1
|
Cho JJ, Forbes CM, Fiore BD, McCarron JD, Padilla L. Sustained Hemostasis With the Padlock™ Over-the-scope Clip for Gastric Fundus Dieulafoy's Lesion in the Setting of Anticoagulation Following Hemorrhagic Shock From Two Dieulafoy's Lesions. Mil Med 2023; 188:e3265-e3268. [PMID: 36355858 DOI: 10.1093/milmed/usac335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/18/2022] [Accepted: 10/13/2022] [Indexed: 08/31/2023] Open
Abstract
Dieulafoy's lesions (DLs) are a rare and difficult-to-identify cause of acute gastrointestinal bleeding that can lead to hemorrhagic shock. We present a case of a 23-year-old previously healthy male presenting with melenic stools and hemorrhagic shock. Computed tomography of abdomen and pelvis with oral and intravenous contrast showed a possible source of hemorrhage as a hyperdense intraluminal material within the stomach. Initial urgent esophagogastroduodenoscopy showed a large, nonbleeding distal esophageal DL, which was treated successfully with 10 mL of 1:10,000 epinephrine and bipolar cauterization with 10 Fr Gold Probe™. Hemorrhage recurred 2 d later, prompting another esophagogastroduodenoscopy, which found another DL within the gastric fundus. Treatment with epinephrine, Gold Probe™, and through-the-scope Hemoclips was unsuccessful because of difficult visualization and positioning. A subsequent attempt was made using the over-the-scope clip (OTSC) Padlock™ Clip Defect Closure System with successful hemostasis and stabilization of the patient. His hospital course was complicated by left lower lobe segmental pulmonary embolism without right heart strain for which he was discharged on 3 months of anticoagulation with apixaban. On follow-up, there was no recurrence of gastrointestinal bleeding (GIB) despite 3 months of anticoagulation. He did not complete the Basic Underwater Demolition/SEAL (BUD/S) Training. This case report demonstrates the evaluation and management of a patient with hemorrhagic shock from two DLs and sustained hemostasis with the Padlock™ OTSC in the setting of apixaban anticoagulation.
Collapse
Affiliation(s)
- Jonathan J Cho
- Department of Internal Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Chelsea M Forbes
- Department of Internal Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Benjamin D Fiore
- Department of Gastroenterology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Joshua D McCarron
- Department of Gastroenterology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Leybelis Padilla
- Department of Gastroenterology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| |
Collapse
|
2
|
Martino A, Di Serafino M, Orsini L, Giurazza F, Fiorentino R, Crolla E, Campione S, Molino C, Romano L, Lombardi G. Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review. World J Gastroenterol 2023; 29:4222-4235. [PMID: 37545636 PMCID: PMC10401659 DOI: 10.3748/wjg.v29.i27.4222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/11/2023] [Accepted: 05/09/2023] [Indexed: 07/13/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.
Collapse
Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Francesco Giurazza
- Department of Interventional Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | | | - Enrico Crolla
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Severo Campione
- Department of Pathology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Carlo Molino
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| |
Collapse
|
3
|
Hollenbach M, Decker A, Schmidt A, Möschler O, Jung C, Blasberg T, Seif AAH, Vu Trung K, Hoffmeister A, Hochberger J, Ellenrieder V, Wedi E. Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching. Gastrointest Endosc 2023; 98:51-58.e2. [PMID: 36738794 DOI: 10.1016/j.gie.2023.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Annegrit Decker
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Möschler
- Department of Internal Medicine and Gastroenterology, Marienhospital Osnabrück, Osnabrück, Germany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Tobias Blasberg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - Ali Amir Hosseini Seif
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Kien Vu Trung
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Albrecht Hoffmeister
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Jürgen Hochberger
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - Volker Ellenrieder
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
| | - Edris Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany; Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
| |
Collapse
|
4
|
Lau JYW, Li R, Tan CH, Sun XJ, Song HJ, Li L, Ji F, Wang BJ, Shi DT, Leung WK, Hartley I, Moss A, Yu KYY, Suen BY, Li P, Chan FKL. 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. Ann Intern Med 2023; 176:455-462. [PMID: 36877964 DOI: 10.7326/m22-1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- James Y W Lau
- Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong SAR, China (J.Y.W.L., K.Y.Y.Y., B.Y.S., F.K.L.C.)
| | - Rui Li
- The First Affiliated Hospital of Soochow University, Suzhou, China (R.L., C.T., D.S.)
| | - Chen-Huan Tan
- The First Affiliated Hospital of Soochow University, Suzhou, China (R.L., C.T., D.S.)
| | - Xiu-Jing Sun
- Beijing Friendship Hospital, Capital Medical University, Beijing, China (X.S., P.L.)
| | - Hao-Jun Song
- Ningbo First Hospital, Ningbo, China (H.S., B.W.)
| | - Lan Li
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China (L.L., F.J.)
| | - Feng Ji
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China (L.L., F.J.)
| | | | - Dong-Tao Shi
- The First Affiliated Hospital of Soochow University, Suzhou, China (R.L., C.T., D.S.)
| | - Wai K Leung
- Queen Mary Hospital, Hong Kong University, Hong Kong SAR, China (W.K.L.)
| | - Imogen Hartley
- Western Health, University of Melbourne, Melbourne, Australia (I.H., A.M.)
| | - Alan Moss
- Western Health, University of Melbourne, Melbourne, Australia (I.H., A.M.)
| | - Karina Y Y Yu
- Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong SAR, China (J.Y.W.L., K.Y.Y.Y., B.Y.S., F.K.L.C.)
| | - Bing Y Suen
- Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong SAR, China (J.Y.W.L., K.Y.Y.Y., B.Y.S., F.K.L.C.)
| | - Peng Li
- Beijing Friendship Hospital, Capital Medical University, Beijing, China (X.S., P.L.)
| | - Francis K L Chan
- Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong SAR, China (J.Y.W.L., K.Y.Y.Y., B.Y.S., F.K.L.C.)
| |
Collapse
|
5
|
Dixit VK, Sahu MK, Venkatesh V, Bhargav VY, Kumar V, Pateriya MB, Venkataraman J. Gastrointestinal Emergencies and the Role of Endoscopy. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1755303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractMany gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies.
Collapse
Affiliation(s)
- Vinod Kumar Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Manoj Kumar Sahu
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Vybhav Venkatesh
- Department of Gastroenterology and Hepatobiliary Sciences, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan (SOA) University, Bhubaneswar, Odisha, India
| | - Varanasi Yugandhar Bhargav
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Vinod Kumar
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mayank Bhushan Pateriya
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| |
Collapse
|
6
|
Negm S, Mohamed H, Shafiq A, AbdelKader T, Ismail A, Yassin M, Mousa B, Abozaid M, Orban YA, Al Alawi M, Farag A. Combined endoscopic and radiologic intervention for management of acute perforated peptic ulcer: a randomized controlled trial. World J Emerg Surg 2022; 17:24. [PMID: 35610657 PMCID: PMC9131571 DOI: 10.1186/s13017-022-00429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/12/2022] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Peptic ulcer perforation is a common life-threatening surgical emergency. Graham omental patch is performed for plugging of perforated peptic ulcer. Many endoscopic methods have been used to treat acute perforated peptic ulcer such as over the scope clips, standard endoscopic clips, endoscopic sewing and metallic stents. The main idea in endoscopic management of acute perforated peptic ulcer is early decontamination and decrease sepsis by interventional radiologic drainage. METHODS This is a prospective randomized controlled clinical trial. This study included patients who were developed acute perforated peptic ulcer manifestations and were admitted to our hospital between December 2019 and August 2021. Sample size was 100 patients divided into 2 equal groups. Endoscopic group (EG): included 50 patients who were subjected to endoscopic management. Surgical group (SG): included 50 patients who were subjected to surgical management. RESULTS One hundred patients were randomized into 2 groups: SG (50) and EG (50). Median age of patients was 36 (range 27:54) and 47 (range 41:50) years-old in SG and EG, respectively. Males constituted 72% and 66% in SG and EG, respectively. Median length of postoperative hospital stay was 1 (range: 1-2) days in EG, while in SG was 7 (range 6-8) days. Postoperative complications in SG patients were 58% in form of fever, pneumonia, leak, abdominal abscess, renal failure and incisional hernia (11%, 5%, 5%, 3%, 2% and 3%, respectively). Postoperative complications in EG patients were 24% in form of fever, pneumonia, leak, abdominal abscess, renal failure and incisional hernia (10%, 0%, 2%, 0%, 0% and 0%, respectively). CONCLUSION Combined endoscopic and interventional radiological drainage can effectively manage acute perforated peptic ulcer without the need for general anesthesia, with short operative time, in high risk surgical patients with low incidence of morbidity & mortality.
