Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers
| Autor: | Markus Escher, Arthur Schmidt, B Walter, Stefan Gölder, Arthur Hoffmann, Reiner Wiest, Alexander Meining, Dominik Bettinger, James H. K. Lau, Karel Caca, Thomas Kratt, Stefan von Delius, Martin Goetz, Helmut Messmann |
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| Rok vydání: | 2018 |
| Předmět: |
Adult
Male medicine.medical_specialty Peptic Salvage therapy law.invention 03 medical and health sciences 0302 clinical medicine Randomized controlled trial Recurrence law Intensive care Clinical endpoint Humans Medicine Prospective Studies 610 Medicine & health Aged Aged 80 and over Hepatology business.industry Standard treatment Hemostasis Endoscopic Gastroenterology Middle Aged Surgical Instruments medicine.disease Surgery Peptic Ulcer Hemorrhage Treatment Outcome 030220 oncology & carcinogenesis Hemostasis Female 030211 gastroenterology & hepatology Upper gastrointestinal bleeding business |
| Zdroj: | Gastroenterology. 155:674-686.e6 |
| ISSN: | 0016-5085 |
| DOI: | 10.1053/j.gastro.2018.05.037 |
| Popis: | Background & Aims Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding. Methods We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n = 31) or thermal therapy plus injection with diluted adrenaline (n = 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy. Results Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P = .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P = .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6–63.2; P = .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P = .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P = .672). There were no significant differences in the other secondary endpoints. Conclusions In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900. |
| Databáze: | OpenAIRE |
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