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November 2017 | Recommendation for OTSC as first-line therapy in non-variceal upper gastrointestinal bleeding

Chan SM and Lau JYW, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China, published an editorial in Endoscopy International Open on the question: “Can we recommend OTSC as first-line therapy in case of non-variceal upper gastrointestinal bleeding?”

The authors explicate that 8 to 15 % of patients with non-variceal upper GI bleeding (NVUGIB) continue to bleed after endoscopic hemostasis and acid suppression therapy. Further bleeding remains one of the most important predictors of mortality. These facts make research on methods to improve endoscopic hemostasis so important.

The authors list several limitations to conventional hemostatic methods such as the impossibility to consistently seal larger vessels with thermocoagulation, the difficulty of tangential application of hemostatic clips, the frequent dislodgement of the clips and the difficulty of clip application in chronic ulcers with a fibrotic base. The authors argue that the Over-the-Scope-Clip, with a wider jaw and greater strength, has the advantages of a firm grip over a larger amount of tissue. Clip retention is almost universal. The editorial names the study from Wedi et al with 100 patients with NVUGIB and first-line OTSC management and a reported 94% success rate for primary hemostasis. Besides, the study of Richter-Schrag et al is cited, including 100 patients with both NVUGIB and lower GI bleeding and showing similar results.

However, the paper also names problems that can lower the success of OTSC hemostasis, namely tangential application or OTSC deployment with scope in retroflexion (when ulcers are located in the lesser curve or the posterior wall of the duodenal bulb). The text offers a solution to this problem: usage of a smaller OTSC and an anchoring device to puncture near the bleeding site to guide the OTSC. Second, pretreatment with adrenaline injection is recommended to improve visualization in case of actively bleeding ulcers.

The authors narrate to eagerly await the publication of the STING trial, which randomized patients with refractory bleeding to OTSC or conventional treatment. They propose an RCT comparing OTSC as primary treatment to current standards.

In summary, the editorial recommends the application of OTSC in patients with hemodynamic instability, comorbid illness, with active bleeding ulcers, large ulcers and ulcers at posterior duodenum and lesser curve. The authors speculate that the added cost in managing further bleeding after standard treatment likely outweighs the cost of OTSC.

Can we now recommend OTSC as first-line therapy in case of non-variceal upper gastrointestinal bleeding?

Chan SM, Lau JYW
Endoscopy International Open 2017; 05: E883–E885