Efficacy of Over-the-Scope Clips in Management of High-Risk Gastrointestinal Bleeding

Colonic diverticular bleeding: An update on pathogenesis and management

Colonic diverticular bleeding is the most common cause of lower gastrointestinal (GI) bleeding, which can be life-threatening and frequently recurrent. In recent years, the prevalence of diverticulosis has increased in developed countries, with a documented incidence of 50% in patients older than 60 years. Based on the evidence, the use of anticoagulants and/or antiplatelets in the elderly population has resulted in an increased incidence of acute diverticular bleeding. According to the literature, about 50% of patients with diverticular bleeding require a blood transfusion, and 18% - 53% need emergency surgery. Although endoscopic identification of the culprit diverticula and appropriate intervention is a challenge, the newer treatment modality, over-the-scope clip method (OTSC) has been demonstrated to be an effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures. In this review, we summarize the pathophysiology of colonic diverticulosis and diverticular bleeding, recent evidence in its management, and existing theories on various preventive strategies to control diverticular bleeding. We also discuss the efficacy and treatment outcome of the OTSC technique in controlling diverticular bleeding.

Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching

BACKGROUND AND AIMS

Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far.

METHODS

This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups.

RESULTS

The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001).

CONCLUSIONS

For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.

Use of over-the-scope clip (OTSC) versus standard therapy for the prevention of rebleeding in large peptic ulcers (size ≥1.5 cm): an open-labelled, multicentre international randomised controlled trial

INTRODUCTION

Over-the-scope clip (OTSC) has been used recently for primary haemostasis of peptic ulcers. This study aimed to compare the efficacy of OTSC to standard endoscopic therapy in primary treatment of patients with peptic ulcer bleeding that are of size ≥1.5 cm. The target population accounts for only 2.5% of all upper GI bleeders.

METHODS

This was a multicentre international randomised controlled trial from July 2017 to October 2020. All patients with Forest IIa or above peptic ulcers of ≥1.5 cm were included. Primary outcome was 30-day clinical rebleeding. Secondary endpoints include 3-day all-cause mortality, transfusion requirement, hospital stay, technical and clinical success, and further interventions. 100 patients are needed to yield a power of 80% to detect a difference of -0.15 at the 0.05 significance level (alpha) using a two-sided Z-test (pooled).

RESULTS

100 patients were recruited. Success in achieving primary haemostasis was achieved in 46/50 (92%) and 48/50 (96%) in the OTSC and conventional arm, respectively. Among patients who had success in primary haemostasis, 2/46 (4.35%) patients in the OTSC arm and 9/48 (18.75%) patients in the conventional arm developed 30-day rebleeding (p=0.03). However, in an intention-to-treat analysis, there was no difference in rebleeding within 30 days (5/50 (10%) OTSC vs 9/50 (18%) standard, p=0.23) or all-cause mortality (2/50 (4%) OTSC vs 4/50 (8%) standard, p=0.68; OR=2.09, 95% CI 0.37 to 11.95). There was also no difference in transfusion requirement, hospital stay, intensive care unit admission and further interventions.

CONCLUSION

The routine use of OTSC as primary haemostasis in large bleeding peptic ulcers was not associated with a significant decrease in 30-day rebleeding.

TRIAL REGISTRATION NUMBER

NCT03160911.

Comparison of Over-the-Scope Clips to Standard Endoscopic Treatment as the Initial Treatment in Patients With Bleeding From a Nonvariceal Upper Gastrointestinal Cause : A Randomized Controlled Trial

BACKGROUND

Current endoscopic methods in the control of acute nonvariceal bleeding have a small but clinically significant failure rate. The role of over-the-scope clips (OTSCs) as the first treatment has not been defined.

OBJECTIVE

To compare OTSCs with standard endoscopic hemostatic treatments in the control of bleeding from nonvariceal upper gastrointestinal causes.

DESIGN

A multicenter, randomized controlled trial. (ClinicalTrials.gov: NCT03216395).

SETTING

University teaching hospitals in Hong Kong, China, and Australia.

PATIENTS

190 adult patients with active bleeding or a nonbleeding visible vessel from a nonvariceal cause on upper gastrointestinal endoscopy.

INTERVENTION

Standard hemostatic treatment (n = 97) or OTSC (n = 93).

