A prospective, randomized trial of endoscopic hemoclip placement and distilled water injection for treatment of high-risk bleeding ulcers

Prophylactic Clipping to Prevent Delayed Bleeding and Perforation After Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

To help prevent delayed adverse events after endoscopic surgery, endoscopists often place clips at the site. This meta-analysis aimed to assess the efficacy and safety of prophylactic clipping in the prevention of delayed bleeding and perforation after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR).

METHODS

Multiple databases were searched from the inception dates to April 2021. And we included all relevant studies. Pooled odds ratio comparing the prophylactic clipped group versus nonprophylactic clipped group were calculated using the random effects model.

RESULTS

Twenty-seven articles fulfilled the inclusion criteria, with a total size of 8693 participants. There was statistically significant difference in prophylactic clipping versus no prophylactic clipping for delayed bleeding and perforation found in all studies (odds ratio: 0.35, 95% confidence interval: 0.25-0.49, P <0.01; odds ratio: 0.42, 95% confidence interval: 0.21-0.83, P <0.05; respectively). Besides, statistically significant difference was also found in subgroup analyses based on patients with lesions larger than 20 mm. Prophylactic clipping was more protective for duodenal delayed adverse events than colorectum. The use of clip closure was more protective to ESD-related delayed adverse events than EMR.

CONCLUSIONS

Prophylactic clipping after ESD and EMR was beneficial in preventing delayed bleeding and perforation.

Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment

Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.

Risk of Delayed Bleeding after a Colorectal Endoscopic Mucosal Resection without Prophylactic Clipping: Single Center, Observational Study

Background/Aims

Bleeding is one of the major complications of a colorectal polypectomy. The aim of this study was to identify the risk of delayed bleeding, particularly after a colorectal endoscopic mucosal resection (EMR) without prophylactic clipping.

Methods

Between April 2014 and August 2014, patients who underwent colorectal EMR (≥6 mm and <2 cm) without prophylactic clipping were included. This study evaluated the incidence of delayed bleeding and the associated factors after colorectal EMR without prophylactic clipping.

Results

A total of 717 colorectal polyps (≥6 mm and <2 cm) of 243 patients resected by colorectal EMR in the study period were evaluated. The mean age of the patients was 63 years; 165 patients were men and 78 patients were women. The mean polyp size removed by colorectal EMR was 9.0 mm (range 6.0-19.0), and the number of polyps larger than 1 cm was 212 (29.6%). Delayed bleeding after colorectal EMR occurred in 12 polyps (1.7%) in eight patients (3.3%), and there were no significant risk factors affecting delayed bleeding.

Conclusions

This study identified that the incidence of delayed bleeding on colorectal polyps (≥6 mm and <2 cm) after EMR without prophylactic clipping was 3.3%, but no significant risk factors affecting delayed bleeding were found.

A Newly Designed 3-Dimensional Printer-Based Gastric Hemostasis Simulator with Two Modules for Endoscopic Trainees (with Video)

Background/Aims

We used 3-dimensional (3D) printing technology to create a new hemostasis simulator for the stomach and investigated its efficacy and realism in endoscopic hemostasis training.

Methods

A new stomach hemostasis simulator, with two hemostasis modules for hemoclipping and injection, was constructed using a 3D printer. Twenty-one endoscopists, including 11 first-year fellows (beginner group) and 10 faculty members (expert group), tested the performance of the simulator. We recorded and reviewed five training sessions and evaluated the simulator with questionnaires using a 7-point Likert scale.

Results

The mean evaluation score of the expert group was 6.3±0.5 for the hemoclipping module and 6.0±0.6 for the injection module. The expert group strongly agreed that endoscopic handling in the simulator was realistic and reasonable for hemostasis training. The mean procedure time for hemoclipping was 72.7±7.1 seconds for the beginner group and 19.7±1.2 seconds for the expert group. The mean procedure time for injection was 92.1±9.8 seconds for the beginner group and 36.3±2 seconds for the expert group. The procedure time of beginner group became shorter with repetition and was significantly lower by the fifth trial.

Conclusions

A new 3D-printed hemostasis simulator is capable of hemostasis training and can very effectively train beginners before they perform the procedure in patients with gastrointestinal bleeding.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials

BACKGROUND

Peptic ulcer represents the most common cause of upper gastrointestinal bleeding. Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this review is to compare the different modalities of endoscopic therapy.

METHODS

Studies were identified by searching electronic databases MEDLINE, Embase, Cochrane, LILACS, DARE, and CINAHL. We selected randomized clinical trials that assessed contemporary endoscopic hemostatic techniques. The outcomes evaluated were: initial hemostasis, rebleeding rate, need for surgery, and mortality. The possibility of publication bias was evaluated by funnel plots. An additional analysis was made, including only the higher-quality trials.

RESULTS

Twenty-eight trials involving 2988 patients were evaluated. Injection therapy alone was inferior to injection therapy with hemoclip and with thermal coagulation when evaluating rebleeding and the need for emergency surgery. Hemoclip was superior to injection therapy in terms of rebleeding; there were no statistically significant differences between hemoclip alone and hemoclip with injection therapy. There was considerable heterogeneity in the comparisons between hemoclip and thermal coagulation. There were no statistically significant differences between thermal coagulation and injection therapy, though their combination was superior, in terms of rebleeding, to thermal coagulation alone.

