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

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.

The use of cap-mounted clips as a primary hemostatic modality in nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis of randomized trials

BACKGROUND

Cap-mounted-clips, especially Over-The-Scope-Clip (OTSC™), are recommended for recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB). There has been recent interest in their use as an initial hemostatic modality. We performed a systematic review of randomized controlled trials (RCTs) assessing cap-mounted clips' efficacy as a primary hemostatic modality in NVUGIB.

METHODS

A literature search of MEDLINE, EMBASE, and ISI Web of Science databases up to April 2024 identified RCTs comparing cap-mounted clips to standard endoscopic therapy (SET) as a primary hemostatic modality in NVUGIB. The primary endpoint was the composite outcome of further bleeding (persistent or recurrent) at 30 days. Secondary outcomes included persistent bleeding at index endoscopy and 30-day rebleeding, individually. Other pertinent outcomes were also recorded. A meta-analysis was performed to determine pooled risk ratios (RRs), comparing cap-mounted clip to SET. Out of 516 citations, five RCTs (n = 555), all assessing OTSC™, were included.

RESULTS

The composite outcome of further bleeding was lower with cap-mounted clip versus SET (RR = 0.33 [95% confidence interval {CI}: 0.20-0.54]). There was no difference in persistent bleeding at initial endoscopy (RR = 0.30 [95% CI: 0.07-1.30]), but 30-day rebleeding was lower with cap-mounted clip (RR = 0.38 [95% CI: 0.21-0.70]). There were no differences in other outcomes. Grading of the evidence ranged from very low to moderate, mainly due to risk of bias and imprecision.

CONCLUSIONS

Cap-mounted clips may be an efficacious primary hemostatic modality, associated with a lower further bleeding at 30 days compared to SET in NVUGIB. However, due to limitations in existing evidence, further research must better characterize an optimal subgroup of patients benefiting most from this approach before adopting its routine use.

Systematic review of self-assembling peptides as topical agents for treatment and prevention of gastrointestinal bleeding

BACKGROUND/AIMS

Gastrointestinal bleeding is a significant and potentially lethal event. We aimed to review the efficiency and safety of self-assembling peptides for the treatment and prevention of gastrointestinal tract bleeding.

METHODS

We conducted a systematic search for studies describing the endoscopic use of self-assembling peptides for treatment or prevention of bleeding in the gastrointestinal tract in a parallel, independent fashion. The primary outcomes were rates of successful initial hemostasis, delayed bleeding, and rebleeding. The secondary outcomes were adverse events and ease and volume of gel used.

RESULTS

Seventeen studies were analyzed. Overall success rate of self-assembling peptides in gastrointestinal bleeding was 87.7% (38%-100%), regardless of etiology or associated treatments. Rebleeding rate ranged from 0% to 16.2%, with a mean of 4.7%, and overall delayed bleeding rate was 5% (range, 0%-15.9%). Only three adverse events were reported in a pooled number of 815 patients. The volume of gel used varied (0.43 to 3.7 mL) according to indication and type of bleeding.

CONCLUSIONS

The limited available data on the use of self-assembling peptides in gastrointestinal endoscopy suggest a high efficiency and good safety profile.

Variceal Bleeding: Beyond Banding

Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.

Over-the-Scope Clip Applications as First-Line Therapy in the Treatment of Upper Non-variceal Gastrointestinal Bleeding, Perforations, and Fistulas

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.

Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.

Progress in new hemostasis techniques for acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (AUGIB) is one of the most common acute and critical illnesses in the emergency department. It mainly refers to gastrointestinal bleeding above the Treitz ligament, and the mortality rate is about 2%-10%. The main clinical manifestations are hematemesis and/or hematochezia. The diagnosis is mainly based on clinical manifestations combined with laboratory and imaging findings. Due to the rapid onset and severe nature of the condition, there are various treatment methods according to different causes. This article reviews the diagnosis and treatment of acute upper gastrointestinal bleeding.

Over-the-Scope Clip-Associated Endoscopic Muscular Dissection for Seven Cases of Small Gastric Submucosal Tumor: A Video-Based Case Series

Objectives

To evaluate the methodology, feasibility, safety, and efficacy of a novel method called over-the-scope clip- (OTSC-) associated endoscopic muscular dissection for small GSMT.

Methods

A pilot study on small GSMT diameter ≤ 1 cm was performed. OTSC-associated endoscopic muscular dissection was based on the requirement of OTSC apparatus and ESD technique; after ligaturing the bottom of small GSMT by OTSC, ESD was performed to resect the tumors, and the wounds of ESD were closed by clips finally. All the patients were followed up for more than 3 months, and the complications during and after OTSC-associated endoscopic muscular dissection were recorded.

Results

A total of 7 consecutive patients with small GSMT were included. All tumors were completely dissected without any perforation or infection during and after the procedure in all cases, while three patients had mild abdominal pain, and one experienced postoperative bleeding after the procedure which was treated by the endoscopy with titanium clips. All the patients were followed by endoscopy three months later, all the wounds healed well, and all the OTSCs were still in the gastric wall.

Conclusions

OTSC-associated endoscopic muscular dissection as a novel endoscopic interventional therapy should be a convenient, safe, and effective therapy for small GSMT. The short-time outcome is excellent, whereas long-term effect is unclear, and the further follow-up is needed to schedule.

Factors to Improve Endoscopic Screening for Colorectal Cancer

INTRODUCTION

Colorectal cancer is one of the most sprayed cancers; the gold standard of diagnostic is a colonoscopy. The quality of this examination is depended on many factors, which includes doctors' experience.

PURPOSE

The purpose of this study is to establish the main factors affecting the completeness of colonoscopy in colorectal cancer screening.

MATERIALS AND METHODS

Endoscopists were questioned; descriptive statistics methods and logistic regression were used.

RESULTS AND DISCUSSION

The main factors that influence the quality of screening colonoscopy were identified: experience in colonoscopy, theoretical training, participation in the screening program, and number of annual colonoscopies. The calculated odds ratio for the selected dependent variable is calculated.

CONCLUSIONS

The experience for more than 5 years (p = 0.017) and at least 200 colonoscopies per year (p = 0.004) are the main factors that allow to perform complete colonoscopy in 90% or more of cases.