MEASUREMENTS

The primary outcome was 30-day probability of further bleeds. Other outcomes included failure to control bleeding after assigned endoscopic treatment, recurrent bleeding after initial hemostasis, further intervention, blood transfusion, and hospitalization.

RESULTS

The 30-day probability of further bleeding in the standard treatment and OTSC groups was 14.6% (14 of 97) and 3.2% (3 of 93), respectively (risk difference, 11.4 percentage points [95% CI, 3.3 to 20.0 percentage points]; P = 0.006). Failure to control bleeding after assigned endoscopic treatment in the standard treatment and OTSC groups was 6 versus 1 (risk difference, 5.1 percentage points [CI, 0.7 to 11.8 percentage points]), respectively, and 30-day recurrent bleeding was 8 versus 2 (risk difference, 6.6 percentage points [CI, -0.3 to 14.4 percentage points]), respectively. The need for further interventions was 8 versus 2, respectively. Thirty-day mortality was 4 versus 2, respectively. In a post hoc analysis with a composite end point of failure to successfully apply assigned treatment and further bleeds, the event rate was 15 of 97 (15.6%) and 6 of 93 (6.5%) in the standard and OTSC groups, respectively (risk difference, 9.1 percentage points [CI, 0.004 to 18.3 percentage points]).

LIMITATION

Clinicians were not blinded to treatment and the option of crossover treatment.

CONCLUSION

Over-the-scope clips, as an initial treatment, may be better than standard treatment in reducing the risk for further bleeding from nonvariceal upper gastrointestinal causes that are amenable to OTSC placement.

PRIMARY FUNDING SOURCE

General Research Fund to the University Grant Committee, Hong Kong SAR Government.

Endoscopic cyanoacrylate injection therapy for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy

OBJECTIVE

To evaluate the efficacy and safety of endoscopic cyanoacrylate injection therapy for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy.

METHODS

154 patients with refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy at the Affiliated Hospital of Zunyi Medical Univesity and the People's Hospital of Liupanshui City from January 2018 to December 2021were enrolled in this study. Endoscopic intracellular cyanoacrylate injection was first carried out. When failure, perintravascullar injection was carried out. The data were retrospectively collected.

RESULTS

Among the 154 patients, 102 patients (66.23%) obtained successful intravascular injection and perivascular injection was performed in 52 patients (33.77%). Immediate hemostatic rate for active bleeding achieved 93.18%. Overall rebleeding rate within 30 days was 12.99% and successful hemostasis rate achieved 87.01%. Immediate hemostatic rate and successful hemostasis rate in intravascular injection patients were markedly superior over perivascular injection. Rebleeding rate in intravascular injection patients was markedly lower than that in perivascular injection patients. 14 patients complicated abdominal pain and no other complication occurred.

CONCLUSION

Endoscopic cyanoacrylate injection therapy, especial intravascular injection, was effective and safe, with high successful hemostasis rate for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy.

Over-the-scope-clip (OTSC®) as a rescue treatment for gastrointestinal bleeding secondary to peptic ulcer disease

BACKGROUND AND AIMS

over-the-scope-clips (OTSC®) have been proposed as a rescue treatment for bleeding peptic ulcers. However, their effectiveness has not been evaluated in Spain.

METHODS

this retrospective and single-center study (January 2018-December 2021) assessed the technical success, clinical success and safety of the device within 30 days. All patients with upper gastrointestinal bleeding due to a peptic ulcer and treated with the OTSC® clip (OVESCO) as a rescue therapy were included in the study.

RESULTS

a total of eleven patients were included in the study, nine due to rebleeding and two due to persistent bleeding. Technical success was 81.9 % (9/11, confidence interval [CI] 95 %: 52-95 %). The per-protocol and intention-to-treat clinical success were 88.9 % (8/9, CI 95 %: 57-98 %) and 72.7 % (8/11, CI 95 %: 43-90 %), respectively. No device-related adverse effects were recorded.

CONCLUSION

the OTSC® clip was an effective and safe rescue therapy for bleeding peptic ulcers.

Scheduled second look endoscopy after endoscopic hemostasis to patients with high risk bleeding peptic ulcers: a Randomized Controlled Trial

BACKGROUND

The recommendation of second look endoscopy (SLOGD) in selected patients at high risk for rebleeding has been inconclusive. This study aimed to evaluate the benefit of SLOGD in selected patients predicted at high risk of recurrent bleeding.