CONCLUSIONS

Injection therapy should not be used alone. Hemoclip is superior to injection therapy, and combining hemoclip with an injectate does not improve hemostatic efficacy above hemoclip alone. Thermal coagulation has similar efficacy as injection therapy; combining these appears to be superior to thermal coagulation alone. Therefore, we recommend the application of hemoclips or the combined use of injection therapy with thermal coagulation for the treatment of peptic ulcer bleeding.

Endoscopic ultrasound guided vascular access and therapy (with videos)

The continued need to develop minimally invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. EUS has now stepped into the therapeutic arena. EUS provides the unique advantage of both real-time imaging and access to structures within and adjacent to the gastrointestinal (GI) tract. Hence, EUS-guided therapeutic techniques continue to evolve in several directions enabling a variety of minimally invasive therapies for pancreatic and biliary pathologies. Furthermore, the close proximity of the GI tract to vascular structures in the mediastinum and abdomen permits EUS-guided vascular access and therapy. Studies have demonstrated several EUS-guided vascular interventions by using standard endoscopic accessories and available tools from the interventional radiology armamentarium. This article provides an overview of the literature including clinical and nonclinical studies for the management of nonvariceal and variceal GI bleeding, formation of intrahepatic portosystemic shunts (IPSS), and EUS-guided cardiac access and therapy.

Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding

One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.

Endoscopic ultrasound-guided intravascular therapy

The gastrointestinal tract provides a unique "window" to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with a standard fine-needle aspiration (FNA) needle. Sclerosants, cyanoacrylate, and coils can be delivered through the lumen of the FNA needle. EUS-guided treatment of gastric varices has theoretical advantages over conventional endoscopy-guided treatment. Controlled studies are needed to determine the role of EUS-guided treatment for primary and secondary prevention of variceal bleeding. There is a growing list of novel indications for EUS-guided vascular therapy that include portal vein angiography and pressure measurements, intrahepatic portosystemic shunt placement, and micro coil embolization of vascular structures. Additionally, access and therapy of the heart and surrounding structures appears feasible.

Comparison of hemostatic efficacy of argon plasma coagulation with and without distilled water injection in treating high-risk bleeding ulcers

Background. Argon plasma coagulation (APC) is useful to treat upper gastrointestinal bleeding, but its hemostatic efficacy has received little attention. Aims. This investigation attempted to determine whether additional endoscopic injection before APC could improve hemostatic efficacy in treating high-risk bleeding ulcers. Methods. From January 2007 to April 2011, adult patients with high-risk bleeding ulcers were included. This investigation compared APC plus distilled water injection (combined group) to APC alone for treating high-risk bleeding ulcers. Outcomes were assessed based on initial hemostasis, surgery, blood transfusion, hospital stay, rebleeding, and mortality at 30 days posttreatment. Results. Totally 120 selected patients were analyzed. Initial hemostasis was accomplished in 59 patients treated with combined therapy and 57 patients treated with APC alone. No significant differences were noted between these groups in recurred bleeding, emergency surgery, 30-day mortality, hospital stay, or transfusion requirements. Comparing the combined end point of mortality plus the failure of initial hemostasis, rebleeding, and the need for surgery revealed an advantage for the combined group (P = 0.040). Conclusions. Endoscopic therapy with APC plus distilled water injection was no more effective than APC alone in treating high-risk bleeding ulcers, whereas combined therapy was potentially superior for patients with poor overall outcomes.

The efficacy of transcatheter arterial embolization as the first-choice treatment after failure of endoscopic hemostasis and endoscopic treatment resistance factors

AIM

The aim of this retrospective study was to evaluate the efficacy of transcatheter arterial embolization (TAE) as the first-choice treatment in patients with bleeding peptic ulcer after the failure of endoscopic hemostasis. An additional objective was to clarify endoscopic treatment resistance factors.

METHODS

Between April 2004 and December 2010, 554 patients were admitted to Kasugai Municipal Hospital for necessary endoscopic hemostasis for bleeding gastric ulcer or duodenal ulcer. In the patients for whom endoscopic hemostasis failed, TAE was attempted. If TAE failed, the patients underwent surgery. The backgrounds of the patients in whom endoscopic treatment was successful and in whom it failed were compared.

RESULTS

TAE was attempted in 15 patients (2.7%). In 12 (80.0%) of 15 patients, embolization with coils was successful. In one patient (6.7%), embolization was ineffective. This patient underwent emergent salvage surgery. In two (13.3%) of 15 patients, no extravasation was observed during arteriography. These patients were cured with medication. In two patients, ulcer perforation was observed during endoscopy after rebleeding. These patients underwent surgery. In total, 3 (0.5%) of 554 patients underwent surgery. No recurrent bleeding was observed after TAE. Hemoglobin level <8 g/dL at presentation (P = 0.02), Rockall score ≥7 at presentation (P = 0.002), and Forrest class Ia/Ib at initial endoscopic hemostasis (P < 0.001) were found to be independent significant endoscopic treatment resistance factors.

CONCLUSIONS

TAE is a safe and effective first-choice treatment for patients in whom endoscopic hemostasis has failed.

