Over-The-Scope Clip vs Conventional Endoscopic Therapy for Bleeding Peptic Ulcers: An Updated Meta-analysis

Introduction: Significant number of patients (around 10-20%) with high-risk (Forrest type Ia, Ib, IIa, IIb) bleeding peptic ulcers manifest rebleeding even after successful routine endoscopic therapy. Over-the-scope clip (OTSC) has been studied in this setting with conflicting results, and the current ACG guidelines recommend OTSC only in patients with recurrent ulcer bleeding. ESGE guidelines however allow for OTSC as a first line option. We, therefore, conducted an updated meta-analysis to reconcile the available data. Methods: Multiple online databases, such as Pubmed, MEDLINE, Cochrane and Embase were searched for studies comparing OTSC to conventional/standard endoscopic therapy (such as heater probe, standard clips, epinephrine injection etc.) in patients with bleeding peptic ulcers. The primary endpoints of interest were early rebleeding (within 48-72 hours), rebleeding and mortality at the longest available follow up. Standard meta-analysis methods were employed using a random-effects model. Results: Five studies: 2 randomized controlled trials (RCTs) and 3 retrospective studies, comprising a total of 399 patients (OTSC group n=171, conventional endoscopic group n=228) were included. The mean follow up duration was 1 month, mean age was 68 years and 68% of the patients were men. Most studies reported data on Forrest type I lesions - 47.6% in the OTSC group and 30% in the conventional group, with the rest being other types. Rebleeding at 30 days was significantly lower in the OTSC group as compared to the conventional endoscopic group (12 vs 27, RR 0.46, 95% CI 0.24-0.87, p = 0.02) and the studies were without any heterogeneity (I2 = 0%). Early rebleeding (within 48-72 hours) was reported in only 2 studies with similar rates between the two groups (RR 0.45, 95% CI 0.10-2.03, p = 0.30, I2 = 0%). No significant difference was observed in the total deaths in OTSC vs conventional groups (RR 0.67, 95% CI 0.16-2.83, p = 0.58, I2 = 41%). Conclusion: Using OTSC clips in bleeding peptic ulcers was associated with overall lower rebleeding rates at 30-days, however with a similar rate of early rebleeding and deaths when compared to conventional endoscopic therapies. Granular data with regards to high-risk features of bleeding ulcers, based on Forrest type, are warranted to further understand the role of OTSC in this patient population (Table 1). Table 1. - Clinical Outcomes Result Outcome Result (Risk ratio, 95% Confidence Interval, p value) Rebleeding 0.46, 0.24-0.87, 0.02 Early rebleeding 0.45, 0.10-2.03, 0.30 Deaths 0.67, 0.16-2.83, 0.58