METHODS

From a cohort of 939 patients with bleeding peptic ulcers who underwent endoscopic hemostasis, we derived a 9-point risk score (age > 60, Male, ulcer ≥ 2 cm in size, posterior bulbar or lesser curve gastric ulcer, Forrest I bleeding, haemoglobin < 8 g/dl) to predict recurrent bleeding. We then validated the score in another cohort of 1334 patients (AUROC 0.77). To test the hypothesis that SLOGD in high-risk patients would improve outcomes, we did a randomized controlled trial to compare scheduled SLOGD with observation alone in those predicted at high risk of rebleeding (a score of ≥ 5). The primary outcome was clinical bleeding within 30 days of the index bleed.

RESULTS

Of 314 required, we enrolled 157 (50%) patients (SLOGD n = 78, observation n = 79). Nine (11.8%) in SLOGD group and 14 (18.2%) in observation group reached primary outcome (absolute difference 6.4%, 95% CI - 5.0% to 17.8%). Twenty-one of 69 (30.4%) patients who underwent SLOGD needed further endoscopic treatment. No surgery for bleeding control was needed. There were 6 vs. 3 of 30-day deaths in either group (p = 0.285, log rank). No difference was observed regarding blood transfusion and hospitalization.

CONCLUSIONS

In this aborted trial that enrolled patients with bleeding peptic ulcers at high-risk of recurrent bleeding, scheduled SLOGD did not significantly improve outcomes.

CLINICALTRIALS

gov:NCT02352155.

Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2)

OBJECTIVE

Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is managed by standard endoscopic combination therapy, but a few cases remain difficult and carry a high risk of persistent or recurrent bleeding. The aim of our study was to compare first-line over-the-scope-clips (OTSC) therapy with standard endoscopic treatment in these selected patients.

DESIGN

We conducted a prospective, randomised, controlled, multicentre study (NCT03331224). Patients with endoscopic evidence of acute NVUGIB and high risk of rebleeding (defined as complete Rockall Score ≥7) were included. Primary endpoint was clinical success defined as successful endoscopic haemostasis without evidence of recurrent bleeding.

RESULTS

246 patients were screened and 100 patients were finally randomised (mean of 5 cases/centre and year; 70% male, 30% female, mean age 78 years; OTSC group n=48, standard group n=52). All but one case in the standard group were treated with conventional clips. Clinical success was 91.7% (n=44) in the OTSC group compared with 73.1% (n=38) in the ST group (p=0.019), with persistent bleeding occurring in 0 vs 6 in the OTSC versus standard group (p=0.027), all of the latter being successfully managed by rescue therapy with OTSC. Recurrent bleeding was observed in four patients (8.3%) in the OTSC group and in eight patients (15.4%) in the standard group (p=0.362).

CONCLUSION

OTSC therapy appears to be superior to standard treatment with clips when used by trained physicians for selected cases of primary therapy of NVUGIB with high risk of rebleeding. Further studies are necessary with regards to patient selection to identify subgroups benefiting most from OTSC haemostasis.

TRIAL REGISTRATION NUMBER

NCT03331224.

Hemostasis Techniques for Non-variceal Upper GI Hemorrhage: Beyond Injection and Cautery

B. Nulsen D. M. Jensen.

Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND AND AIMS

No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim.

METHODS

Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots - with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation - MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician.

RESULTS

53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p = .017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH.

CONCLUSION

1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov, Number: NCT03065465).

Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage

Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.

Towards personalised management for non-variceal upper gastrointestinal bleeding

Guidelines from national and international professional societies on upper gastrointestinal bleeding highlight the important clinical issues but do not always identify specific management strategies pertaining to individual patients. Optimal treatment should consider the personal needs of an individual patient and the pertinent resources and experience available at the point of care. This article integrates international guidelines and consensus into three stages of management: pre-endoscopic assessment and treatment, endoscopic evaluation and haemostasis and postendoscopic management. We emphasise the need for personalised management strategies based on patient characteristics, nature of bleeding lesions and the clinical setting including available resources.