EUS-guided vascular access and therapy

The gastrointestinal tract provides a unique window to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with standard fine-needle aspiration. EUS-guided treatment of varices has been largely reserved as rescue therapy for refractory bleeding but has theoretic advantages over conventional endoscopy-guided treatment. Data are limited and multicenter, prospective controlled trials are needed to show clinical effectiveness and safety in humans. The development of new tools designed for EUS-guided vascular therapy is needed.

Hemodynamic efficacy of the over-the-scope clip in an established porcine cadaveric model for spurting bleeding

BACKGROUND

Clip application has been proven to be effective for endoscopic hemostasis. There are limited bench data on the efficacy of the over-the-scope clip (OTSC) for the treatment of spurting GI hemorrhage. We evaluated the hemodynamic efficacy of the OTSC in an established bleeding model.

OBJECTIVE

To evaluate the hemodynamic efficacy of the OTSC in an established bleeding model.

DESIGN

Prospective experimental trial with historical comparison.

SETTING

We tested the OTSC prospectively in a validated bleeding model by using the compact Erlangen Active Simulator for Interventional Endoscopy equipped with an upper GI organ package. The artificial blood circulation system of the simulator was connected to an arterial pressure transducer. Two investigators with different endoscopic experience (4000 and 10,000 endoscopies performed) participated. Each investigator treated 16 bleeding sites in the simulator with the OTSC by using only suction (n = 8) and a novel retraction device to grasp tissue (n = 8). Systemic pressures were recorded 1 minute before, during, and 1 minute after clip application to objectify the effects of clipping on the vessel diameter.

MAIN OUTCOME MEASUREMENTS

Mean and maximum reduction in vessel diameter.

RESULTS

The application of the OTSC on the bleeding vessel led to a significant increase in systemic pressure (P < .001) and decreased vessel diameter (P < .001) independent of the endoscopic experience of the investigator. There was no difference in the decrease in vessel diameter based on the application technique (suction vs suction plus grasping). A historical comparison with our former trials demonstrated that the OTSC decreased the vessel diameter significantly more than other traditional endoclips.

LIMITATIONS

Small sample size.

CONCLUSIONS

We could demonstrate the efficacy of the OTSC with increased hemodynamic efficiency compared with other endoscopic clip devices tested previously.

Endoscopic management of GI perforations with a new over-the-scope clip device (with videos)

BACKGROUND

Through-the-scope endoclips have been used to manage small perforations in the GI tract, but they have limitations. A new over-the-scope clip system, OTSC (Ovesco Endoscopy, Tuebingen, Germany), may be suitable for the closure of larger GI leaks.

OBJECTIVE

To evaluate the clinical outcomes of patients with GI perforations of up to 20 mm, treated with OTSC.

DESIGN

Prospective, single-arm, pilot study.

SETTING

General hospitals referral centers for endotherapy.

PATIENTS

This study involved 10 patients (median age 58.5 years [range 27-82 years], 7 men) with GI leaks from perforations, fistulas, and anastomotic dehiscence. Two gastric, 2 duodenal, and 6 colonic leaks were treated with OTSC. The diameter of leaks ranged between 7 and 20 mm.

INTERVENTIONS

OTSC devices were used to seal the GI leaks. Then Gastrografin (Bayer AG, Germany) was introduced via the endoscope and complete sealing confirmed under fluoroscopy. Patients underwent a second endoscopic examination 3 months later.

MAIN OUTCOME MEASUREMENT

Complete sealing of the leak.

RESULTS

Complete sealing of leaks was achieved by using OTSC alone in 8 of 10 patients. For one patient, successful endoscopic management was completed by placing two additional covered stents. Only one patient required surgical repair of the leak. Endoscopic examination 3 months after treatment confirmed that leaks in 8 of 9 endoscopically treated patients were healed, and the patients did not have recurrence of the leaks or complications from the OTSC devices. One patient died from neoplastic progression before the second endoscopy could be performed.

LIMITATIONS

Uncontrolled study.

CONCLUSIONS

The OTSC system appears to be a useful device in the management of larger GI leaks in a variety of clinical scenarios.

[Classification and management of upper gastrointestinal bleeding]

The upper gastrointestinal bleeding remains the most frequent emergency in gastroenterology. Due to the different therapeutic approach a distinction between the variceal and the non-variceal bleeding has been established. A risk assessment for the individual patient is crucial for timing of the endoscopic procedure as well as for the estimation of prognosis. This review gives an overview on modern therapeutic techniques for both, variceal and non-variceal bleeding highlighting on success rates but also on potential complications of the different therapeutic interventions.

Comparison of hemostatic efficacy for argon plasma coagulation and distilled water injection in treating high-risk bleeding ulcers

GOALS AND BACKGROUND

Endoscopic treatment is recommended for initial hemostasis in nonvariceal upper gastrointestinal bleeding. Many endoscopic devices have been demonstrated to be effective in the hemostasis of bleeding ulcers. However, the hemostatic efficacy of argon plasma coagulation (APC) has not been widely investigated.

STUDY

From February 2007 to February 2008, 271 consecutive patients with high-risk bleeding ulcers, characterized by active bleeding, nonbleeding visible vessels and adherent clots, were admitted to our hospital. Among these patients, 135 nonrandomly underwent either APC therapy or distilled water injection. Pantoprazole infusion was conducted during the fasting period after endoscopy and orally for 8 weeks to encourage ulcer healing. Episodes of rebleeding were retreated with endoscopic combination therapy. Patients who did not benefit from retreatment underwent emergency surgery.