Collapse
Affiliation(s)
- Said Negm
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hatem Mohamed
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Shafiq
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Adel Ismail
- Ismailia Teaching Oncology Hospital, Ismailia, Egypt
| | | | - Bassam Mousa
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | | | | | - Ahmed Farag
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| |
Collapse
|
7
|
Qiu J, Xu J, Zhang Y, Liao F, Zhu Z, Shu X, Chen Y, Pan X. Over-the-Scope Clip Applications as First-Line Therapy in the Treatment of Upper Non-variceal Gastrointestinal Bleeding, Perforations, and Fistulas. Front Med (Lausanne) 2022; 9:753956. [PMID: PMID: 35242770 PMCID: PMC8886136 DOI: 10.3389/fmed.2022.753956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 01/06/2022] [Indexed: 12/17/2022] Open
Abstract
Background The over-the-scope clip (OTSC) is an innovative device and has been successfully used in endoscopic treatment, however, there is a lack of clinical data from China. The aim of this study is to investigate the OTSC applications in the treatment of upper non-variceal gastrointestinal bleeding (UNVGIB), perforations, and fistulas in China. Methods In total, 80 patients were treated with one OTSC respectively as first-line therapy in our endoscopy center between January 2016 and November 2020. Among them, 41 patients had UNVGIB, 34 patients had perforations, and five patients had fistulas. The technical and clinical success rates were used to assess the efficacy of OTSC on the above diseases. In addition, we compared the hemostatic efficacy of OTSC with the standard endoscopic therapy in ulcer bleeding and Dieulafoy's lesion by propensity score matching analysis. Results In general, the OTSCs were applied successfully in all patients and achieved 100% (80/80) technical success. The clinical success of all patients was 91.3% (73/80). Among 41 patients with UNVGIB, the clinical success was 85.4% (35/41); 6 patients presented with recurrence. For patients of Dieulafoy's lesion and under antithrombotic therapy, we found that OTSC treatment had both efficient and reliable hemostasis effects. In addition, according to the characteristics of ulcers, site of bleeding lesion, and Blatchford score, all patients received similar and reliable clinical success rates. After propensity score matching, we found that OTSC treatment had low rebleeding rates when compared with standard endoscopic therapy in both Dieulafoy's lesion (15.0 vs 30.0%) and ulcer bleeding (17.6 vs 29.4%). Among 34 patients with perforations, the clinical success was 100% (34/34). Among five patients with fistulas, only one patient failed in maintaining the OTSC before esophageal fistula healing, and the clip achieved an overall clinical success of 80% (4/5). Conclusion The OTSC represents a safe and effective endoscopic therapy for UNVGIB, perforations, and fistulas as first-line treatment, especially for Dieulafoy's lesion or patients under antithrombotic therapy for UNVGIB, etc. However, OTSC application in these specific lesions or patients lacks adequate evidence as first-line treatment. Therefore, further larger sample and multi-center clinical trials are required to improve its indications in clinical treatment.
Collapse
Affiliation(s)
- Jiayu Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yanxia Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Foqiang Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenhua Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Youxiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaolin Pan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| |
Collapse
|
8
|
Abstract
B. Nulsen D. M. Jensen.
Collapse
|
9
|
Kubota Y, Yamauchi H, Nakatani K, Iwai T, Ishido K, Masuda T, Maruhashi T, Tanabe S. Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding. Scand J Gastroenterol 2021; 56:1396-1405. [PMID: 34455892 DOI: 10.1080/00365521.2021.1969593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. MATERIALS AND METHODS Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. RESULTS There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. CONCLUSIONS When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.
Collapse
Affiliation(s)
- Yo Kubota
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kento Nakatani
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kenji Ishido
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomonari Masuda
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Satoshi Tanabe
- Department of Research and Development Center for New Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
| |
Collapse
|
10
|
Goda Y, Kobara H, Kobayashi N, Nishiyama N, Fujihara S, Tada N, Kozuka K, Matsui T, Chiyo T, Shi T, Fujita K, Tani J, Yachida T, Takata M, Okano K, Nakano D, Nishiyama A, Mori H, Masaki T. Long-term outcomes of over-the-scope clip for refractory gastrointestinal diseases. MINIM INVASIV THER 2021; 31:628-634. [PMID: 33423604 DOI: 10.1080/13645706.2020.1867584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Over-The-Scope Clip (OTSC) can effectively treat refractory gastrointestinal diseases. However, most reports have focused on short-term effectiveness. We examined clinical outcomes of the deployed clips and long-term characteristics. MATERIAL AND METHODS Of 47 patients with OTSC treatment, 35 with follow-up periods of ≥3 months were retrospectively examined. The indications were 11 bleedings, 17 perforations, and seven fistulas. The observation period was defined as medium-term (3 to <12 months) or long-term (≥12 months). The primary outcome was the clinical success rate without disease recurrence. The secondary outcomes were the complication rate, survival duration, and clip retention rate. RESULTS The medium- and long-term clinical success rates were 100% during the observation period (median, 44 months; range, 3-78 months). The complication rate was 2.9% (n = 1). The median survival time was 1,634 days for bleeding, 1,757 days for perforation, and 444 days for fistulas. The overall clip retention rates were 56.4%, 38.1%, 30.9%, and 25.9% after one, six, and 12 months and at the final follow-up, respectively. The average clip retention duration was 244 days in bleeding, 656 days in perforations, and 188 days in fistulas. CONCLUSIONS Regardless of clip detachment, the OTSC can be effective in long-term.
