Prophylactic Clip Closure for the Prevention of Delayed Bleeding After EMR of Proximal Large Nonpedunculated...

Clinically significant post-endoscopic mucosal resection bleeding (CSPEB) is one of the most common adverse events after EMR. In this meta-analysis, we evaluated the efficacy of prophylactic clipping after EMR of proximal, large (≥ 20 mm) nonpedunculated colon polyps.

We reviewed several databases from inception to September 19, 2025. Outcomes of interest were CSPEB, perforation, post-polypectomy syndrome, and abdominal pain. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random effects model. Subgroup analyses were performed based on trials conducted in specialized/high-volume tertiary referral settings vs mixed practice settings (including community and nonacademic hospitals).

There was no significant difference in risk of CSPEB between the groups RR, 0.59(95% CI 0.28, 1.23), τ² = 0.43, p = 0.16, I² = 65%. Subgroup analysis showed prophylactic clipping was associated with reduced CSPEB in trials conducted in specialized, high-volume tertiary referral settings, RR, 0.34 (95% CI 0.20, 0.57). However, trials conducted in mixed or community-based settings have not demonstrated a similar benefit, RR, 1.44 (95% CI 0.75, 2.78). Clipping corresponds to an ARR of 3.6%, yielding an NNT of 28. Certainty of evidence was low based on GRADE framework (due to inconsistency and imprecision). There was no statistically significant difference in risk of perforation between the groups RR, 0.68(95% CI 0.19, 2.41), τ² = 0, p = 0.55, I² = 0. Certainty of evidence was moderate (due to imprecision). There was no statistically significant difference in risk of post-polypectomy syndrome between the groups RR, 1.67(95% CI 0.47, 5.89), τ² = 0, p = 0.43, I² = 0. Certainty of evidence was moderate (due to imprecision). There was no statistically significant difference in abdominal pain rates between the groups RR, 1.00(95% CI 0.36, 2.71), p = 0.99, τ² = 0, I² = 0. Certainty of evidence was moderate (due to imprecision).

In conclusion, this study demonstrates that prophylactic clip closure after EMR of proximal large nonpedunculated colorectal polyps did not present a statistically significant reduction in CSPEB. However, prophylactic clipping was associated with reduced CSPEB in trials conducted in specialized, high-volume tertiary referral settings, whereas trials conducted in mixed or community-based settings have not demonstrated a similar benefit. Additional randomized controlled trials with standardized reporting of operator experience, center volume, and closure success are needed to clarify effectiveness across broader practice settings.