RESULTS

In all,135 patients were enrolled, among whom 6 with gastric malignancy, acute severe illness or multiple bleeding sites were excluded. Finally, hemostatic efficacy in 59 patients treated with APC was prospectively compared with 70 patients treated with distilled water injection. The two treatment groups were similar with respect to all baseline characteristics. Initial hemostasis was accomplished in 57 patients treated with APC, and 64 patients with distilled water injection therapy (97% vs. 91%, P=0.29). Bleeding recurred in 6 patients treated with APC, and in 17 patients treated with distilled water injection (11% vs. 27%, P=0.03). No significant differences were observed between the 2 groups in hospital stay, transfusion requirements, surgery and mortality.

CONCLUSIONS

Endoscopic therapy with APC is more effective than distilled water injection for preventing rebleeding in the treatment of high-risk bleeding ulcers.

Adrenaline injection plus argon plasma coagulation versus adrenaline injection plus hemoclips for treating high-risk bleeding peptic ulcers: a prospective, randomized trial

BACKGROUND/OBJECTIVE

Several combination endoscopic therapies are currently in use. The present study aimed to compare argon plasma coagulation (APC) + adrenaline injection (AI) with hemoclips + AI for the treatment of high-risk bleeding peptic ulcers.

METHODS

In a prospective randomized trial, 172 patients with major stigmata of peptic ulcer bleeding were randomly assigned to receive APC + AI (n = 89) or hemoclips + AI (n = 83). In the event of rebleeding, the initial modality was used again. Patients in whom treatment or retreatment was unsuccessful underwent emergency surgery. The primary end point of rebleeding rate and secondary end points of initial and definitive hemostasis need for surgery and mortality were compared between the two groups.

RESULTS

The two groups were similar in all background variables. Definitive hemostasis was achieved in 85 of 89 (95.5%) of the APC + AI and 82 of 83 (98.8%) of the hemoclips + AI group (P = 0.206). The mean volume of adrenaline injected in the two groups was equal (20.7 mL; P = 0.996). There was no significant difference in terms of initial hemostasis (96.6% versus 98.8%; P = 0.337), rate of rebleeding (11.2% versus 4.8%; P = 0.124), need for surgery (4.5% versus 1.2%; P = 0.266) and mortality (2.2% versus 1.2%; P = 0.526). When compared for the combined end point of mortality plus rebleeding and the need for surgery, there was an advantage for the hemoclip group (6% versus 15.7%, P = 0.042).

CONCLUSION

Hemoclips + AI has no superiority over APC + AI in treating patients with high-risk bleeding peptic ulcers. Hemoclips + AI may be superior when a combination of all negative outcomes is considered.

The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding

Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.

Application of endoscopic hemoclips for nonvariceal bleeding in the upper gastrointestinal tract

AIM: To investigate acute nonvariceal bleeding in the upper gastrointestinal (GI) tract and evaluate the effects of endoscopic hemoclipping.

METHODS: Sixty-eight cases of acute nonvariceal bleeding in the upper GI tract were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated.

RESULTS: The 68 cases (male:female = 42:26, age from 9 to 70 years, average 54.4) presented with hematemesis in 26 cases (38.2%), melena in nine cases (13.3%), and both in 33 cases (48.5%). The causes of the bleeding included gastric ulcer (29 cases), duodenal ulcer (11 cases), Dieulafoy’s lesion (11 cases), Mallory-Weiss syndrome (six cases), post-operative (three cases), post-polypectomy bleeding (five cases), and post-sphincterotomy bleeding (three cases); 42 cases had active bleeding. The mean number of hemoclips applied was four. Permanent hemostasis was obtained by hemoclip application in 59 cases; 6 cases required emergent surgery (three cases had peptic ulcers, one had Dieulafoy’s lesion, and two were caused by sphincterotomy); three patients died (two had Dieulafoy’s lesion and one was caused by sphincterotomy); and one had recurrent bleeding with Dieulafoy’s lesion 10 mo later, but in a different location.

CONCLUSION: Endoscopic hemoclip application was an effective and safe method for acute nonvariceal bleeding in the upper GI tract with satisfactory outcomes.

Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses

BACKGROUND AND OBJECTIVE

Optimal endoscopic hemostasis remains undetermined. This was a systematic review of contemporary methods of endoscopic hemostasis for patients with bleeding ulcers that exhibited high-risk stigmata.

SETTING

Randomized trials that evaluated injection, thermocoagulation, clips, or combinations of these were evaluated from MEDLINE, EMBASE, and CENTRAL (1990-2006).

PATIENTS

A total of 4261 patients were evaluated.

OUTCOMES

Outcomes were rebleeding (primary), surgery, and mortality (secondary). Summary statistics were determined; publication bias and heterogeneity were sought by using funnel plots or by subgroup analyses and meta-regression.