Collapse
Affiliation(s)
- Yasuhiro Goda
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Hideki Kobara
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Nobuya Kobayashi
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Shintaro Fujihara
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Naoya Tada
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Kazuhiro Kozuka
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Takanori Matsui
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Taiga Chiyo
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Tingting Shi
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Koji Fujita
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Joji Tani
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Tatsuo Yachida
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Masashi Takata
- Department of Gastroenterology, Kochi Health Sciences Center, Kochi, Japan
| | - Keiichi Okano
- Gastroenterological Surgery, Kagawa University, Miki, Japan
| | - Daisuke Nakano
- Pharmacology, Faculty of Medicine, Kagawa University, Kita, Japan
| | - Akira Nishiyama
- Pharmacology, Faculty of Medicine, Kagawa University, Kita, Japan
| | - Hirohito Mori
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Kagawa University, Miki, Japan
| |
Collapse
|
11
|
Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| |
Collapse
|
12
|
Lai YK, Peng CY, Guo GH, Shu X. Use of over-the-scope clip for ulcer hemostasis after failure of both surgery and interventional therapy: A case report. Medicine (Baltimore) 2020; 99:e22646. [PMID: 33031324 PMCID: PMC7544317 DOI: 10.1097/md.0000000000022646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
|
13
|
Chavan R, Nabi Z, Karayampudi A, Jagtap N, Asif S, Yaralagadda R, Basha J, Lakhtakia S, Tandan M, Ramchandani M, Reddy DN. Outcomes of over-the-scope clip application in various gastrointestinal indications: experience from a tertiary care in India. Ann Gastroenterol 2020; 33:473-479. [PMID: 32879593 PMCID: PMC7406817 DOI: 10.20524/aog.2020.0515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022] Open
Abstract
Background Recent advances in endoscopic tools and techniques have allowed the minimally invasive management of iatrogenic gastrointestinal (GI) perforations and bleedings. However, surgery may be required in cases with larger defects and bleeding refractory to conventional endoscopic modalities. The use of over-the-scope clips (OTSC) has been shown to improve the outcomes in these patients compared with conventional treatment modalities. In this study, we evaluated the safety and efficacy of OTSC for different indications in the GI tract. Methods The data of consecutive patients in whom OTSC was utilized for different indications between February 2017 and October 2019 were analyzed retrospectively. The following outcomes were recorded: technical and clinical success, and adverse events related to the procedure. Results Thirty-six patients (22 male, mean age 52.673±14.97 years, range 11-72 years) underwent OTSC application. Indications for OTSC were: GI defects (perforation n=13, fistula n=5); esophageal metallic stent fixing n=9; GI bleeding n=8; and neuroendocrine tumor endotherapy n=1. The average size of the defect was 15.88±8.01 mm. The technical and clinical success rates were 88.89% and 83.33%, respectively. There were 4 (11.1%) technical failures: colonic perforations n=2; duodenal ulcer bleeding n=1; and esophageal metal stent fixation n=1. There were 2 (9.5%) adverse events, including 1 partial duodenal obstruction and 1 delayed bleeding. Conclusions The use of OTSC is safe, easy and effective for various indications in the GI tract. Prospective trials are required to see if the use of OTSC is cost effective as a primary endoscopic treatment method in these cases.
Collapse
Affiliation(s)
- Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Arun Karayampudi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Shujaath Asif
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| |
Collapse
|
14
|
Mullady DK, Wang AY, Waschke KA. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. Gastroenterology 2020; 159:1120-1128. [PMID: 32574620 DOI: 10.1053/j.gastro.2020.05.095] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/19/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.
Collapse
Affiliation(s)
- Daniel K Mullady
- Division of Gastroenterology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Kevin A Waschke
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
15
|
Bartell N, Bittner K, Kaul V, Kothari TH, Kothari S. Clinical efficacy of the over-the-scope clip device: A systematic review. World J Gastroenterol 2020; 26:3495-3516. [PMID: 32655272 PMCID: PMC7327783 DOI: 10.3748/wjg.v26.i24.3495] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Nicholas Bartell
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Krystle Bittner
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Truptesh H Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| |
Collapse
|
16
|
Over-The-Scope Clip system as a first-line therapy for high-risk bleeding peptic ulcers: a retrospective study. Surg Endosc 2020; 35:2198-2205. [PMID: 32394167 DOI: 10.1007/s00464-020-07625-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
17
|
Amarnath S, Philipose J, Abergel J, Khan H. Over-the-Scope Clip to the Rescue! A Novel Tool for Refractory Acute Nonvariceal Upper Gastrointestinal Hemorrhage. Case Rep Gastroenterol 2020; 14:261-270. [PMID: 32518537 PMCID: PMC7265719 DOI: 10.1159/000507610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022] Open
Abstract
Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is more prevalent than lower gastrointestinal hemorrhage and carries a high risk of mortality in the elderly, especially those with significant cardiovascular comorbidities. Traditional endoscopic methods, such as through-the-scope clips, electrocautery, and epinephrine injection, are frequently used to control these bleeds; however, they carry a 10% risk of rebleeding, and this itself carries a mortality risk of 36%. The larger over-the-scope clips (OTSC) that were initially used for the closure of fistulas and perforations are now gradually being implemented to manage NVUGIH. To our knowledge, we present the first cases to be reported in the literature where OTSC was successfully used as salvage therapy for refractory acute upper gastrointestinal bleeders who failed traditional endoscopic management and interventional radiology-guided embolization of the bleeding artery. We also provide an up-to-date literature review on the use of OTSC and its superiority to traditional endoscopic interventions in the management of complicated NVUGIH.
Collapse
Affiliation(s)
- Shivantha Amarnath
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Jobin Philipose
- Department of Gastroenterology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Jeffrey Abergel
- Department of Gastroenterology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Hafiz Khan
- Department of Gastroenterology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| |
Collapse
|
18
|
Naseer M, Lambert K, Hamed A, Ali E. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World J Gastrointest Endosc 2020; 12:1-16. [PMID: 31942229 PMCID: PMC6939122 DOI: 10.4253/wjge.v12.i1.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/28/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Maliha Naseer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Karissa Lambert
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Ahmed Hamed
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Eslam Ali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| |
Collapse
|
19
|
Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 2020; 15:3. [PMID: 31921329 PMCID: PMC6947898 DOI: 10.1186/s13017-019-0283-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
Collapse
Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Dieter G. Weber
- Royal Perth Hospital, Perth, Australia & The University of Western Australia, Crawley, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fabio C. Campanile
- Division of Surgery, ASL VT - Ospedale “Andosilla”, Civita Castellana, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Michael D. Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Andrew Peitzman
- University of Pittsburgh, School of Medicine, UPMC – Presbyterian, Pittsburgh, PA USA
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Marco Ceresoli
- Department of General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Michael Sugrue
- Letterkenny University Hospital, Donegal Clinical Research Academy Centre for Personalized Medicine, Donegal, Ireland
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| |
Collapse
|
20
|
Yu JX, Russell WA, Asokkumar R, Kaltenbach T, Soetikno R. Clipping Over the Scope for Recurrent Peptic Ulcer Bleeding is Cost-Effective as Compared to Standard Therapy: An Initial Assessment. Gastrointest Endosc Clin N Am 2020; 30:91-97. [PMID: 31739969 DOI: 10.1016/j.giec.2019.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jessica X Yu
- Division of Gastroenterology and Hepatology, University of Michigan, 1301 Catherine Street, Ann Arbor, MI 48109, USA.
| | - W Alton Russell
- Department of Management Sciences and Engineering, Stanford University, 475 Via Ortega, Stanford, CA 94305, USA
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Tonya Kaltenbach
- Division of Gastroenterology and Hepatology, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143, USA; Department of Gastroenterology, Veterans Affairs Medical Center; Advanced Gastrointestinal Endoscopy, Mountain View, CA, USA
| | - Roy Soetikno
- Advanced Gastrointestinal Endoscopy, Mountain View, CA, USA
| |
Collapse
|
21
|
Abstract
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.