Hazardous repeat bleeding after colorectal endoscopic submucosal dissection in a patient with immune thrombocytopenia: complete hemostasis using an over-the-scope clip

A 76-year-old man diagnosed with early-stage colorectal cancer was referred to our hospital for endoscopic submucosal dissection (ESD). The patient had a low platelet count (31,000/µL) due to immune thrombocytopenia (ITP). The cancerous lesion was completely resected without any adverse events. A blood test performed 1 day post-ESD showed no progression of anemia and the initial postoperative course was uneventful. However, 7 days after ESD, dark red stools were observed, and we performed an emergency colonoscopy. We stopped the bleeding twice using hemoclips and hemostatic forceps. Since the patient's platelet count remained below 50,000/µL, we started thrombopoietin receptor agonist treatment with eltrombopag (12.5 mg/day) for thrombocytopenia. Although the platelet count increased, the patient experienced rebleeding for the fourth time and underwent an emergency colonoscopy, during which we used an over-the-scope clip (OTSC) to achieve hemostasis. No rebleeding occurred after OTSC intervention, and the platelet count stabilized at approximately 50,000/µL. We discharged the patient on Day 34 after ESD. Although the guidelines do not specify a target platelet count for performing ESD, a platelet count < 50,000/µL should be considered low. Furthermore, an OTSC may be useful for treating intractable bleeding.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes

The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.

Use of over-the-scope clip for ulcer hemostasis after failure of both surgery and interventional therapy: A case report

RATIONALE

Non-variceal gastrointestinal bleeding is a common critical disease worldwide, and according to relevant guidelines, surgery and interventional treatment are the final therapies. However, few studies have reported on therapeutic strategies to employ when the ultimate treatment fails. This report offers a reasonable option for hemostasis after surgery and interventional treatment both fail.

PATIENT CONCERNS

A 47-year-old man with recurrent bleeding had undergone endoscopy, surgery, and interventional therapy; however, effective hemostasis was not achieved.

DIAGNOSIS

This patient's clinical manifestations and typical gastroscopic findings confirmed duodenal bulb ulcer with hemorrhage INTERVENTIONS:: A Billroth II + Bancroft operation, interventional treatment, and endoscopic hemostasis with an over-the-scope clip (OTSC) system were administered.

OUTCOMES

The bleeding was successfully controlled, and the patient remained well during long-term follow-up.

LESSONS

The OTSC system can represent a reasonable option for ulcer hemostasis after surgery when other interventional therapies have failed.

Clinical efficacy of the over-the-scope clip device: A systematic review

BACKGROUND

The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.

AIM

To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.

METHODS

A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.

RESULTS

A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE’s related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).

CONCLUSION

This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.

Over-The-Scope Clip system as a first-line therapy for high-risk bleeding peptic ulcers: a retrospective study

BACKGROUND

Effective hemostasis is essential to prevent rebleeding. We evaluated the efficacy and feasibility of the Over-The-Scope Clip (OTSC) system compared to combined therapy (through-the-scope clips with epinephrine injection) as a first-line endoscopic treatment for high-risk bleeding peptic ulcers.

METHODS

We retrospectively analyzed data of 95 patients from a single, tertiary center and underwent either OTSC (n = 46) or combined therapy (n = 49). The primary outcome of the present study was the efficacy of the OTSC system as a first-line therapy in patients with high-risk bleeding peptic ulcers compared to combined therapy with TTS clips and epinephrine injection. The secondary outcomes included the rebleeding rate, perforation rate, mean procedure time, reintervention rate, mean procedure cost and days of hospitalization in the two study groups within 30 days of the index procedure.

RESULTS

All patients achieved hemostasis within the procedure; two patients in the OTSC group and four patients in the combined therapy group developed rebleeding (p = 0.444). No patients experienced gastrointestinal perforation. OTSC had a shorter median procedure time than combined therapy (11 min versus 20 min; p < 0.001). The procedure cost was superior for OTSC compared to combined therapy ($102,000 versus $101,000; p < 0.001). We found no significant difference in the rebleeding prevention rate (95.6% versus 91.8%, p = 0.678), hospitalization days (3 days versus 4 days; p = 0.215), and hospitalization costs ($108,000 versus $240,000, p = 0.215) of the OTSC group compared to the combined therapy group.

CONCLUSION

OTSC treatment is an effective and feasible first-line therapy for high-risk bleeding peptic ulcers. OTSC confers comparable costs and patient outcomes as combined treatments, with a shorter procedure time.

Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review

Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.