RESULTS

Forty-one trials assessed 4261 patients. All endoscopic therapies decreased rebleeding versus pharmacotherapy alone, including sole intravenous (IV) proton pump inhibition (PPI) (OR 0.56 [95% CI, 0.34-0.92]); only one trial assessed high-dose IV PPI. Injection alone was inferior compared with other methods, except for thermal hemostasis (OR 1.02 [95% CI, 0.74-1.40]), with a strong trend of increased rebleeding if 1 injectate is used rather than 2 (OR 1.40 [95% CI, 0.95-2.05]). Injection followed by thermal therapy did not decrease rebleeding compared with clips (OR 0.82 [95% CI, 0.28-2.38]) or thermal therapy alone (OR 0.79 [95% CI, 0.24-2.62]). Subgroup analysis, however, suggested that injection followed by thermal therapy was superior to thermal therapy alone. Clips were superior to thermal therapy (OR 0.24 [95% CI, 0.06-0.95]) but, when followed by injection, were not superior to clips alone (OR 1.30 [95% CI, 0.36-4.76]). Surgery or mortality was not altered in most comparisons.

CONCLUSIONS

All endoscopic treatments are superior to pharmacotherapy alone; only 1 study assessed high-dose IV PPI. Optimal endoscopic therapies include thermal therapy or clips, either alone or in combination with other methods. Additional data are needed that compare injection followed by thermal therapy to clips alone or clips combined with another method.

Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials

The aim of this study was to determine appropriate endoscopic treatment of patients with bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal therapy, injection therapy, or clips for bleeding ulcers with active bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent) bleeding. Compared with epinephrine, further bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, 0.36-0.93]; number-needed-to-treat [NNT], 9 [95% CI, 5-53]), and epinephrine followed by another modality (RR, 0.34 [95% CI, 0.23-0.50]; NNT, 5 [95% CI, 5-7]); epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic therapy, further bleeding was reduced by thermal contact (heater probe, bipolar electrocoagulation) (RR, 0.44 [95% CI, 0.36-0.54]; NNT, 4 [95% CI, 3-5]) and sclerosant therapy (RR, 0.56 [95% CI, 0.38-0.83]; NNT, 5 [95% CI, 4-13]). Clips were more effective than epinephrine (RR, 0.22 [95% CI, 0.09-0.55]; NNT, 5 [95% CI, 4-9]), but not different than other therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic therapy was effective for active bleeding (RR, 0.29 [95% CI, 0.20-0.43]; NNT, 2 [95% CI, 2-2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, 0.40-0.59]; NNT, 5 [95% CI, 4-6]), but not for a clot. Bolus followed by continuous-infusion proton pump inhibitor after endoscopic therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]), but not compared with histamine(2)-receptor antagonists. Thermal devices, sclerosants, clips, and thrombin/fibrin glue appear to be effective endoscopic hemostatic therapies. Epinephrine should not be used alone. Endoscopic therapy should be performed for ulcers with active bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-infusion intravenous proton pump inhibitor should be used after endoscopic therapy.

Endoscopic haemostasis

Endoscopic haemostasis should be attempted as the initial approach in most cases of gastrointestinal (GI) bleeding, although cross-disciplinary collaboration is a prerequisite. For variceal bleeding, band ligation is the method of choice in the elective setting, although injection therapy still has a role in acute bleeding. Histoacryl remains preferable for fundic varices in most parts of the world. For peptic ulcer bleeds, injection therapy should be combined with at least one 'mechanical' modality, thermal treatment or clipping. In rebleeding, a single endoscopic retreatment can be attempted, but alternative approaches must be considered. Acute lower GI bleeding is primarily a diagnostic challenge but, if the focus is found, the regular techniques for haemostasis can usually be applied. If small bowel haemorrhage is suspected after upper and lower endoscopy, capsule endoscopy and balloon enteroscopy offer make it possible to address even small bowel foci.

Endoscopic clipping for the management of gastrointestinal bleeding

Endoscopic clipping is a safe and effective technique for the treatment of various bleeding gastrointestinal lesions. Randomized controlled trials and a meta-analysis have shown comparable efficacy between clipping and conventional contact thermal therapy for definitive hemostasis of nonvariceal upper gastrointestinal hemorrhage. Clipping also seems to be efficacious for selected lower gastrointestinal bleeding lesions, such as diverticular bleeding and postpolypectomy bleeding. Proficiency in clip application and endoscopic identification of lesions that are amenable to clipping are key determinants of a successful outcome.

Endoscopic clipping for acute nonvariceal upper-GI bleeding: a meta-analysis and critical appraisal of randomized controlled trials

BACKGROUND

Acute nonvariceal upper-GI bleeding (NVUGIB) is common, with a high rate of recurrent bleeding and substantial mortality rate. Endoscopic clipping has the theoretical advantage of minimizing tissue injury and is increasingly used.

OBJECTIVE

We conducted a systematic review and meta-analysis to investigate any potential benefits of clipping over other endoscopic techniques for NVUGIB.

DESIGN

Randomized controlled trials (RCT) that compared clipping with other endoscopic hemostatic methods to treat NVUGIB were included. Summary effect size was estimated by odds ratio (OR) with a random-effects model.

RESULTS

Twelve RCTs met inclusion criteria. For peptic ulcer bleeding (PUB), the hemoclip (n = 351 patients) was compared with the heat probe alone, thermal therapy plus injection, and injection alone in 2, 2, and 5 studies, respectively (n = 348 patients). The rate of the initial hemostasis was nonsignificantly increased in the control group compared with the hemoclip group (92% vs 96%, OR 0.58 [95% CI, 0.19-1.75]). The rebleeding rate was nonsignificantly decreased with hemoclips compared with controls (8.5% vs 15.5%, OR 0.56 [95% CI, 0.30-1.05]). Emergency surgery and the mortality rate were not significantly different between the hemoclip and controls. Subgroup analysis conducted in studies that compared hemoclips with injection alone show similar results. Two studies and one study reported outcomes of interest for Dieulafoy's lesions and Mallory-Weiss syndrome, respectively.

