Prophylactic clipping after colorectal endoscopic submucosal dissection in randomized controlled trials: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) is a minimally invasive and effective treatment for large nonpedunculated colorectal polyps; however, it carries a relevant risk of adverse events (AEs), such as delayed bleeding, as well as postprocedural perforation (PPP) and postelectrocoagulation syndrome (PECS). Systematic defect closure may reduce these risks, but its preventive efficacy remains uncertain. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prophylactic clipping after colorectal ESD.Following PRISMA guidelines, we searched MEDLINE, Embase, and SCOPUS through to June 2025 for RCTs comparing prophylactic clipping vs. no clipping after colorectal ESD in adults. The primary outcome was clinically significant delayed bleeding; secondary outcomes included PPP and PECS, as well as subanalysis by location and size. Random-effects models were used to compute risk ratios (RRs) and 95%CIs.Four RCTs from Asia including 684 patients were analyzed (336 with clipping, 348 controls). Prophylactic clipping significantly reduced clinically significant delayed bleeding risk (0.3% vs. 3.4%; RR 0.26, 95%CI 0.08-0.88). No significant differences were found for PPP (0.4% vs. 1.0%; RR 0.74; 95%CI 0.23-2.35) or PECS (12.2% vs. 11.8%; RR 1.06; 95%CI 0.74-1.52). Subgroup analyses by lesion size (>30 mm vs. <30 mm) and location (proximal vs. distal colon) were not significant.A 74% decrease in the risk of clinically significant delayed bleeding is achieved by prophylactic clipping after colorectal ESD, supporting its adoption in routine practice.