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

Stefan Gölder, Lukas Neuhas, Denis Freuer, Andreas Probst, Alanna Ebigbo, Georg Braun, Juliane Brueckner, Johannes Stueckle, Alexander Meier, Helmut Messmann, Stefan Gölder, Lukas Neuhas, Denis Freuer, Andreas Probst, Alanna Ebigbo, Georg Braun, Juliane Brueckner, Johannes Stueckle, Alexander Meier, Helmut Messmann

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.

Conflict of interest statement

Competing interests None

Figures

Fig. 1
Fig. 1
Flowchart of the OTSC (over-the-scope-clip) treatment in n = 100 patients with peptic ulcer bleeding (PUB). Primary-OTSC treatment was when no other endoscopic hemostatic approach had been performed. Secondary-OTSC was a rescue OTSC-therapy after failed initial endoscopic hemostasis with the combination of injection therapy and through-the-scope clips (TTS). Persistent bleeding was when the bleeding source could not be controlled by endoscopic treatment alone. If initial endoscopic OTSC treatment (primary-OTSC or secondary-OTSC) could stop the bleeding, the case was counted as successful hemostasis. Recurrent bleeding was detected by clinical presentation or endoscopy and further therapy initiated. If no other treatment modality was necessary besides the OTSC application, the case was classified as clinical success with OTSC treatment. 1 F = Forrest stage of the ulcer 2 OP = operative treament of the bleeding site 3 Angio = angiographic treatment of the bleeding 4 BRM = Bleeding related mortality 5 EndoTx = Endoscopic therapy
Fig. 2
Fig. 2
Primary-OTSC.aForrest Ia bleeding in the stomach diagnosed during emergency endoscopy.bAn OTSC mounted on the therapeutic endoscope was successfully placed on the bleeding site.c, dAfter initial bleeding control and in the control endoscopy after 3 days, the clip was found in position.
Fig. 3
Fig. 3
Secondary-OTSC. aLarge ulcer with a central vessel. Prior to examination, TTS clips had been placed.bBecause of recurrent bleeding, the TTS clips were removed.cAn OTSC was placed on the central vessel.dIn the second-look endoscopy the vessel was successfully closed by the OTSC.

References

    1. van Leerdam M E. Epidemiology of acute upper gastrointestinal bleeding. BestPractRes Clin Gastroenterol. 2008;22:209–224.
    1. Hearnshaw S A, Logan R F, Lowe D et al.Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut. 2011;60:1327–1335.
    1. Laine L, Yang H, Chang S Cet al.Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009 Am J Gastroenterol 20121071190–1195.; quiz 1196
    1. Gralnek I M, Dumonceau J M, Kuipers E J et al.Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47:a1–46.
    1. Barkun A N, Bardou M, Kuipers E J et al.International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101–113.
    1. Götz M, Anders M, Biecker E et al.[S2k Guideline Gastrointestinal Bleeding – Guideline of the German Society of Gastroenterology DGVS] Z Gastroenterol. 2017;55:883–936.
    1. van Leerdam M E, Vreeburg E M, Rauws E AJ et al.Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98:1494–1499.
    1. Schmidt A, Gölder S, Goetz M et al.Over-the-scope clips are more effective than standard endoscopic therapy for patients with recurrent bleeding of peptic ulcers. Gastroenterology. 2018;155:674–INF.
    1. Laine L, Peterson W L. Bleeding peptic ulcer. N Engl J Med. 1994;331:717–727.
    1. Albert J G, Friedrich-Rust M, Woeste G et al.Benefit of a clipping device in use in intestinal bleeding and intestinal leakage. Gastrointest Endosc. 2011;74:389–397.
    1. Baron T H, Song L M, Ross A et al.Use of an over-the-scope clipping device: multicenter retrospective results of the first U.S. experience (with videos) Gastrointest Endosc. 2012;76:202–208.
    1. Brandler J, Baruah A, Zeb M et al.Efficacy of over-the-scope clips in management of high-risk gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2017;16:690–696.
    1. Chan S M, Chiu P W, Teoh A Y et al.Use of the over-the-scope clip for treatment of refractory upper gastrointestinal bleeding: a case series. Endoscopy. 2014;46:428–431.
    1. Kirschniak A, Subotova N, Zieker D et al.The over-the-scope clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc. 2011;25:2901–2905.
    1. Manno M, Mangiafico S, Caruso A et al.First-line endoscopic treatment with OTSC in patients with high-risk non-variceal upper gastrointestinal bleeding: preliminary experience in 40 cases. Surg Endosc. 2016;30:2026–2029.
    1. Manta R, Galloro G, Mangiavillano B et al.Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques. Surg Endosc. 2013;27:3162–3164.
    1. Monkemuller K, Peter S, Toshniwal J et al.Multipurpose use of the 'bear claw' (over-the-scope-clip system) to treat endoluminal gastrointestinal disorders. Dig Endosc. 2014;26:350–357.
    1. Nishiyama N, Mori H, Kobara H et al.Efficacy and safety of over-the-scope clip: including complications after endoscopic submucosal dissection. World J Gastroenterol. 2013;19:2752–2760.
    1. Richter-Schrag H J, Glatz T, Walker C et al.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.
    1. Skinner M, Gutierrez J P, Neumann H et al.Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding. Endosc Int Open. 2014;2:E37–E40.
    1. Wedi E, Gonzalez S, Menke D et al.One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas. World J Gastroenterol. 2016;22:1844–1853.
    1. Ogasawara N, Mizuno M, Masui R et al.Predictive factors for intractability to endoscopic hemostasis in the treatment of bleeding gastroduodenal peptic ulcers in Japanese patients. Clin Endosc. 2014;47:162–173.
    1. Elmunzer B J, Young S D, Inadomi J M et al.Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol. 2008;103:2625–2632.
    1. Roy A, Kim M, Hawes R et al.The clinical and cost implications of failed endoscopic hemostasis in gastroduodenal ulcer bleeding. United European Gastroenterol J. 2017;5:359–364.
    1. Jensen D M, Kovacs T OG, Ohning G V et al.Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes of patients with severe nonvariceal upper gastrointestinal hemorrhage. Gastroenterology. 2017;152:1310–1318 e1311.
    1. Jensen D M, Ohning G V, Kovacs T O et al.Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding. Gastrointest Endosc. 2016;83:129–136.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する