Prophylactic methods were effective at reducing early bleeding rates, but may not have had an effect on late bleeding for patients who received colonoscopic polypectomy. Due to limitations in the search, concerns about the analyses and the limited number of studies, the reliability of the conclusions is unclear.

To assess whether bleeding prophylaxis benefits patients after the resection of colonic polyps.

The following databases were searched PubMed (from 1980) and The Cochrane Library (up to 2010). References of included studies and recent review articles were consulted for additional trials. Searches were restricted to full texts of studies published in English. Search terms were reported.

Randomised controlled trials (RCTs) were eligible if they evaluated the efficacy of endoscopic postpolypectomy haemorrhage prophylaxis and included patients with early or late bleeding after polypectomy under colonoscopy. Trials had to include at least two branches of endoscopic treatment (monotherapy versus control, monotherapy versus another, or combined therapy versus monotherapy or control). Patient characteristics at baseline, selection criteria and results that allowed evaluation had to have been reported.

Studies about laparoscopic surgery or with no raw data on an outcome of interest were excluded. Studies were excluded if bleeding was related to polypectomy or if they did not distinguish between early and late bleeding.

Mean patient age ranged from 57 to 67. Polyp size varied between the studies (from 0.5mm to more than 20mm). Endoscopic epinephrine-saline injection was the most common intervention, followed by endoloops and endoclips. Half the studies compared combination versus single therapy. Studies were conducted in Europe (none in the UK) and Asia. Most were conducted in a single centre.

Studies were selected independently by two reviewers. Discrepancies were addressed by consensus or with the help of a third reviewer.

The quality of included trials was assessed by a scale which covered 10 quality items such as: randomisation, blinding, allocation concealment, outcomes definition, baseline differences between groups, reporting of withdrawals and drop-outs, description of anticoagulant/antiplatelet treatments. The minimum score on the scale was 1, the maximum 10.

The authors did not state how many reviewers assessed study quality.

Data on early and late bleeding was extracted to calculate odds ratios (ORs). Early bleeding was defined as taking place during the procedure for at least one minute or as haematochezia within 24 hours of the procedure. Bleeding was late if it occurred between 24 hours and 30 days after the procedure.

Studies were extracted independently by two reviewers. Discrepancies were addressed by consensus or with the help of a third reviewer.

Odds ratios were pooled using a fixed-effect (Peto) meta-analysis. Subgroups analyses were performed as necessary. Heterogeneity was assessed using Cochran Q and Ι² tests.

Eight RCTs (2,595 polyps) were included in the review. Quality scores ranged from 7 to 10 out of 10. Gaps in reporting of randomisation, allocation concealment methods and blinding were present in several studies.

Early bleeding

Early bleeding rate was significantly lower for those who received monotherapy compared to control (OR 0.34, 95% CI 0.20 to 0.58; four trials), and for those who received epinephrine-saline injection compared to control (OR 0.37, 95% CI 0.22 to 0.64; four trials). Combined therapy was significantly more effective than the use of a single technique (OR 0.12, 95% CI 0.03 to 0.47; two trials). Endloop techniques were more effective than epinephrine-saline injection or control (OR 0.25, 95% CI 0.11 to 0.58; three trials). There was no evidence of heterogeneity in the analyses (Ι²=0%).

Late bleeding

No significant differences in late bleeding rates were observed between monotherapy and control, between epinephrine-saline injection and control, or between combined and single therapy. No significant differences were found between endoloop and epinephrine-saline injection or control, or between endoclips and epinephrine-saline injection or control. There was no evidence of heterogeneity in the analyses (Ι²=0%).

Prophylactic methods were effective in reducing early bleeding rates, but may not have been effective at reducing late bleeding for patients who recieved colonoscopic polypectomy.

The review question and inclusion criteria were clear. Only studies published in English were included, so some studies may have been missed. The study selection and data extraction process included measures to minimise error and bias; it was not clear whether similar measures were applied the quality assessment of included studies.

The results of the quality assessment were reported. Appropriate justifications for the choice of a Peto method were provided. The decision to conduct separate analyses appeared appropriate given the various interventions used. However, there was limited explanation for the choice of comparisons that were analysed, and for the apparent overlap between the subgroups (identical number of events and patients were reported in separate subgroup analyses). Few studies were included in each analysis. However, the effect estimates appeared consistent and no evidence of heterogeneity was found.

Due to limitations in the search, concerns about the analyses and the limited number of studies, the reliability of the conclusions is unclear.

Practice: The authors stated that it was inappropriate to use prophylaxis to prevent late bleeding. Several recommendations were made on the use of epinephrine saline injection, endoloop and endoclips, as well as on treatment of patients at high risk of bleeding following polypectomy.

Research: The authors stated that high-quality trials with larger sample sizes, robust designs and analyses of cost-effectiveness were needed to assess the benefits of bleeding prophylaxis following resection of colonic polyps.

Not stated.