Impact of prophylactic clipping on delayed bleeding after colorectal endoscopic submucosal dissection: a multicenter propensity score-matched study

Introduction: Clinically significant delayed bleeding (CSDB) is the most common complication after colorectal endoscopic submucosal dissection (ESD). The Limoges Bleeding Score (LBS) was recently developed to identify high-risk patients. The efficacy of prophylactic clipping in reducing CSDB remains debated. This study assessed the effectiveness of complete clip closure in preventing CSDB after colorectal ESD. Methods: A retrospective analysis of prospectively collected data from ten centers (2019–2022) was conducted. Epithelial colorectal lesions treated with ESD were included. Patients were categorized into closure and non-closure groups, compared using propensity-score matching (PSM) based on LBS factors (age >75, lesion size >50 mm, ASA III-IV, rectal location, anticoagulant/antiplatelet use). Subgroup analyses focused on anticoagulant users and high-risk patients (LBS 5–8). Environmental impact was estimated based on a representative sample. Results: Among 3,142 patients (1,199 closure, 1,943 non-closure), 216 (7%) developed CSDB, with no statistically significant difference (closure: 7.2% vs. non-closure: 6.7%; p = 0.656). PSM analysis (944 matched cases) confirmed no statistically significant difference in CSDB (7.73% vs. 5.72%; p = 0.098). Subgroup analyses in patients on anticoagulants and those at high-risk (LBS 5-8) showed no significant differences between the two groups (p = 0.39 and p = 0.73, respectively). Mean waste, and carbon footprint was 283.2 grams and 2.9 kg CO2 equivalents for single-use clips per closure (clip-to-lesion ratio: 0.8 clips/cm). Conclusions: In our cohort, prophylactic clipping did not significantly reduce CSDB following colorectal ESD, even in high-risk patients. Given its environmental impact and technical challenges, routine closure should be reconsidered.