Clipping Over the Scope for Recurrent Peptic Ulcer Bleeding is Cost-Effective as Compared to Standard Therapy: An Initial Assessment

Clipping over the scope (C-OTS) is a novel closure technique used for the treatment of nonvariceal gastrointestinal bleeding, especially for high-risk lesions. C-OTS devices cost more than clipping through the scope and thermal devices. The high upfront cost of C-OTS may pose a barrier to its use and the cost-effectiveness of C-OTS for peptic ulcer disease bleeding is unknown. Cost-effectiveness studies of C-OTS for peptic ulcer bleeding as both first-line and second-line therapy can provide the current estimate of the conditions in which the use of C-OTS is cost-effective and give insights of the determinants to the cost-effectiveness of C-OTS.

The Use of the Over the Scope Clip to Treat Upper Gastrointestinal Bleeding

The over-the-scope clip is a novel endoscopic tool developed for tissue compression in the gastrointestinal tract. It has already revolutionized the management of acute perforations and leaks. In the past decade, it has also increasingly been used for treatment of severe and/or refractory gastrointestinal hemorrhage. Available studies report high rates of primary hemostasis and rebleeding. This article provides an overview on available literature, potential indications, and technical aspects of hemostasis with over-the-scope clip.

Over-the-scope clip vs epinephrine with clip for first-line hemostasis in non-variceal upper gastrointestinal bleeding: a propensity score match analysis

Background and study aims  The over-the-scope clip (OTSC) is a novel tool used to improve the maintenance of hemostasis for non-variceal upper gastrointestinal bleeding (NVUGIB); however, studies on the comparison with "conventional" techniques are lacking. In this study, we aimed to compare first-line endoscopic hemostasis achieved using conventional techniques with that achieved using OTSC placement for NVUGIB. Patients and methods  From January 2007 to March 2018, 793 consecutive patients underwent upper endoscopy with the hemostasis procedure. Among them, 327 patients were eligible for inclusion (112 patients had OTSC placement and 215 underwent conventional hemostasis). After propensity score matching and adjustment for confounding factors, 84 patients were stratified into the "conventional" group and 84 into the OTSC group. Patient characteristics and outcomes (rebleeding rate, mortality rate within 30 days, and adverse events) were compared between the two groups. Results  In the unmatched cohort, hemostasis with OTSC was more frequent in cases of duodenal ulcers with Forrest Ia to IIa and in patients with a higher Rockall score compared with the "conventional group". In the matched cohort, 93 % of the patients in the "conventional group" underwent hemostasis with epinephrine + through-the-scope clip. Rebleeding events were significantly less frequent in the OTSC group (8 % vs 20 %, 95 %CI 3 - 16 vs 12 - 30; P  = 0.02); however, the mortality rate in the two groups was not significantly different (6 % vs 2 %, 95 %CI 1 - 8 vs 2 - 13; P  = 0.4). Conclusions  OTSC is a safe and effective tool for achieving hemostasis, and we recommend its use as the first-line therapy for lesions with a high risk of rebleeding and in patients with a high risk Rockall score.

Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis

BACKGROUND

Conventional endoscopic treatments can't control bleeding in as many as 20% of patients with non-variceal gastrointestinal (GI) bleeding. Recent studies have shown that over-the-scope-clip (OTSC) system allowed for effective hemostasis for refractory GI bleeding lesions. So we aimed to conduct a systematic review to evaluate the effectiveness and safety of the OTSC system for management of acute non-variceal upper GI bleeding.

METHOD

A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2007 to May 2019. The literature was selected independently by two reviewers according to the inclusion and exclusion criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 3.0.

RESULTS

A total of 16 studies including 769 patients with 778 GI bleeding lesions were identified. Pooled technical success was achieved in 761 lesions [95.7%; 95% confidence interval (CI), 93.5-97.2%], and the pooled clinical success was achieved in 666 lesions (84.2, 95% CI, 77.4-89.2%). The incidence of re-bleeding was reported in 81 patients and the post-procedure mortality was 10.9% (n = 84). Only 2 (0.3%) patients occurred complications after OTSC system procedure.

CONCLUSIONS

Our study demonstrated that the OTSC system was a technically feasible modality and highly efficacious in achieving hemostasis in acute non-variceal upper gastrointestinal bleeding.