CONCLUSIONS

RCTs that compared clipping alone with other endoscopic hemostatic techniques for NVUGIB were limited. Current evidence suggests that the hemoclip is not superior to other endoscopic modalities in terms of initial hemostasis, rebleeding rate, emergency surgery, and the mortality rate for treatment of PUB.

Endoscopic clipping

Endoscopic clips are relatively new devices that have been shown to be effective for the control of acute gastrointestinal hemorrhage. Various different models are available and offer simplicity of use with relatively few complications. Recently, endoscopic clips have been used for a variety of non-hemorrhagic conditions. In this article we review the literature and present current thinking about the indications, efficacy and safety of these devices.

Current endoscopic and pharmacological therapy of peptic ulcer bleeding

Peptic ulcer bleeding is the most significant complication of ulcer disease, remaining the most important reason for upper gastrointestinal bleeding even in the era of Helicobacter eradication. Endoscopic triage and management plays a vital role in the handling of these patients, albeit in close collaboration with radiological and surgical expertise. Injection therapy, preferably with large volume epinephrine remains a core technology. Histoacryl and fibrin glue are more costly and less widely adopted alternatives. Mechanical measures are attractive and clips offer an excellent solution, particularly in soft tissues, and in combination with initial injection. Thermal methods with coagulation and coaptive axial force have similar performance characteristics. Increasingly, the combination of injection therapy with either a mechanical or thermal method appears the best option to achieve permanent haemostasis. PPIs for potent acid inhibition improves the clotting regardless of other treatment modalities. In the setting of rebleeding, patient and ulcer factors determine whether repeat endoscopy should be attempted, but the surgeon should be close at hand in this situation.

Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding

BACKGROUND

There are well-established methods for treating gastrointestinal (GI) bleeding, although some lesions prove refractory to conventional techniques. Little consideration has been directed toward the use of endoscopic ultrasound (EUS) in the management of refractory bleeding.

AIMS

To discuss patient selection, technique, and clinical outcomes for EUS-guided angiotherapy for severe refractory bleeding after conventional therapies.

METHODS

The EUS database was reviewed to identify all patients who underwent EUS-directed angiotherapy.

RESULTS

Five patients, four with severe bleeding from hemosuccus pancreaticus, Dieulafoy lesion, duodenal ulcer, or gastrointestinal stromal tumor (GIST) and one with occult GI bleeding, had an average of three prior episodes (range 2-4) of severe bleeding and had received 18 (range 14-25) units of packed red blood cells (PRBC). All had failed in at least two conventional attempts to control the bleeding. Under EUS guidance, 99% alcohol was injected (4-7 mL) in two patients, one each with a pancreatic pseudoaneurysm and a duodenal Dieulafoy lesion. In three other patients, cyanoacrylate (3-5 mL) was injected into a duodenal ulcer, and in two patients with a GIST. No patient rebled and no complications were reported.

CONCLUSIONS

EUS-guided angiotherapy appears safe and effective in managing selected patients with clinically severe or occult GI bleeding from lesions potentially refractory to standard endoscopic and/or angiographic techniques. Further studies are needed to confirm the safety and efficacy and to refine the selection criteria in an effort to improve patient care.

Randomized controlled study of 3 different types of hemoclips for hemostasis of bleeding canine acute gastric ulcers

BACKGROUND

Mechanical closure of bleeding vessels is clinically appealing, and several types of hemoclips are now marketed for endoscopic hemostasis of nonvariceal lesions. No comparative data have been reported on ease of clip placement, hemostasis efficacy, or clip retention rates on bleeding ulcers.

OBJECTIVE

To compare 3 different types of hemoclips for hemostasis of bleeding ulcers.

DESIGN

Randomized controlled study.

SUBJECTS

Seven adult dogs with prehepatic portal hypertension were heparinized, and acute gastric ulcers were made with jumbo biopsy forceps. Animals had oral proton pump inhibitors daily and weekly endoscopies to quantitate clip retention and ulcer healing.

INTERVENTIONS

Bleeding ulcers were randomized in pairs (2 for each treatment/dog) to endoscopic hemoclip treatment or control.

MAIN OUTCOME MEASUREMENTS

Initial times and success of deployment, hemostasis efficacy, clip retention rates, and ulcer healing during endoscopic follow-ups.

RESULTS

There was no difference in initial hemostasis rates of hemoclips, and no major complications occurred. Ulcer healing times were faster (Resolution Clip [RC] or TriClip [TC]) or similar (QuickClip2 [QC]) to controls. Clip retention at 1 week was significantly less with TC and, at 3 to 7 weeks, was significantly higher with RC.

CONCLUSIONS

(1) For the 3 hemoclip devices, initial hemostasis rates were 100%, but all devices required similar learning time to place clips successfully. (2) Short-term retention rates of TC were significantly less than QC or RC. (3) Long-term clip retention was significantly higher with RC. (4) All 3 hemoclips were safe, and none interfered with ulcer healing.

Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers

BACKGROUND

Rebleeding occurs in 10% to 30% of bleeding ulcer patients receiving endoscopic epinephrine injection therapy. It remains unclear whether addition of a secondary clip therapy following epinephrine injection may reduce the rebleeding rate of high-risk bleeding ulcers.

OBJECTIVE

To compare the efficacies of epinephrine injection alone and epinephrine injection combined with hemoclip therapy in treating high-risk bleeding ulcers.

DESIGN

Prospective randomized controlled trial.

SETTING

A medical center in Taiwan.

PATIENTS

One hundred five bleeding ulcer patients with active spurting, oozing, nonbleeding visible vessels or adherent clots in ulcer bases.

INTERVENTIONS

Endoscopic combination therapy (n = 52) or diluted epinephrine injection alone (n = 53).

MAIN OUTCOME MEASUREMENTS

Initial hemostasis rates and recurrent bleeding rates.

RESULTS

Initial hemostasis was achieved in 51 patients treated with combination therapy and 49 patients with epinephrine injection therapy (98% vs 92%, P = .18). Bleeding recurred in 2 patients in the combination therapy group and 11 patients in the epinephrine injection group (3.8% vs 21%, P = .008). Among the patients with rebleeding, repeated combination therapy was more effective than repeated injection therapy in achieving permanent hemostasis (100% vs 33%, P = .02). No patient required an emergency operation in the combination therapy group. However, 5 patients in the epinephrine injection group underwent emergency surgery to arrest bleeding (0% vs 9%, P = .023).

LIMITATIONS

Treatment outcome of endoscopic hemoclip therapy is related to the techniques of endoscopists.

CONCLUSION

Endoscopic combination therapy is superior to epinephrine injection alone in the treatment of high-risk bleeding ulcers.

Factors associated with failure of initial endoscopic hemoclip hemostasis for upper gastrointestinal bleeding

BACKGROUND

Endoscopic hemoclip is widely used for the management of bleeding peptic ulcers. The major difficulty in clinical application of the hemoclip is deployment to the lesion during initial hemostasis. The aim of this study was to define factors associated with the failure of endoscopic hemoclip for initial hemostasis of upper GI bleeding.

PATIENTS AND METHODS

From January to December 2003, we prospectively studied 77 randomized patients with clinical evidence of upper GI bleeding due to either active bleeding or a visible vessel identified by upper GI endoscopy in our emergency department.

RESULTS

Among the 77 patients, 13 (16.9%) failed treatment (Group 1) and 64 (83.1%) were successfully (Group 2) treated by endoscopic hemoclip for lesions related to upper GI bleeding. There were no differences due to gender, blood pressure, initial heart rate, and hemoglobulin before or after endoscopic treatment, platelet count, serum creatinine, and albumin between groups. The mean age of Group 1 was higher than that of Group 2 (73.31+/-9.38 years vs. 65.41+/-16.45 years, respectively; P=0.083). Most patients who did not achieve initial hemostasis by endoscopic hemoclip had upper GI lesions over the gastric antrum and duodenal bulb. Among the 13 patients who failed to achieve endoscopic hemoclip initial hemostasis, four lesions were located over the posterior wall of the antrum, and four lesions over the lesser curvature side of the duodenal bulb.

CONCLUSION

Endoscopic hemoclip is an effective hemostatic method for upper GI bleeding. Age, gastric antrum, and duodenal bulb lesions may be associated with the failure of initial hemostasis by endoscopic hemoclip.

Nonvariceal upper gastrointestinal bleeding: standard and new treatment

Nonvariceal upper gastrointestinal bleeding remains a challenging problem with a significant morbidity and mortality. In recent years endoscopic techniques have evolved, resulting in improved primary hemostasis and a reduction in the risk of rebleeding. Combination endoscopic therapy followed by high-dose proton pump inhibitor shows improved outcomes. Innovative endoscopic therapies hold promise but are as yet unproved. An aging population with significant medical comorbidities has a major influence on the overall outcome from upper gastrointestinal bleeding.

Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT--UGI bleeding)

BACKGROUND

It is not known if combination therapy of epinephrine injection and multipolar electrocoagulation or hemoclips are a more efficient or effective treatment for patients with acute nonvariceal upper gastrointestinal (GI) bleeding.

METHODS

Adult patients with active nonvariceal upper GI bleeding, a nonbleeding visible vessel, or after removal of an adherent clot findings of active bleeding or a visible vessel were studied. Patients were randomized to either therapy and the outcomes were assessed at 30 days.

RESULTS

Forty-seven patients were studied: 26 patients randomized to hemoclips and 21 to combination therapy. There were 22 patients with active bleeding, 13 with a nonbleeding visible vessel, and 12 with an adherent clot. The median duration of endoscopic therapy was 17 min in the hemoclip group versus 20 min for the combination therapy, p= 0.29. Primary hemostasis with successful initial control of bleeding occurred in 26 (100%) of 26 hemoclip patients and 20 (95.2%) of 21 combination therapy patients, p= 0.45. The rebleeding rates were: 4 (15.4%) of 26 hemoclip patients versus 5 (23.8%) of 21 combination therapy patients, p= 0.49. Overall, the length of hospital stay, units of blood transfused, surgery rates, and mortality were not different.

CONCLUSIONS

In this prospective, randomized controlled trial of endoscopic hemoclips versus combination therapy in the nonvariceal upper GI bleeding, the efficiency, efficacy, and complications of the two treatment modalities were not significantly different.

