Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: a large-scale multicenter cohort study

Abstract

BACKGROUND : Prior studies have shown the effectiveness of both endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Therefore, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. METHODS : We reviewed data for 1679 patients with CDH who were treated with EBL (n = 638) or clipping (n = 1041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J study). Logistic regression analysis was used to compare outcomes between the two treatments. RESULTS : In multivariate analysis, EBL was independently associated with reduced risk of early rebleeding (adjusted odds ratio [OR] 0.46; P < 0.001) and late rebleeding (adjusted OR 0.62; P < 0.001) compared with clipping. These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant differences were found between the treatments in the rates of initial hemostasis or mortality. Compared with clipping, EBL independently reduced the risk of needing interventional radiology (adjusted OR 0.37; P = 0.006) and prolonged length of hospital stay (adjusted OR 0.35; P < 0.001), but not need for surgery. Diverticulitis developed in one patient (0.16 %) following EBL and two patients (0.19 %) following clipping. Perforation occurred in two patients (0.31 %) following EBL and none following clipping. CONCLUSIONS : Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH, offering the advantages of lower early and late rebleeding rates, reduced need for interventional radiology, and shorter length of hospital stay.

Fig. 1

Example endoscopic appearances of: a the stigmata of recent hemorrhage as evidenced by active bleeding; b the stigmata of recent hemorrhage as evidenced by adherent clot; c endoscopic clipping (indirect placement of endoclips) for colonic diverticular hemorrhage; d endoscopic band ligation for colonic diverticular hemorrhage.

Fig. 2

Flow chart of patients in this study. *The high identification rate of stigmata of recent hemorrhage, about one-third of the 6501 patients diagnosed with colonic diverticular hemorrhage, may be associated with the high early colonoscopy rate (64.4 % underwent early colonoscopy [within 24 hours of admission]), high preparation rate (81.4 % received polyethylene glycol or glycerin enema), and high levels of endoscopic device use (distal attachment used in 77.1 %; water-jet device used in 79.3 %).