Collapse
|
22
|
Mangiafico S, Pigò F, Bertani H, Caruso A, Grande G, Sgamato C, Manta R, Conigliaro R. Over-the-scope clip vs epinephrine with clip for first-line hemostasis in non-variceal upper gastrointestinal bleeding: a propensity score match analysis. Endosc Int Open 2020; 8:E50-E58. [PMID: 31921984 PMCID: PMC6949178 DOI: 10.1055/a-1005-6401] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/29/2019] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Santi Mangiafico
- Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Gastroenterology and Digestive Endoscopy Unit, Modena, Italy
| | - Flavia Pigò
- Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Gastroenterology and Digestive Endoscopy Unit, Modena, Italy
| | - Helga Bertani
- Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Gastroenterology and Digestive Endoscopy Unit, Modena, Italy
| | - Angelo Caruso
- Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Gastroenterology and Digestive Endoscopy Unit, Modena, Italy
| | - Giuseppe Grande
- Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Gastroenterology and Digestive Endoscopy Unit, Modena, Italy
| | - Costantino Sgamato
- University of Naples Federico II, Department of Clinical Medicine and Surgery, Gastroenterology Unit, Naples, Italy
| | - Raffaele Manta
- Azienda Ospedaliera di Perugia, Gastroenterology and Digestive Endoscopy Unit, Perugia, Italy
| | - Rita Conigliaro
- Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Gastroenterology and Digestive Endoscopy Unit, Modena, Italy
| |
Collapse
|
23
|
Mönkemüller K, Martínez-Alcalá A, Schmidt AR, Kratt T. The Use of the Over the Scope Clips Beyond Its Standard Use: A Pictorial Description. Gastrointest Endosc Clin N Am 2020; 30:41-74. [PMID: 31739967 DOI: 10.1016/j.giec.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite major improvements in endoscopic devices and therapeutic endoscopy, closure of gastrointestinal perforations, dehiscence, and fistulae had remained problematic. However, since the advent of devices such as the over the scope clip and others, endoscopic closure of gastrointestinal defects has become a routine approach. Furthermore, because of its strong apposition force, the over the scope clip may also be used to anchor fully covered self-expanding metal stents. In addition, the over the scope clip is an effective rescue therapy for various types of gastrointestinal bleeding pathologies. It is frequently used as an additional tool in complex gastrointestinal leak cases requiring internal and external drains.
Collapse
Affiliation(s)
- Klaus Mönkemüller
- Department of Gastroenterology, Helios Frankenwaldklinik, Kronach, Germany; Department of Gastroenterology, Otto-von-Guericke University, Magdeburg, Germany; University of Belgrade, Belgrade, Serbia.
| | | | - Arthur R Schmidt
- Division of Interdisciplinary Endoscopy, University of Freiburg, Germany
| | - Thomas Kratt
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
24
|
Zhong C, Tan S, Ren Y, Lü M, Peng Y, Fu X, Tang X. Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis. BMC Gastroenterol 2019; 19:225. [PMID: 31870315 PMCID: PMC6929512 DOI: 10.1186/s12876-019-1144-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/15/2019] [Indexed: 02/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Road Wenhua 63#, Region Shunqing, Nanchong, 637000, Sichuan, China.
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
| |
Collapse
|
25
|
Friedel D. Potential role of new technological innovations in nonvariceal hemorrhage. World J Gastrointest Endosc 2019; 11:443-453. [PMID: 31523376 PMCID: PMC6715570 DOI: 10.4253/wjge.v11.i8.443] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 06/16/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
The present armamentarium of endoscopic hemostatic therapy for non-variceal upper gastrointestinal hemorrhage includes injection, electrocautery and clips. There are newer endoscopic options such as hemostatic sprays, endoscopic suturing and modifications of current options including coagulation forceps and over-the-scope clips. Peptic hemorrhage is the most prevalent type of nonvariceal upper gastrointestinal hemorrhage and traditional endoscopic interventions have demonstrated significant hemostasis success. However, the hemostatic success rate is less for other entities such as Dieulafoy’s lesions and bleeding from malignant lesions. Novel innovations such as endoscopic submucosal dissection and peroral endoscopic myotomy has spawned a need for dependable hemostasis. Gastric antral vascular ectasias are associated with chronic gastrointestinal bleeding and usually treated by standard argon plasma coagulation (APC), but newer modalities such as radiofrequency ablation, banding, cryotherapy and hybrid APC have been utilized as well. We will opine on whether the newer hemostatic modalities have generated success when traditional modalities fail and should any of these modalities be routinely available in the endoscopic toolbox.
Collapse
Affiliation(s)
- David Friedel
- Department of Gastroenterology, New York University Winthrop Hospital, Mineola, NY 11501, United States
| |
Collapse
|
26
|
Wellington J, Canakis A, Kim R. Endoscopic closure devices: A review of technique and application for hemostasis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jennifer Wellington
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew Canakis
- Department of Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Raymond Kim
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
27
|
Parsi MA, Schulman AR, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Trikudanathan G, Trindade AJ, Watson RR, Maple JT. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VideoGIE 2019; 4:285-299. [PMID: 31334417 PMCID: PMC6616320 DOI: 10.1016/j.vgie.2019.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Key Words
- ABS, Ankaferd blood stopper
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- CPT, Current Procedural Terminology
- CSEMS, covered self-expandable metallic stent
- EBL, endoscopic band ligation
- EDP, endoscopic Doppler probe
- GAVE, gastric antral vascular ectasia
- HP, heater probe
- LGIB, lower GI bleeding
- MPEC, multipolar electrocoagulation
- OTSC, over-the-scope clip
- PTFE, polytetrafluoroethylene
- RCT, randomized controlled trial
- TTS, through-the-scope
- U.S. FDA, United States Food and Drug Administration
- UGIB, upper GI bleeding
Collapse
Affiliation(s)
| | - Mansour A Parsi
- Section for Gastroenterology & Hepatology, Tulane University Health Sciences Center, New Orleans, LA
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Harry R Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, CT
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kuman Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | |
Collapse
|
28
|
Gölder S, Neuhas L, Freuer D, Probst A, Ebigbo A, Braun G, Brueckner J, Stueckle J, Meier A, Messmann H. Over-the-scope clip in peptic ulcer bleeding: clinical success in primary and secondary treatment and factors associated with treatment failure. Endosc Int Open 2019; 7:E846-E854. [PMID: 31206010 PMCID: PMC6565427 DOI: 10.1055/a-0898-3357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Stefan Gölder
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany,Corresponding author Dr. Stefan Karl Gölder University Hospital Augsburg – Department of Internal Medicine IIIStenglinstraße 2Augsburg 86156Germany+498214003331
| | - Lukas Neuhas
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Denis Freuer
- Chair of Epidemiology of the LMU Munich at UNIKA-T, Augsburg, Germany
| | - Andreas Probst
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| | - Alanna Ebigbo
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| | - Georg Braun
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| | - Juliane Brueckner
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Johannes Stueckle
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Alexander Meier
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Helmut Messmann
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| |
Collapse
|
29
|
Wang TX, Zhang J, Cui LH, Tian JJ, Wei R. Efficacy of Therapeutic Endoscopy for Gastrointestinal Lesion (GI): A network meta-analysis. Pak J Med Sci 2019; 35:561-568. [PMID: 31086551 PMCID: PMC6500798 DOI: 10.12669/pjms.35.2.636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Tian-Xi Wang
- Tian-xi Wang, Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, 300100, China
| | - Jun Zhang
- Jun Zhang, General Medicine, Tianjin Beichen Hospital, Tianjin, 300401, China
| | - Li-Hong Cui
- Li-hong Cui, Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, 300100, China
| | - Jing-Jing Tian
- Jing-jing Tian, Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, 300100, China
| | - Rongna Wei
- Rongna Wei, Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, 300100, China
| |
Collapse
|
30
|
Weiland T, Rohrer S, Schmidt A, Wedi E, Bauerfeind P, Caca K, Khashab MA, Hochberger J, Baur F, Gottwald T, Schurr MO. Efficacy of the OTSC System in the treatment of GI bleeding and wall defects: a PMCF meta-analysis. MINIM INVASIV THER 2019; 29:121-139. [PMID: 30957599 DOI: 10.1080/13645706.2019.1590418] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.
