Over-the-scope clips outdoes standard treatment in preventing gastrointestinal bleeding

Initial treatment with over-the-scope clips (OTSCs) appears superior to standard endoscopic treatment in reducing the risk for further bleeding from nonvariceal upper gastrointestinal causes that are responsive to OTSC placement, results of a study have shown.

“Current endoscopic methods in the control of acute nonvariceal bleeding have a small but clinically significant failure rate,” according to the researchers, adding that the role of OTSCs as the first treatment has not been defined.

A multicentre, randomized controlled trial was conducted at university teaching hospitals in Hong Kong, China, and Australia to compare OTSCs with standard endoscopic haemostatic treatments in the management of bleeding from nonvariceal upper gastrointestinal causes.

In total, 190 adult patients with active bleeding or a nonbleeding visible vessel from a nonvariceal cause on upper gastrointestinal endoscopy were included. The researchers randomly assigned 97 participants to standard haemostatic treatment and 93 to OTSC.

Thirty-day probability of further bleeding was the primary outcome measured, while secondary outcomes included failure to control bleeding after assigned endoscopic treatment, recurrent bleeding after initial haemostasis, further intervention, blood transfusion, and hospitalization.

OTSC vs standard treatment

The 30-day probability of further bleeding was significantly higher in the standard treatment than in the OTSC group (14.6 percent vs 3.2 percent; 14 of 97 vs three of 93, respectively; risk difference, 11.4 percentage points, 95 percent confidence interval [CI], 3.3‒20.0; p=0.006). [Ann Intern Med 2023;doi:10.7326/M22-1783]

In other outcomes, failure to control bleeding after assigned endoscopic treatment was also higher in the standard treatment group compared to the OTSC group (6 vs 1; risk difference, 5.1 percentage points, 95 percent CI, 0.7‒11.8), as was 30-day recurrent bleeding (8 vs 2; risk difference, 6.6 percentage points, 95 percent CI, ‒0.3 to 14.4).

Additionally, the need for further interventions was eight in the standard treatment group compared to just two in the OTSC group, while 30-day mortality was four and two, respectively.

Post hoc analysis with a composite endpoint of failure to successfully apply assigned treatment and further bleeding revealed significantly higher event rates in the standard group than in the OTSC group (15.6 percent vs 6.5 percent; 15 of 97 vs six of 93, respectively; risk difference, 9.1 percentage points, 95 percent CI, 0.004‒18.3).

Superior treatment

A recent systematic review and meta-analysis revealed that haemostasis with OTSCs resulted in lower 7-day and 30-day rebleeding rates, higher clinical success rates, and shorter procedure time with similar mortality rates and length of hospital stay when compared with standard treatment. [Gastrointest Endosc 2022;96:712-720.e7]

In another study, endoscopic treatment with OTSC was also more effective than standard treatment with through-the-scope clips for patients with recurrent peptic ulcer bleeding. [Gastroenterology 2018;155:674-686.e6]

The current study was limited by the nonblinding of the clinicians to treatment and the option of crossover treatment, according to the researchers.