Endoscopic Management of Post-Polypectomy Bleeding

Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. There are multiple risk factors related to patient and polyp characteristics that should be considered. In most cases, immediate PPB can be effectively managed endoscopically when recognized and managed promptly. Delayed PPB can manifest in a myriad of ways. In severe delayed PPB, resuscitation for hemodynamic stabilization should be prioritized, followed by endoscopic evaluation and therapy once the patient is stabilized. Future areas of research in PPB include the risks of direct oral anticoagulants and of specific electrosurgical settings for hot-snare polypectomy vs. cold-snare polypectomy, benefits of closure of post-polypectomy mucosal defects using through-the-scope clips, and prospective comparative evaluation of newer hemostasis agents such as hemostatic spray powder and over-the-scope clips.

Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.

Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos)

Background

Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data.

Methods

In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use.

Results

Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays).

Conclusions

Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.

Boerhaave's Syndrome: Delayed Management Using Over-the-Scope Clip

Patient: Male, 43

Final Diagnosis: Boerhaave’s syndrome

Symptoms: Dyspnoea • epigastric pain • vomiting

Medication: —

Clinical Procedure: Over-the scope-clip and pleurodesis

Specialty: Gastroenterology and Hepatology

Over-the-scope clip in peptic ulcer bleeding: clinical success in primary and secondary treatment and factors associated with treatment failure

Background and study aims  It is unclear if the clinical success rate of the over-the-scope-clip (OTSC) in peptic ulcer bleeding (PUB) is comparable when it is used in the first- or in the second-line of treatment. Patients and methods  Data on endoscopic treatment (first- vs. second-line) in PUB with OTSC and clinical data were analyzed. The primary outcome was the clinical success of hemostasis, defined as the absence of recurrent bleeding or further intervention. Secondary outcomes were factors associated with OTSC failure. Results  From April 2014 to March 2018, 100 patients (age 72 [20 - 98] y, female 36 %) with PUB in the stomach or the duodenum were treated endoscopically with the OTSC. The OTSC was used as a first-line procedure (primary-OTSC) in 66 pts. Successful hemostasis could be achieved in 90.9 %. After failure of an initial endoscopic treatment, 34 patients were treated with the OTSC (secondary-OTSC) and the treatment was successful in 94.1 %. Recurrent bleeding occurred in n = 10 for primary-OTSC (16.7 %) and in n = 7 pts in the secondary-OTSC (21.9 %) ( P  = 0.81). Clinical success in the primary-OTSC was 75.8 % and 73.5 % in the secondary-OTSC respectively. Conclusions  The OTSC has a high rate of initial bleeding control in first- and second line treatment of PUB. OTSC failure occurs more often in the duodenum than in the stomach and results in longer intensive care unit stay, higher amount of transfusions, and a higher reimbursement per case.

Efficacy of Therapeutic Endoscopy for Gastrointestinal Lesion (GI): A network meta-analysis

Objective:

Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this systematic review was to compare the different modalities of endoscopic therapy for GI bleeding.

Methods:

Studies were identified by searching electronic databases MEDLINE. We selected all available clinical studies published after 2000 that assessed efficacy and/or safety of different endoscopic hemostatic techniques in treating GI bleeding. The outcomes evaluated included initial hemostasis, rebleeding rate, and 30-day all-cause mortality. Network meta-analyses were performed to summarize the treatment effects.

Results:

Total 20 studies involving 1845 patients were evaluated. Ten different treatment categories including mechanic, ablative, injection, and combined therapy were compared in our analysis in terms of their efficacy in stopping bleeding and complications. Band ligation [rate: 0.757; 95% Credible Interval (0.565, 0.887)] and injection therapy [rate: 0.891; 95% CI (0.791, 0.944)] had inferior efficacy in attaining initial hemostasis compared to others. Combined therapy of band ligation and HPC and hemoclip may represent the best options for preventing rebleeding and mortality respectively. No significant difference was found among other treatments in terms of complications.

Conclusions:

We recommend the application of hemoclips in treating GI bleeding due to its high hemostasis efficacy and low risk of 30-day mortality.