Collapse
Affiliation(s)
| | | | - Arthur Schmidt
- Faculty of Medicine, Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Goettingen, Germany
| | - Peter Bauerfeind
- Department of Gastroenterology and Hepatology, Triemli Hospital, Zurich, Switzerland
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MA, USA
| | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Berlin, Germany
| | | | - Thomas Gottwald
- Ovesco Endoscopy AG, Tuebingen, Germany.,Medical Faculty, Eberhard Karls University, Tuebingen, Germany
| | - Marc O Schurr
- Ovesco Endoscopy AG, Tuebingen, Germany.,Steinbeis University, Berlin, IHCI-Institute, Tuebingen, Germany
| |
Collapse
|
31
|
Nassri AB, Alkhasawneh A, Scolapio JS, Malespin MH, Ribeiro BDS. Safety and efficacy of over-the-scope clip-assisted full thickness resection of duodenal subepithelial tumors: A case report. World J Gastrointest Endosc 2019; 11:168-173. [PMID: 30788035 PMCID: PMC6379745 DOI: 10.4253/wjge.v11.i2.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/15/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Over-the-scope clip-assisted endoscopic full thickness resection (eFTR) of subepithelial tumors is a novel and promising endoscopic technique. Recently, there have been prospective studies investigating its use for colonic masses, but data regarding its use and efficacy in the duodenum are limited to a few reports.
CASE SUMMARY A 65-year-old African American female presents for evaluation of persistent gastroesophageal reflux disease not responsive to medical treatment. A 1 cm nodule was incidentally found in the duodenum and biopsies revealed a low grade well differentiated neuroendocrine tumor. The nodule was removed using over-the-scope clip-assisted eFTR and pathology revealed clear margins. We review the available literature with a discussion on the efficacy and safety of clip-assisted eFTR s of subepithelial lesions in the duodenum.
CONCLUSION Clip assisted eFTR appears to be a safe and efficacious treatment approach to duodenal subepithelial lesions. Further prospective studies are needed to investigate the long-term utility and safety of clip-assisted eFTR in the management of subepithelial duodenal lesions.
Collapse
Affiliation(s)
- Ammar B Nassri
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida Health at Jacksonville, Jacksonville, FL 32209, United States
| | - Ahmad Alkhasawneh
- Department of Pathology and Laboratory Medicine, University of Florida Health at Jacksonville, Jacksonville, FL 32209, United States
| | - James S Scolapio
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida Health at Jacksonville, Jacksonville, FL 32209, United States
| | - Miguel H Malespin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida Health at Jacksonville, Jacksonville, FL 32209, United States
| | - Bruno de Souza Ribeiro
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida Health at Jacksonville, Jacksonville, FL 32209, United States
| |
Collapse
|
32
|
Kobara H, Mori H, Nishiyama N, Fujihara S, Okano K, Suzuki Y, Masaki T. Over-the-scope clip system: A review of 1517 cases over 9 years. J Gastroenterol Hepatol 2019; 34:22-30. [PMID: 30069935 DOI: 10.1111/jgh.14402] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/12/2018] [Accepted: 07/24/2018] [Indexed: 12/13/2022]
Abstract
Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over-the-scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC-associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.
Collapse
Affiliation(s)
- Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Hirohito Mori
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Noriko Nishiyama
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Shintaro Fujihara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| |
Collapse
|
33
|
Ofosu A, Ramai D, John F, Barakat M, Sunkara T, Sharma S, Gaduputi V, Adler DG, Reddy M. Over-the-scope-clips as primary and rescue therapy for non-variceal gastrointestinal bleeding: a systematic review and meta-analysis. MINERVA GASTROENTERO 2018; 65:70-76. [PMID: 30417630 DOI: 10.23736/s1121-421x.18.02513-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Endoscopic hemostasis in patients with non-variceal bleeding (NVGIB) with standard therapy has improved outcomes. However, persistent bleeding and re-bleeding continues to drive morbidity and mortality. Use of over-the-scope clips (OTSC) is an emerging treatment modality for managing gastrointestinal (GI) bleeding. We performed a systematic review and meta-analysis to evaluate the ability of OTSC to achieve primary hemostasis and re-bleeding rates as primary therapy and rescue endoscopic interventions in patients with NVGIB. EVIDENCE ACQUISITION We searched articles in PubMed, Ovid Medline In- Process & Other Non-Indexed Citations, Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from inception to July 2017 using keywords such as "OTSC" and "NVGIB." EVIDENCE SYNTHESIS A total of 16 studies which involved 475 patients met the inclusion criteria. 288 patients were treated with OTSC as primary therapy while 187 patients were treated with OTSC as rescue therapy. Primary hemostasis rate achieved with primary endoscopic therapy with OTSC was 0.93 (95% CI: 0.89-0.96). Similarly, primary hemostasis rate achieved with rescue endoscopic therapy with OTSC was 0.91 (95% CI: 0.84-0.95). Re-bleeding rates after primary endoscopic therapy with OTSC was 0.21 (95% CI:0.08-0.43) and 0.25 (95% CI:0.17-0.34) with rescue therapy. There was a decreased risk of re-bleeding in patients treated with OTSC as primary therapy versus rescue therapy. RR=0.52 (95% CI: 0.31-0.89). CONCLUSIONS This meta-analysis demonstrates success on the use of OTSC as primary and rescue therapy in the management of NVGIB. Further trials should clarify the ideal setting for the use of OTSC and assess the cost of these devices as compared to standard therapy.
Collapse
Affiliation(s)
- Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| | - Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| | - Febin John
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| | - Mohammed Barakat
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| | - Santosh Sharma
- Department of Medicine, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| | - Vinaya Gaduputi
- Department of Gastroenterology and Hepatology, St. Barnabas Hospital, Bronx, NY, USA
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA -
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY, USA
| |
Collapse
|
34
|
Over the Scope Clips for Treatment of Acute Nonvariceal Gastrointestinal Bleeding in Children Are Safe and Effective. J Pediatr Gastroenterol Nutr 2018; 67:458-463. [PMID: 29927862 DOI: 10.1097/mpg.0000000000002067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE There is little published experience with the use of over-the-scope clips (OTSCs) in pediatric patients. The aim of this study is to present our single-center experience utilizing OTSCs for nonvariceal gastrointestinal (GI) bleeding. METHODS This is a retrospective case series of pediatric patients who underwent endoscopic management of GI bleeding during which OTSCs were used. RESULTS Eleven cases of OTSC utilization for hemostasis were identified in 10 unique patients between November 2014 and May 2016. The median age at intervention was 14.7 years (range 3.9-16.8 years) and median weight was 39 kg (range 17.4-85.8 kg). Technical success and hemostasis were achieved in all cases and there were no complications. Median follow-up was 32.9 months (range 21.2-39.4 months). All nonanastomotic ulcers (4), polypectomy bleeding (2), and sphincterotomy bleeding (1) had no evidence of recurrent GI bleeding at last follow-up. Two patients with anastomotic ulcerations required additional medical interventions. CONCLUSIONS Our series demonstrates the safety and effectiveness of the OTSCs in the pediatric population for acute GI bleeding throughout the GI tract. In our experience, it is effective for nonanastomotic ulcers, postpolypectomy bleeding, and postsphincterotomy bleeding even when other hemostatic techniques have failed. OTSCs may be less effective in the setting of anastomotic ulcerations, reaffirming the refractory nature of these lesions.
Collapse
|
35
|
Schmidt A, Gölder S, Goetz M, Meining A, Lau J, von Delius S, Escher M, Hoffmann A, Wiest R, Messmann H, Kratt T, Walter B, Bettinger D, Caca K. Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers. Gastroenterology 2018; 155:674-686.e6. [PMID: 29803838 DOI: 10.1053/j.gastro.2018.05.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding. METHODS We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n = 31) or thermal therapy plus injection with diluted adrenaline (n = 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy. RESULTS Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P = .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P = .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6-63.2; P = .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P = .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P = .672). There were no significant differences in the other secondary endpoints. CONCLUSIONS In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900.
