Endoscopists in Training and the Use of Over the Scope Clips as First Line Treatment in Non-variceal Upper Gastrointestinal Bleeding

Abstract

Introduction. Treatment with over the scope clips is useful for perforations, fistulas, and bleeding in the digestive tract. Operated by expert endoscopists, it is an effective method for the management of ulcer rebleeding, and there is recent evidence that its use may be superior to standard combination therapy as a first-line treatment of non-variceal upper gastrointestinal bleeding in selected patients.

Aim. To describe the results of the use of over the scope clips in patients at high risk of rebleeding, as a first-line treatment, performed by endoscopists in training at a third-level center.

Materials and methods. A cross-sectional study included patients undergoing endoscopy for non-variceal upper gastrointestinal bleeding treated with over the scope clips as first-line endoscopic therapy. Operators were simulation-trained gastroenterology residents. Before placing the over the scope clip, 0.01% diluted adrenaline was injected. Successful hemostasis was defined as the absence of persistent or recurrent bleeding. Subsequent complications were analyzed: new endoscopy, need for surgery and/or death.

Results. Eleven cases were included with a median age of 65. Of the total causes of bleeding, 8 were ulcers, predominantly duodenal. Hemostasis was achieved in 100% of cases, with no persistent bleeding. Subsequent transfusion support was required in 6 of the 11 patients. A new endoscopy was performed in 4 of the patients, and none had evidence of rebleeding associated with the lesion initially treated with an over the scope clip. However, after 72 hours, one of the patients presented with melena and hemodynamic instability requiring emergency surgery, where an atypical gastrectomy was performed. The surgical specimen showed the presence of a vascular lesion in the periphery of the over the scope clip. No mortality related to gastrointestinal bleeding within the first 30 days was detected in any of the cases. 

Conclusion. The scope clip system could be considered for use by endoscopists in training for the treatment of non-variceal upper gastrointestinal bleeding, under supervision and with prior training on simulation models, performing an appropriate selection of patients.