First-line endoscopic treatment with over-the-scope clips in patients with either upper or lower gastrointestinal bleeding: a multicenter study

Background and study aims  Endoscopic treatment is the mainstay approach for gastrointestinal bleeding, in either upper (UGIB) or lower (LGIB) tract. The over-the-scope clip (OTSC) may overcome limitations of standard clips or thermocoagulation in high-risk bleeding lesions. We evaluate the main clinically relevant outcomes following endoscopic hemostasis with OTSC in high-risk lesions and/or patients. Patients and methods  This was a retrospective analysis of prospectively collected databases including all patients with UGIB and LGIB who underwent OTCS placement as first-line treatment in eleven tertiary endoscopic referral centers. Technical success, primary hemostasis, rebleeding, blood transfusion, hospital stay, and hemorrhage-related mortality rates were evaluated. Results  Data from 286 patients, with either UGIB (N = 214) or LGIB (N = 72) were available. Overall, 112 patients (39.2 %) were receiving antithrombotic therapy. Technical success and primary hemostasis rates were 97.9 % and 96.4 %, respectively. Early rebleeding occurred in 4.4 %, more frequently in those on antithrombotic therapy, and no late rebleeding was observed. Following a successful primary haemostasis, only 5.2 % patients needed blood transfusions, and the median hospital stay was 4 days (range: 3 - 11). Eighteen patients with either technical failure (N = 6) or rebleeding (N = 12) underwent radiological or surgical approaches. Overall, bleeding-related deaths occurred in 5 (1.7 %) patients, including 3 patients with technical procedural failure, and 2 in the rebleeding group.  Conclusions  Data from our large, multicenter study show that OTSC placement is an effective first-line treatment for hemostasis in high-risk patients and/or lesions both in upper and lower gastrointestinal tract.

Advances in the Therapy of Bleeding Peptic Ulcer

Peptic ulcer bleeding remains an important medical emergency. Important recent advances are reviewed. These include further support for a more restrictive transfusion strategy aiming for a target haemoglobin of 70-90 g/L. The Glasgow-Blatchford score remains the most useful assessment score for identifying the lowest risk patients suitable for outpatient management and predicting the need for intervention. Newer scores such as the AIMS65 and Progetto Nazionale Emorragia Digestive score (PNED) may be more accurate in predicting mortality. Pre-endoscopy erythromycin improves outcomes and is underused. A new disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Over-the-scope clips and haemostatic powders appear to have some role as endoscopic salvage therapies. Non- H. pylori, non-aspirin/non-steroidal anti-inflammatory drug (NSAID) ulcers contribute to an increasing percentage of bleeding peptic ulcers and are associated with a high rebleeding rate. The optimal management of these ulcers remains to be determined.

Use of over-the-scope-clip (OTSC) improves outcomes of high-risk adverse outcome (HR-AO) non-variceal upper gastrointestinal bleeding (NVUGIB)

BACKGROUND AND STUDY AIMS

Endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB) with high-risk adverse outcome (HR-AO) features has a high risk of failure. We studied the safety and efficacy of over-the-scope clips (OTSC) to treat these lesions.

PATIENTS AND METHODS

We included patients who were treated using OTSC for NVUGIB from January 2015 to October 2017. We studied rebleeding and mortality rates and used the Rockall data and our institution's prior data for comparison. We used descriptive and chi-square statistics.

RESULTS

We studied 18 patients with 19 bleeding lesions: 9 (47 %) duodenal ulcers, 4 (21 %) Dieulafoy's lesion, 3 (16 %) gastric ulcer, and 3 (16 %) bleeding after gastric biopsy, gastric polypectomy and endoscopic ultrasound-guided fine-needle aspiration of peri-gastric mass. We applied OTSC as the first-line treatment in 10 (53 %) and as the second-line treatment in 9 (47 %) bleeding lesions. Continued bleeding after OTSC occurred in six patients, but we treated it successfully and achieved complete hemostasis in all patients. We found OTSC use significantly decreased (0 % vs. 53 %, P  < 0.01) and reduced (0 % vs. 24 %, P  = 0.08) the rebleeding rate in our high-risk (RS ≥ 8) and intermediate-risk (RS = 4 - 7) Rockall score patients as compared to the rates reported by the Rockall study, respectively. When compared to our institution's prior study, we found a decrease in the rebleeding rate with OTSC (0 % vs. 21 %, P  = 0.06) in our intermediate-to-high risk Rockall score patients (RS ≥ 4). There was no difference in mortality rates as compared to both control studies.

CONCLUSION

Use of OTSC is safe, efficacious and appears superior to standard treatment for HR-AO NVUGIB. OTSC should be considered as first-line treatment for HR-AO bleeding.