Collapse
Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany; Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Gölder
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Goetz
- Interdisciplinary Endoscopy, University of Tübingen, Tübingen, Germany
| | | | - James Lau
- Department of Surgery, University of Hong Kong, Hong Kong
| | - Stefan von Delius
- Department of Gastroenterology, Klinikum Rechts der Isar, TU München, München, Germany
| | - Markus Escher
- Department of Gastroenterology, Robert Bosch Krankenhaus Stuttgart, Stuttgart, Germany
| | - Arthur Hoffmann
- Department of Gastroenterology, Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Reiner Wiest
- Department of Gastroenterology, Inselspital Bern, Bern, Switzerland
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Thomas Kratt
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Benjamin Walter
- Department of Gastroenterology, University of Ulm, Ulm, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany.
| |
Collapse
|
36
|
Abstract
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.
Collapse
Affiliation(s)
- Ian LP Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
| |
Collapse
|
37
|
Martínez-Alcalá A, Mönkemüller K. Emerging Endoscopic Treatments for Nonvariceal Upper Gastrointestinal Hemorrhage. Gastrointest Endosc Clin N Am 2018; 28:307-320. [PMID: 29933777 DOI: 10.1016/j.giec.2018.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite major improvements in endoscopic devices and therapeutic endoscopy, rebleeding rates and mortality have remained the same for several decades. Therefore, much interest has been paid to emerging therapeutic devices, such as the over-the-scope clip and hemostatic sprays. Other emerging technologies, such as radiofrequency ablation, endoscopic suturing devices, and ultrasound-guided angiotherapy, are also being investigated to improve therapeutic outcomes in specific situations. This narrative review details the technical aspects, clinical applications, outcomes, and potential limitations of these devices in the context of nonvariceal upper gastrointestinal hemorrhage.
Collapse
Affiliation(s)
| | - Klaus Mönkemüller
- Department of Visceral Surgery, Division of Endoscopy, Frankenwaldklinik, Kronach, Germany.
| |
Collapse
|
38
|
[New endoscopic methods: hemostasis by over-the-scope clip (OTSC) and endoscopic full-thickness resection with the Full Thickness Resection Device (FTRD)]. MMW Fortschr Med 2018; 160:61-64. [PMID: 29943006 DOI: 10.1007/s15006-018-0710-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
39
|
Brandler J, Baruah A, Zeb M, Mehfooz A, Pophali P, Wong Kee Song L, AbuDayyeh B, Gostout C, Mara K, Dierkhising R, Buttar N. Efficacy of Over-the-Scope Clips in Management of High-Risk Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2018; 16:690-696.e1. [PMID: 28756055 DOI: 10.1016/j.cgh.2017.07.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/04/2017] [Accepted: 07/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Standard endoscopic therapies do not control bleeding or produce complications in as many as 20% of patients with nonvariceal gastrointestinal bleeding. Most bleeding comes from ulcers with characteristics such as high-risk vascular territories and/or large vessels. We evaluated the efficacy of using over-the-scope clips (OTSCs) as primary or rescue therapy for patients with bleeding from lesions that have a high risk for adverse outcomes. METHODS We performed a retrospective analysis of data from 67 patients with gastrointestinal bleeding from high-risk lesions who were treated with OTSCs as primary (n = 49) or rescue therapy (n = 18) at a quaternary center, from December 2011 through February 2015. The definition of high-risk lesions was lesions that were situated in the area of a major artery and larger than 2 mm in diameter and/or a deep penetrating, excavated, fibrotic ulcer with high-risk stigmata, in which a perforation could not be ruled out or thermal therapy would cause perforation, or lesions that could not be treated by standard endoscopy. Clinical severity was determined based on the Rockall score and a modified Blatchford score. Our primary outcome was the incidence of rebleeding within 30 days after OTSC placement. We assessed risk factors for rebleeding using univariate hazard models followed by multivariable analysis. RESULTS Of the 67 patients, 47 (70.1%) remained free of rebleeding at 30 days after OTSC placement. We found no difference in the proportion of patients with rebleeding who received primary or rescue therapy (hazard ratio, 0.639; 95% confidence interval, 0.084-4.860; P = .6653). Only 9 rebleeding events were linked clearly to OTSCs and required intervention, indicating an OTSC success rate of 81.3%. We found no significant associations between rebleeding and clinical scores. However, on multivariable analysis, patients with coronary artery disease had a higher risk of rebleeding after OTSC independent of international normalized ratio and antiplatelet use (hazard ratio, 7.30; P = .0002). CONCLUSIONS In a retrospective analysis of 67 patients with bleeding from high-risk gastrointestinal lesions, we found OTSCs to prevent rebleeding in more than 80% of cases. In the past, these lesions were treated with surgical or radiologic interventions. Patients with coronary artery disease have an increased risk of rebleeding after OTSCs, suggesting the need for escalated therapies.
Collapse
Affiliation(s)
- Justin Brandler
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | - Barham AbuDayyeh
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Navtej Buttar
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
40
|
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.
Collapse
|
41
|
Abstract
BACKGROUND To assess the safety and efficacy of the Instinct clip in the acute endoscopic treatment of upper gastrointestinal bleeding (UGIB). MATERIALS AND METHODS This is the first large series reporting this clip in achieving hemostasis. A retrospective descriptive chart review was performed on patients presenting with recent overt GI bleeding treated with endoclip therapy at Mount Sinai Beth Israel Medical Center between May 2013 and January 2016. Results are expressed in absolute numbers, percentages, and trends. RESULTS In total, 178 consecutive patients with UGIB were included. Source of bleeding was identified as duodenal ulcer (29.2%), gastric ulcer (22.5%), gastro-esophageal junction tear (8.4%), anastomosis (5.6%), erosive gastropathy (5.6%), Dieulafoy (5.1%), gastric polyp (4.5%), postendoscopic procedure (3.9%), angioectasia (3.4%), esophageal ulcer (2.8%), benign duodenal mass (2.8%), peg tube site (2.3%), gastric neoplasm (1.7%), esophagitis (1.1%), and small bowel ulcer (1.1%). Lesions demonstrated active bleeding in 47.5% (11.3% spurting and 36.2% oozing) and nonbleeding lesions in 52.5% (25.0% visible vessel, 11.9% hematin in ulcer base, 10.0% adherent clot, 5.6% flat spot). Initial hemostasis was achieved in 96.6%. Additional methods were used in 24.1% (argon plasma coagulation and epinephrine injection in 21.3%, surgery in 0.6%, and interventional radiology in 2.2%). There were no adverse events. In-hospital rebleeding was 7.3% and 3.9% presented with rebleeding within 30 days. Average procedure duration was 22.9 minutes and average length of hospital stay was 11.3 days. CONCLUSIONS The Instinct clip, when used for UGIB, seems to be safe and effective with similar rebleeding rates compared with other modalities.
Collapse
|
42
|
Liu S, Jacobsen GR, Sandler BJ, Savides TJ, Fehmi S, Fuchs H, Luo RB, Delong JC, Coker AM, Houghton C, Horgan S. Preventing Rescue Surgeries by Endoscopic Clipping: A Valuable Resource in the Surgeon's Toolbox. J Laparoendosc Adv Surg Tech A 2018; 28:439-444. [PMID: 29432050 DOI: 10.1089/lap.2017.0167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIM Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years. METHODS Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution. RESULTS Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms <6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%). CONCLUSIONS The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.
