Upper GI bleeding
OTS (Over the scope clips) are big circumferencial clips that, contrary to classic through the channel clips, they are attached to the tip of the endoscope and they are released with a releasing mechanism (similar to the rubber bands for varices).
The most common brands are Ovesco and Padlock
Ovesco®
Padlock®
These clips have shown higher efficacy than standard endoscopic therapy in acute non variceal upper gastrointestinal bleeding (NVUGIB) from different causes (mostly ulcers). Even the ESGE guidelines 2021 starting to suggest Cap mounted clip as first and only therapy for specific ulcers, such as big (>2cm) (FIa, FIb) large visible vessel >2mm, or located in a high risk vascular area (e.g., gastroduodenal, left gastric arteries), or in excavated/fibrotic ulcers, however this recommendation was weak due to limited evidence.
This study is a head to head RCT which ramdomized to OTC vs TTS, only for ulcers and wihtout possibility of using any other treatment modalities except diluted adrenaline in the TTS arm. Overall clinical success rates were 96.7% (59/61) and 74.5% (38/51) in patients treated with OTS clips and TTS clips, which is a very important finding, however no significan differencet
The 30-day rebleeding rates were 1.6% (1/61) and 3.9% (2/ 51) in patients treated with OTS clips and TTS clips, respectively. Successful initial hemostasis rates were 98.4% (60/61) in the OTS clip group and 78.4% (40/51) in the TTS clip group (P=0.001). Overall clinical success rates were 96.7% (59/61) with OTS clips and 74.5% (38/51) with TTS clips (P=0.001).
Conclusions Low rates of 30-day rebleeding were observed after first-line endoscopic treatment of acute peptic ulcer bleeding with either OTS or TTS clips. However, OTS clips showed higher efficacy thanTTS clips in achieving successful initial hemostasis and overall clinical success.
Pros:
- First RCT head to head 2 modalities of clips for upper GI ulcers
- Better Hemostatic and clinical success with OTC
- OTC better for difficult fibrotic ulcers, especially in posterior duodenal wall where conventional clips struggle to hold
Cons
- OTC still significantly more expensive that TTS (5-10 times more)
- 30 day mortality and rebleeding similar in both groups , so not really able to justify the costs for universal use of OTC
- Endoscopist who performed OTC in this trial had a lifetime experience of at least 20 cases for non bleeding and 10 OTC for upper GI bleeding patients- this would be difficult to apply to real life centres and the first cases would be likely to have more rates of misdisplacements.