Intravenous pantoprazole versus ranitidine for prevention of rebleeding after endoscopic hemostasis of bleeding peptic ulcers

AIM: The role of intravenous pantoprazole in treatment of patients with high-risk bleeding peptic ulcers following endoscopic hemostasis remains uncertain. We therefore conducted the pilot prospective randomized study to assess whether intravenous pantoprazole could improve the efficacy of H₂-antagonist as an adjunct treatment following endoscopic injection therapy for bleeding ulcers.

METHODS: Patients with active bleeding ulcers or ulcers with major signs of recent bleeding were treated with distilled water injection. After hemostasis was achieved, they were randomly assigned to receive intravenous pantoprazole or ranitidine.

RESULTS: One hundred and two patients were enrolled in this prospective trial. Bleeding recurred in 2 patients (4%) in the pantoprazole group (n = 52), as compared with 8 (16%) in the ranitidine group (n = 50). The rebleeding rate was significantly lower in the pantoprazole group (P = 0.04). There were no statistically significant differences between the groups with regard to the need for emergency surgery (0% vs 2%), transfusion requirements (4.9 ± 5.9 vs 5.7 ± 6.8 units), hospital days (5.9 ± 3.2 vs 7.5 ± 5.0 d) or mortality (2% vs 2%).

CONCLUSION: Pantoprozole is superior to ranitidine as an adjunct treatment to endoscopic injection therapy in high-risk bleeding ulcers.

Upper gastrointestinal bleeding

PURPOSE OF REVIEW

This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation, sedation, hemostatic techniques, disposition, and recommended pharmacologic interventions.

RECENT FINDINGS

Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure. In a retrospective evaluation of patients with upper gastrointestinal bleeding, multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation. In a prospective, randomized clinical trial, patients who received intravenous proton pump inhibitor therapy after endoscopic intervention had a significantly reduced rebleeding rate compared with their placebo control group.

SUMMARY

The algorithms described in this review can be applied clinically today and should directly lead to improved outcome. Nevertheless, even with the latest care available, results are not optimal. This review points to two major areas where we can benefit from improvement: primary hemostasis and recurrent bleeding. By pointing to these limitations, it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems. Endoscopic ultrasound, for example, could be used to help identify feeding vessels that can be treated endoscopically, thus potentially decreasing the incidence of failed primary hemostasis. Endoscopic suturing, when more fully developed, may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding. It is only through these reviews that our state of knowledge in the field can be constantly reevaluated to update today's clinician with the latest knowledge and stimulate tomorrow's researchers with challenging problems.

Endoscopic hemostatic treatment under irrigation for upper-GI hemorrhage: a comparison of one third and total circumference transparent end hoods

BACKGROUND

Endoscopic hemostasis for upper-GI hemorrhage often is difficult to achieve if the view of the bleeding lesion is poor because of the presence of mucus, blood, and clots. An end hood that facilitates endoscopic hemostatic procedures while simultaneously allowing irrigation of the bleeding site was designed by us. Based on this design, a one-third partial irrigating end hood was developed, and its usefulness for treatment of non-variceal hemorrhage was evaluated.

METHODS

The end hood was fabricated by drilling a side hole in the cap portion of a transparent end hood. An irrigation tube was glued to the exterior surface over the hole. A "total" (type 1) and a "one-third partial" (type 2) transparent end hood were fabricated. These differ with respect to the proportion of the endoscope circumference that is hooded by the device. The fabricated transparent end hood was placed on the tip of a standard endoscope. With the end hood in place, endoscopic hemostatic treatment under irrigation was performed in 35 patients (type 1 end hood, 18; type 2, 17) with non-variceal upper-GI hemorrhage.

OBSERVATIONS

Hemostatic treatment was enhanced by simultaneous irrigation beneath the end hood, and hemostasis was successfully achieved in 34 of 35 cases. The time required to achieve hemostasis was significantly shorter in the type 2 group than the type 1 group (median 11.8 vs. 16.9 minutes; p < 0.05).

CONCLUSIONS

The end hood was extremely useful for endoscopic hemostatic treatment under irrigation. The "one-third partial" end hood is superior to the total end hood in terms of duration of time required to achieve hemostasis.

Interventional endoscopy

PURPOSE OF REVIEW

This review provides an updated summary of gastric interventional endoscopy. Relevant original articles and topic reviews are highlighted in the areas of infection control, light sedation, hemostasis, endoscopic mucosal resection, and endoscopic placement of enteric devices.

RECENT FINDINGS

Several key findings are worth noting: the increased use of propofol by nonanesthesiologists for deep sedation with minimal adverse side effects, the adaptation of tissue adhesive agents for the treatment of bleeding gastric varices, the successful treatment of early gastric cancer by endoscopic mucosal resection, and the development of direct percutaneous endoscopic jejunostomy tubes for patients at high risk of aspiration.

SUMMARY

These recent developments in the field of interventional endoscopy have already made a great impact on clinical care. More advanced procedures can be performed safely while the patient is under deep sedation. Yet, these developments have not slowed down the need for improvement in interventional endoscopy. Researchers continue to look for smaller instruments, better optics, and more advanced accessories. This constant state of flux marks the field of interventional endoscopy and ensures its progress.