Collapse
Affiliation(s)
- Shanglei Liu
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Garth R Jacobsen
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Bryan J Sandler
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Thomas J Savides
- 2 Department of Gastroenterology, University of California at San Diego , San Diego, California
| | - Syed Fehmi
- 2 Department of Gastroenterology, University of California at San Diego , San Diego, California
| | - Hans Fuchs
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Ran B Luo
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Jonathan C Delong
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Alisa M Coker
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Caitlin Houghton
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| | - Santiago Horgan
- 1 Department of Surgery, Center for the Future of Surgery, University of California at San Diego , San Diego, California
| |
Collapse
|
43
|
Abstract
Acute upper gastrointestinal haemorrhage due to peptic ulcer bleeding remains an important cause of emergency presentation and hospital admission. Despite advances in many aspects of management, peptic ulcer bleeding is still associated with significant morbidity, mortality, and healthcare costs. Comprehensive international guidelines have been published, but advances as well as controversies continue to evolve. Important recent advances include the evidence supporting a more restrictive transfusion strategy aiming for a target haemoglobin of 70–90 g/l. Comparative studies have confirmed that the Glasgow–Blatchford score remains the most useful score for predicting the need for intervention as well as for identifying the lowest-risk patients suitable for outpatient management. New scores, including the AIMS65 and Progetto Nazionale Emorragia Digestiva score, may be more accurate in predicting mortality. Pre-endoscopy erythromycin appears to improve outcomes and is probably underused. High-dose oral proton pump inhibition (PPI) for 11 days after PPI infusion is advantageous in those with a Rockall score of 6 or more. Oral is as effective as parenteral iron at restoring haemoglobin levels after a peptic ulcer bleed and both are superior to placebo in this respect. Within endoscopic techniques, haemostatic powders and over-the-scope clips can be used when other methods have failed. A disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Non-
Helicobacter pylori, non-aspirin/non-steroidal anti-inflammatory drug ulcers contribute an increasing percentage of bleeding peptic ulcers and are associated with a poor prognosis and high rebleeding rate. The optimal management of these ulcers remains to be determined.
Collapse
Affiliation(s)
- Ian Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
| |
Collapse
|
44
|
Wedi E, von Renteln D, Gonzalez S, Tkachenko O, Jung C, Orkut S, Roth V, Tumay S, Hochberger J. Use of the over-the-scope-clip (OTSC) in non-variceal upper gastrointestinal bleeding in patients with severe cardiovascular comorbidities: a retrospective study. Endosc Int Open 2017; 5:E875-E882. [PMID: 28924593 PMCID: PMC5595576 DOI: 10.1055/s-0043-105496] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/13/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The over-the-scope-clip (OTSC) can potentially overcome limitations of standard clips and achieve more efficient and reliable hemostasis. Data on OTSC use for non-variceal upper gastrointestinal bleeding (NVUGIB) in patients with cardiovascular comorbidities are currently limited. PATIENTS AND METHODS We prospectively collected and retrospectively analyzed our database from February 2009 to September 2015 from all patients who underwent emergency endoscopy for high-risk NVUGIB in 2 academic centers and were treated with OTSC as first-line (n = 81) or second-line therapy (n = 19). RESULTS One hundred patients mean age 72 (range 27 - 97 years) were included in this study. Fifty-one percent (n = 51) had severe cardiovascular co-morbidity (ischemic heart disease, congestive heart failure, hypertension, valvular heart disease, peripheral arterial occlusive disease and atrial fibrillation) and 73 % (n = 73) were on antiplatelet or/and anticoagulation therapy. The median size of the treated ulcers was 3 cm (range 1 - 5 cm). In 94 % (n = 94) primary hemostasis with OTSC was achieved. Clinical long-term success during a mean 6-month follow-up without rebleeding was 86 % (n = 86). CONCLUSIONS In this cohort OTSC was demonstrated to be a safe and effective first- or second-line treatment for NVUGIB in high-risk patients with cardiovascular disease and complex, large ulcers.
Collapse
Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Department of Gastroenterology, Nouvel
Hôpital Civil, University Hospitals, Strasbourg, France,Corresponding author Edris Wedi,
MD Department of Gastroenterology and GI
OncologyUniversity Medical Centre
GoettingenCenter of Interdisciplinary
EndoscopyGeorg-August-UniversityEndoscopyD-37075
GoettingenGermany+495121901241
| | - Daniel von Renteln
- Division of Gastroenterology, Centre
Hospitalier de l’Université de Montréal (CHUM), Research Centre CHUM (CRCHUM)
Montreal, Quebec, Canada
| | - Susana Gonzalez
- Division of Gastroenterology, NYU Langone
Medical Center, New York, New York, United States
| | - Olena Tkachenko
- Division of Reproductive and Developmental
Sciences, Oregon National Primate Research Center, Oregon Health & Science
University, Beaverton, Oregon, United States
| | - Carlo Jung
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Department of Gastroenterology, Nouvel
Hôpital Civil, University Hospitals, Strasbourg, France
| | - Sinan Orkut
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Victor Roth
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Selin Tumay
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Juergen Hochberger
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Division of Gastroenterology, Vivantes
Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University,
Berlin, Germany
| |
Collapse
|
45
|
Wedi E, Fischer A, Hochberger J, Jung C, Orkut S, Richter-Schrag HJ. Multicenter evaluation of first-line endoscopic treatment with the OTSC in acute non-variceal upper gastrointestinal bleeding and comparison with the Rockall cohort: the FLETRock study. Surg Endosc 2017; 32:307-314. [PMID: 28656336 DOI: 10.1007/s00464-017-5678-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/19/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The over-the-scope clip (OTSC) overcomes limitations of standard clips and achieves a more efficient and reliable hemostasis in non-variceal upper gastrointestinal bleeding (NVUGIB). The study aims to evaluate mortality, rebleeding, and mortality after rebleeding of patients in whom the OTSC was used as the first-line endoscopic treatment (FLET) of NVUGIB. PATIENTS AND METHODS In total, 118 patients (FLET cohort) with a median age of 73.5 years (range 29-93 years; mean (±SD) 71.39 ± 12.39 years) were included. The distribution of patients with respect to risk category revealed a median Rockall score of 7 (range 3-10). For hypothesis testing, the FLET cohort was categorized into three risk groups taking into account the Rockall score: low risk [Rockall risk category (RRC ≤3)], moderate risk (RRC 4-7), and high risk (RRC ≥8). Event rates (mortality, rebleeding, and mortality after rebleeding) observed per risk group were compared to predicted event rates (Rockall cohort) using Fisher's Exact Test. RESULTS Primary successful hemostasis (PSH) was achieved in 92.4% either by FLET alone or in combination with an additional hemostasis technique in 1.7% (SCS = secondary clinical success). In 7.5% of the FLET cohort PSH could not be achieved. Compared to RRC prediction, mortality after rebleeding was significantly reduced from 27.9 to 10.9% in the high-risk group (RRC ≥8) treated with FLET (p < 0.011). Furthermore, the occurrence of rebleeding or continued bleeding was significantly lower in the moderate risk group (RRC 4-7) with 4.9% as well as in the high-risk group (RRC ≥8) with 21.4% compared to the Rockall cohort 24.0 and 53.2%, respectively (p < 0.001). CONCLUSIONS This study shows that OTSC is superior to standard care and FLET reduces significantly rebleeding and rebleeding-associated mortality in NVUGIB. For this reason, OTSC could be the treatment of choice as the first-line treatment as an alternative to standard hemostasis techniques in high-risk patients.
