High efficacy of otsc as first-line endoscopic treatment in patients with gastrointestinal bleeding: an italian multicentric experience in a large cohort of patients.

Introduction: The over-the-scope clip (OTSC) is a known endoscopic clipping device designed for tissue approximation, used for endoscopic closure of perforations, leaks, fistulas and for endoscopic hemostasis. Emerging evidences report high efficacy when such device is used both as first-line or rescue endoscopic therapy for acute gastrointestinal bleeding management. Aims & Methods: Our aim is to report a large series of patients with non-variceal upper and lower gastrointestinal bleeding lesions in whom OTSCs were used as first-line endoscopic treatment. In a retrospective analysis of prospectively collected data in tertiary referral centers, patients undergoing emergency endoscopy for severe acute nonvariceal gastrintestinal bleeding were treated with OTSC as primary first-line therapy. The endoscopic procedures were performed in anaestesiologic- assisted deep sedation, by skilled operators. Technical and clinical success, rate of re-bleeding, blood infusion, days of hospitalization were recorded for each patient. Results: Over a period of 3 years, from January 2014 to January 2017, we included 201 consecutive patients with mean age 68 years (range 28–89 years). Out of 106/201 patients were treated with the non-traumatic version of the OTSC system while in 95/201 the traumatic clip was preferred. Indications for OTSC treatment included, for the upper gastrointestinal tract, duodeno-jejunal ulcer Forrest 1a (n¼29) and Forrest 1b (n¼35), gastric ulcer Forrest 1a (n¼19) and Forrest 1b (n¼28), Mallory Weiss (n¼19), Dieulafoy’s lesion (n¼9), post gastric- ESD bleeding (n¼14); for the lower gastrointestinal tract indications for OTSC treatment included post EMR bleeding (n¼15), post ESD bleeding (n¼12), traumatic rectal ulcer (n¼2), colonic diverticulum (n¼4); 15 patients with upper or lower gastrointestinal tract surgical anastomosis bleeding were also included. Technical success was achieved in all cases 201/201 (100%). Primary haemostasis was achieved in 193/201 patients (96%). In the remaining 8 patients haemostasis was obtained with radiological vascular embolization (n¼5) or surgery (n¼3). Early re-bleeding occurred in 9/201 patients (4%) after 12–24 hours and it was treated with epinephrine injection with or without use of through the scope clips in case of minor oozing from the bleeding site (n¼6) while radiological vascular embolization was required for major bleeding events (n¼3). In these 9 patients median number of packed red cell unitstransfused was 2U(1–3 U) whilst it was not needed in patients successfully treated with OTSC. Finally no late re-bleeding was observed in our series and a median length of total hospital stay of 4 days (3–11 days) was required in patients responsive to OTSC treatment. Conclusion: Our multicenter report has shown that the use of OTSC as first-line therapy in acute high-risk gastrointestinal bleeding appears to be safe and highly effective.