183.
Discussion: Our analysis suggests that prophylactically clip placement after resection of large (≥1cm) polyp reduces the risk of DB. Such a strategy is cost-effective if the cost of the clip(s) used is less than $183.
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Citation: Babu P. Mohan, MD; Ravishankar Asokkumar, MRCP; Jessica X. Yu, MD, MS; Tonya Kaltenbach, MD, MS, FACG; Roy Soetikno, MD, MS. P1016 - IS PROPHYLACTIC CLIPPING NECESSARY AFTER THE RESECTION OF LARGE (≥1CM) COLORECTAL LESIONS? IF SO, AT WHAT COST?. Program No. P1016. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.