Use of over-the-scope-clip (OTSC) improves outcomes of high-risk adverse outcome (HR-AO) non-variceal upper gastrointestinal bleeding (NVUGIB)

Abstract

Background and study aims: Endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB) with high-risk adverse outcome (HR-AO) features has a high risk of failure. We studied the safety and efficacy of over-the-scope clips (OTSC) to treat these lesions.

Patients and methods: We included patients who were treated using OTSC for NVUGIB from January 2015 to October 2017. We studied rebleeding and mortality rates and used the Rockall data and our institution's prior data for comparison. We used descriptive and chi-square statistics.

Results: We studied 18 patients with 19 bleeding lesions: 9 (47 %) duodenal ulcers, 4 (21 %) Dieulafoy's lesion, 3 (16 %) gastric ulcer, and 3 (16 %) bleeding after gastric biopsy, gastric polypectomy and endoscopic ultrasound-guided fine-needle aspiration of peri-gastric mass. We applied OTSC as the first-line treatment in 10 (53 %) and as the second-line treatment in 9 (47 %) bleeding lesions. Continued bleeding after OTSC occurred in six patients, but we treated it successfully and achieved complete hemostasis in all patients. We found OTSC use significantly decreased (0 % vs. 53 %, P < 0.01) and reduced (0 % vs. 24 %, P = 0.08) the rebleeding rate in our high-risk (RS ≥ 8) and intermediate-risk (RS = 4 - 7) Rockall score patients as compared to the rates reported by the Rockall study, respectively. When compared to our institution's prior study, we found a decrease in the rebleeding rate with OTSC (0 % vs. 21 %, P = 0.06) in our intermediate-to-high risk Rockall score patients (RS ≥ 4). There was no difference in mortality rates as compared to both control studies.

Conclusion: Use of OTSC is safe, efficacious and appears superior to standard treatment for HR-AO NVUGIB. OTSC should be considered as first-line treatment for HR-AO bleeding.

Fig. 1

Use of OTSC as a second-line treatment modality for a bleeding duodenal ulcer. a A visible artery was seen proximal to a previously deployed clip.  b The endoscope was equipped with an OTSC. Active bleeding occurred during suction. c The bleeding vessel was placed in the center of the OTSC cap and using the suction technique, the OTSC was deployed. The bleeding stopped completely. d There was no recurrent bleeding. The clip 24 hours later.

Fig. 2

Cause and solution of incomplete hemostasis after OTSC placement. a nonsteroidal anti-inflammatory drug-related duodenal ulcer with a large visible vessel was seen in the distal duodenal bulb of an elderly patient with metastatic lung cancer. The ulcer was located within a narrowed lumen. b A therapeutic endoscope with 6-mm channel that was equipped with a large OTSC was used (OD of OTSC = 21 mm). The tip of the OTSC anchor was placed next to the visible vessel. c After opening the anchor, the ulcer was pulled and simultaneously suctioned into the OTSC, and the clip was released. d A large stream of blood was seen flowing from the artery. The clip was misplaced. The endoscope was left to suction the blood to prevent formation of large clots and to maintain visualization, while another therapeutic endoscope was being equipped with a medium-size OTSC. e The bleeding vessel was suctioned into the OTSC. The clip was placed ideally. Bleeding ceased instantly. f There was no further bleeding. The clip at 24 hours.

Fig. 3

Results of our study as compared to original Rockall study. Use of OTSC significantly reduced risk of rebleeding in the high-risk Rockall score patients. A trend toward decreased rebleeding was seen in the intermediate-risk Rockall score patients. The mortality rate from bleeding or from all causes was similar to the original Rockall study.

Fig. 4

Classification of causes for incomplete hemostasis after OTSC. a Delayed compression of a large-caliber Dieulafoyʼs vessel resulting in continued bleeding. Using additional thermal therapy, the bleeding vessel was coagulated and complete hemostasis was achieved. b Delayed compression of high-risk stigmata within a fibrotic duodenal ulcer. Using additional application of hemostatic powder, we achieved complete hemostasis. c Shallow placement of OTSC in duodenal ulcer resulting in continued bleeding. The clip was pulled and removed using forceps, and with a second OTSC, the bleeding was stopped. d Misplacement of OTSC in the narrow lumen of the duodenum, causing massive bleeding. Using a second OTSC, we crossed the first clip and clamped the bleeding vessel achieving permanent hemostasis.