Prophylactic Clip Closure to Prevent Bleeding After Colorectal Endoscopic Submucosal Dissection: A Cost-Effectiveness Study

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) enables en-bloc resection of large and complex colorectal neoplasms but is associated with a clinically significant risk of delayed bleeding. Prophylactic clip closure of post-ESD mucosal defects reduces bleeding risk; however, its routine use remains unclear. We evaluated the cost-effectiveness of prophylactic clipping following colorectal ESD. METHODS: We developed a decision-analytic Markov model comparing colorectal ESD with prophylactic clip closure versus ESD without closure. The model incorporated probabilities of delayed bleeding, subsequent management pathways, costs, and health utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER), evaluated against a willingness-to-pay (WTP) threshold of $100,000 per quality-adjusted life-year (QALY). Deterministic (one-way, two-way, and threshold) and probabilistic sensitivity analyses (10,000 Monte Carlo simulations) were performed. RESULTS: In the base-case analysis, prophylactic clipping was more effective and more costly than no clipping, yielding an ICER of $88,843/QALY. The incremental cost was $1,102 with a QALY gain of 0.01. One-way sensitivity analyses demonstrated robust findings; clipping remained cost-effective provided total costs were below $8,943, and no clipping was favored only if delayed bleeding risk without clips fell below 3.12%. Probabilistic sensitivity analysis showed prophylactic clipping was the preferred strategy in 83.8% of simulations at a WTP of $100,000/QALY. CONCLUSIONS: Prophylactic clip closure following colorectal ESD appears to be a cost-effective strategy, with the potential to reduce delayed bleeding at an acceptable incremental cost. However, these findings are based on model assumptions and should be interpreted in the context of these parameters.