Surgery

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Computer science

Political science

MEDLINE

Medicine

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General surgery

Scopus

Randomized controlled trial

Clinical Gastroenterology and Hepatology

We read with great interest the paper written by Jensen et al1Jensen D.M. et al.Clin Gastroenterol Hepatol. 2021; 19: 2315-2323Abstract Full Text Full Text PDF Scopus (29) Google Scholar of over-the-scope clip (OTSC) as initial treatment of severe nonvariceal upper gastrointestinal bleeding. We congratulate the authors for conducting a head-to-head randomised controlled trial of OTSC with standard endoscopic hemostatic techniques. This randomised controlled trial also signifies importance of using OTSC in major stigmata of recent hemorrhage.1Jensen D.M. et al.Clin Gastroenterol Hepatol. 2021; 19: 2315-2323Abstract Full Text Full Text PDF Scopus (29) Google Scholar In the present study, patients were randomized to the standard endoscopic treatment arm and OTSC arms. The standard endoscopic hemostasis was achieved in the form of hemoclips, multipolar electrocoagulation, or both. We would like to know the number of patients receiving either or both methods for hemostasis because both techniques have different success and rebleeding rates. The rebleeding rates have been found to be as low as 1.8% for hemoclips and 5% for multipolar electrocoagulation.2Cipolletta L. et al.Gastrointest Endosc. 2001; 53: 147-151Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar,3Lin H.-J. et al.Am J Gastroenterol. 2002; 97: 2250-2254Crossref PubMed Scopus (99) Google Scholar In the present study, patients with adherent clot who underwent standard treatment had higher rebleeding rates (50%) than those (13%) reported in a meta-analysis of 240 patients.4Kahi C. et al.Gastroenterology. 2005; 129: 855-862Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar There were 2 patients with active arterial bleeding (Forrest 1A) who were included in the OTSC arm versus 7 patients in the standard treatment arm. There were 17 patients with major stigmata of recent hemorrhage in the OTSC arm versus 23 patients in the standard treatment arm. This disproportionate distribution might have led to higher rebleeding rates in the standard treatment arm. Finally in resource-limited settings, which is the case in most parts of the world, standard endoscopic treatment in combination with either multipolar electrocoagulation and/or hemoclips may still remain as the initial modality of treatment given the requirement of a double-channel therapeutic endoscope coupled with the higher cost of OTSC. In patients with lesser stigmata of recent hemorrhage as described in the current paper in which even the current study finds no difference between OTSC and standard therapy, we think the standard therapy would still be a reasonable approach. However, in cases of rebleeding with single or combination therapy using standard endoscopic hemostasis treatments or failure of hemostasis with standard therapy, OTSC can be considered as the next modality before considering transarterial embolization or surgery. OTSC as the initial treatment for endoscopic hemostasis may be useful in large, fibrotic ulcer beds with a large visible vessel that may not be amenable to through-the-scope hemoclip or when thermal therapy is likely to be ineffective.5Mullady D.K. et al.Gastroenterology. 2020; 159: 1120-1128Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal BleedingClinical Gastroenterology and HepatologyVol. 19Issue 11PreviewNo prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. Full-Text PDF ReplyClinical Gastroenterology and HepatologyVol. 19Issue 12PreviewThanks to Dr. P. Sethiya and colleagues for their letter to the editor and interest in our over-the-scope clip (OTSC) randomized controlled trial (RCT).1 Herein, I address their questions and comments. In addition, I explain that definitive hemostasis is not just controlling active bleeding; it is obliterating arterial blood flow under stigmata of recent hemorrhage (SRH) to prevent rebleeding. In my CURE Hemostasis group’s experience managing high-risk patients with peptic ulcer bleeding (PUBs) in this RCT or another recently reported RCT of Doppler endoscopic probe (DEP) monitoring of arterial blood flow under SRH,2 there was no difference in the rates of residual arterial blood flow or rebleeding after standard treatments with either multipolar electrocoatulation (MPEC) or hemoclips. Full-Text PDF

To Over-the-Scope Clip or Not to Over-the-Scope Clip Is the Question!