Collapse
Affiliation(s)
- E Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Goettingen, Germany.
| | - A Fischer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - J Hochberger
- Departement of Gastroenterology, Vivantes Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University, 10249, Berlin, Germany
| | - C Jung
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Goettingen, Germany
| | - S Orkut
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Goettingen, Germany
| | - H J Richter-Schrag
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| |
Collapse
|
46
|
Lamberts R, Koch A, Binner C, Zachäus M, Knigge I, Bernhardt M, Halm U. Use of over-the-scope clips (OTSC) for hemostasis in gastrointestinal bleeding in patients under antithrombotic therapy. Endosc Int Open 2017; 5:E324-E330. [PMID: 28484732 PMCID: PMC5419843 DOI: 10.1055/s-0043-104860] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and study aims In patients taking different regimens of antithrombotic and/or anticoagulant therapy, endoscopic management of gastrointestinal bleeding represents a major challenge due to failing endogenous hemostasis. In this retrospective study we report on success rates with the over-the-scope clip (OTSC) system in upper and lower gastrointestinal bleeding in this high-risk patient population. Patients and methods Between February 2011 and June 2014, 75 patients were treated with an OTSC for active gastrointestinal bleeding. Success rates with the first endoscopic therapy, rebleeding episodes, their management and the influence of antithrombotic or anticoagulant therapy were analyzed retrospectively. Results Application of the OTSC resulted in immediate hemostasis (primary success rate) in all 75 patients. However, in 34.7 % a rebleeding episode was noted that could be treated by further endoscopic interventions. Only 3 patients had to be sent to the operating room because of failure of endoscopic therapy. In the rebleeding group the use of antiplatelet therapies was higher (73.1 % vs. 48.9 %). Conclusions Application of the OTSC in GI bleeding results in a high rate of primary hemostasis. Rebleeding occurs in up to 35 % of patients receiving antithrombotic/anticoagulant therapy but can be managed successfully with further endoscopic treatments. Patients in the rebleeding group were more frequently treated with antiplatelet agents. Radiological or surgical therapy was reserved for a small subgroup not successfully managed by repeated endoscopic therapies. OTSC application is the treatment of choice in high-risk patients when conventional clips used as first-line treatment fail.
Collapse
Affiliation(s)
- Regina Lamberts
- HELIOS Park-Klinikum Leipzig, Klinik für Innere Medizin II, Leipzig, Germany,Corresponding author Prof. Dr. med. Regina Lamberts HELIOS Park-Klinikum LeipzigStrümpellstrasse 41D-04289 Leipzig+49/0341/8642264
| | - Anna Koch
- HELIOS Park-Klinikum Leipzig, Klinik für Innere Medizin II, Leipzig, Germany
| | | | - Marcus Zachäus
- HELIOS Park-Klinikum Leipzig, Klinik für Innere Medizin II, Leipzig, Germany
| | - Ingrid Knigge
- HELIOS Park-Klinikum Leipzig, Klinik für Innere Medizin II, Leipzig, Germany
| | - Mark Bernhardt
- HELIOS Park-Klinikum Leipzig, Klinik für Innere Medizin II, Leipzig, Germany
| | - Ulrich Halm
- HELIOS Park-Klinikum Leipzig, Klinik für Innere Medizin II, Leipzig, Germany
| |
Collapse
|
47
|
Richter-Schrag HJ, Glatz T, Walker C, Fischer A, Thimme R. First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: A single-center experience with 100 cases. World J Gastroenterol 2016; 22:9162-9171. [PMID: 27895403 PMCID: PMC5107597 DOI: 10.3748/wjg.v22.i41.9162] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 08/01/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate rebleeding, primary failure (PF) and mortality of patients in whom over-the-scope clips (OTSCs) were used as first-line and second-line endoscopic treatment (FLET, SLET) of upper and lower gastrointestinal bleeding (UGIB, LGIB).
METHODS A retrospective analysis of a prospectively collected database identified all patients with UGIB and LGIB in a tertiary endoscopic referral center of the University of Freiburg, Germany, from 04-2012 to 05-2016 (n = 93) who underwent FLET and SLET with OTSCs. The complete Rockall risk scores were calculated from patients with UGIB. The scores were categorized as < or ≥ 7 and were compared with the original Rockall data. Differences between FLET and SLET were calculated. Univariate and multivariate analysis were performed to evaluate the factors that influenced rebleeding after OTSC placement.
RESULTS Primary hemostasis and clinical success of bleeding lesions (without rebleeding) was achieved in 88/100 (88%) and 78/100 (78%), respectively. PF was significantly lower when OTSCs were applied as FLET compared to SLET (4.9% vs 23%, P = 0.008). In multivariate analysis, patients who had OTSC placement as SLET had a significantly higher rebleeding risk compared to those who had FLET (OR 5.3; P = 0.008). Patients with Rockall risk scores ≥ 7 had a significantly higher in-hospital mortality compared to those with scores < 7 (35% vs 10%, P = 0.034). No significant differences were observed in patients with scores < or ≥ 7 in rebleeding and rebleeding-associated mortality.
CONCLUSION Our data show for the first time that FLET with OTSC might be the best predictor to successfully prevent rebleeding of gastrointestinal bleeding compared to SLET. The type of treatment determines the success of primary hemostasis or primary failure.
Collapse
|
48
|
New and emerging technologies to endoscopically manage nonvariceal upper gastrointestinal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
49
|
Donatelli G, Cereatti F, Dhumane P, Vergeau BM, Tuszynski T, Marie C, Dumont JL, Meduri B. Closure of gastrointestinal defects with Ovesco clip: long-term results and clinical implications. Therap Adv Gastroenterol 2016; 9:713-21. [PMID: 27582884 PMCID: PMC4984331 DOI: 10.1177/1756283x16652325] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Over-The-Scope Clip (OTSC®, Ovesco Endoscopy GmbH, Tübingen, Germany) is an innovative clipping device that provides a strong tissue grasp and compression without provoking ischemia or laceration. In this retrospective study we evaluated immediate and long-term success rates of OTSC deployment in various pathologies of the gastrointestinal (GI) tract. METHODS A total of 45 patients (35 female, 10 male) with an average age of 56 years old (range, 24-90 years) were treated with an OTSC for GI defects resulting from a diagnostic or interventional endoscopic procedure (acute setting group) or for fistula following abdominal surgery (chronic setting group). All procedures were performed with CO2 insufflation. RESULTS From January 2012 to December 2015 a total of 51 OTSCs were delivered in 45 patients for different kinds of GI defects. Technical success was always achieved in the acute setting group with an excellent clip adherence and a clinical long-term success rate of 100% (15/15). Meanwhile, considering the chronic setting group, technical success was achieved in 50% of patients with a long-term clinical success of 37% (11/30); two minor complications occurred. A total of three patients died due to causes not directly related to clip deployment. Overall clinical success rate was achieved in 58% cases (26/45 patients). A mean follow-up period of 17 months was accomplished (range, 1-36 months). CONCLUSION OTSC deployment is an effective and minimally-invasive procedure for GI defects in acute settings. It avoids emergency surgical repair and it allows, in most cases, completion of the primary endoscopic procedure. OTSC should be incorporated as an essential technique of today's modern endoscopic armamentarium in the management of GI defects in acute settings. OTSCs were less effective in cases of chronic defects.
Collapse
Affiliation(s)
| | - Fabrizio Cereatti
- Digestive Endoscopy and Gastroenterology Unit, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Parag Dhumane
- Department of General and Laparoscopic Surgery, Lilavati Hospital and Research Center, Bandra (w), Mumbai, India
| | - Bertrand Marie Vergeau
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Thierry Tuszynski
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Christian Marie
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Jean-Loup Dumont
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Bruno Meduri
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| |
Collapse
|
50
|
Ghassemi KA, Jensen DM. Evolving techniques for gastrointestinal endoscopic hemostasis treatment. Expert Rev Gastroenterol Hepatol 2016; 10:615-23. [PMID: 26651414 PMCID: PMC6063521 DOI: 10.1586/17474124.2016.1130623] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.
Collapse
Affiliation(s)
- Kevin A. Ghassemi
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group
| | - Dennis M. Jensen
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group,Division of Gastroenterology, VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
| |
Collapse
|