Randomized comparison of endoscopic microwave coagulation and endoscopic sclerosis in the treatment of bleeding peptic ulcers

doi:10.1016/S0016-5107(91)70865-1

Gastrointestinal Endoscopy

Volume 37, Issue 6, November 1991, Pages 611-616

https://doi.org/10.1016/S0016-5107(91)70865-1 Get rights and content

We conducted a prospective randomized trial to evaluate the effectiveness and safety of endoscopic microwave coagulation in comparison to endoscopic sclerosis in the treatment of peptic ulcer bleeding. Over 15 months 127 ulcer-bleeding patients with an actively bleeding vessel (N = 21), a non-bleeding vessel (N = 53), oozing hemorrhage (N = 25), or an adherent clot (N = 28) in the ulcer base were randomly assigned during endoscopy to receive treatment with endoscopic sclerosis or with microwave coagulation.

There were no significant differences in effectiveness between endoscopic sclerosis and microwave coagulation in any of the assessed parameters: the percentage of patients with major recurrent hemorrhage (5 vs. 12), the percentage who needed emergency surgery (5 vs. 9), the mean (±SD) transfusion requirements (0.32 ± 0.89 vs. 0.78 ± 1.65), the mean number of hospital days (10.3 ± 3.5 vs. 10.7 ± 4.1), and the number of deaths due to bleeding (0 vs. 2) were similar in both groups. No case of perforation occurred in either group. The data suggest that microwave coagulation is as effective and safe as endoscopic sclerosis in the treatment of bleeding peptic ulcers.

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Cited by (25)

Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses
2009, Gastrointestinal Endoscopy
Citation Excerpt :
Rebleeding and surgery were significantly reduced with thermal therapy compared with pharmacotherapy, respectively (OR 0.41 [95% CI, 0.26-0.65] and OR 0.51 [95% CI, 0.28-0.94]) but not mortality (OR 0.64 [95% CI, 0.25-1.65]). Thermal hemostasis was compared with injection therapy in 12 studies (634 thermal, 627 controls), including epinephrine injection in 4 studies,26,31,44,45 alcohol injection in 4,48,50,56,57 injection of epinephrine combined with polidocanol in 3,52,53,55 and distilled water injection in 1 study.49 The study by Sofia et al56 contained 5 arms (Table 2).
Optimal endoscopic hemostasis remains undetermined. This was a systematic review of contemporary methods of endoscopic hemostasis for patients with bleeding ulcers that exhibited high-risk stigmata.
Randomized trials that evaluated injection, thermocoagulation, clips, or combinations of these were evaluated from MEDLINE, EMBASE, and CENTRAL (1990-2006).
A total of 4261 patients were evaluated.
Outcomes were rebleeding (primary), surgery, and mortality (secondary). Summary statistics were determined; publication bias and heterogeneity were sought by using funnel plots or by subgroup analyses and meta-regression.
Forty-one trials assessed 4261 patients. All endoscopic therapies decreased rebleeding versus pharmacotherapy alone, including sole intravenous (IV) proton pump inhibition (PPI) (OR 0.56 [95% CI, 0.34-0.92]); only one trial assessed high-dose IV PPI. Injection alone was inferior compared with other methods, except for thermal hemostasis (OR 1.02 [95% CI, 0.74-1.40]), with a strong trend of increased rebleeding if 1 injectate is used rather than 2 (OR 1.40 [95% CI, 0.95-2.05]). Injection followed by thermal therapy did not decrease rebleeding compared with clips (OR 0.82 [95% CI, 0.28-2.38]) or thermal therapy alone (OR 0.79 [95% CI, 0.24-2.62]). Subgroup analysis, however, suggested that injection followed by thermal therapy was superior to thermal therapy alone. Clips were superior to thermal therapy (OR 0.24 [95% CI, 0.06-0.95]) but, when followed by injection, were not superior to clips alone (OR 1.30 [95% CI, 0.36-4.76]). Surgery or mortality was not altered in most comparisons.
All endoscopic treatments are superior to pharmacotherapy alone; only 1 study assessed high-dose IV PPI. Optimal endoscopic therapies include thermal therapy or clips, either alone or in combination with other methods. Additional data are needed that compare injection followed by thermal therapy to clips alone or clips combined with another method.
Current status of endoscopic therapy for ulcer bleeding
2000, Bailliere's Best Practice and Research in Clinical Gastroenterology
This article provides an overview of the therapeutic endoscopic modalities available for the treatment of peptic ulcer bleeding. The benefits of endoscopic haemostasis have been fully demonstrated by three meta-analyses, which included most of the controlled trials published until 1992. In this review, an emphasis is placed on randomized, prospective comparative trials published during the past 20 years. Using an evidence-based medicine approach, the results of meta-analyses are translated into efficacy measures known as relative and absolute risk reductions, and number needed to treat. Single-modality treatments with injection agents such as epinephrine, sclerosants and thrombogenic substances, or with thermal therapies, are efficacious and comparable. Combination therapy involving injection and thermal techniques may offer an advantage over single-method therapy. The differences in the results between clinical trials and routine clinical practice, and among the various randomized studies, are probably related to operators' experience and variations in technique rather than to inconsistency of endoscopic haemostasis.
Mechanical endoscopic methods of haemostasis for bleeding peptic ulcers: A review
2000, Bailliere's Best Practice and Research in Clinical Gastroenterology
Re-bleeding following endoscopic therapy for gastrointestinal bleeding remains common probably because injection and thermal methods for treating bleeding are of limited efficacy, especially in the presence of a large bleeding artery. This chapter reviews mechanical methods of endoscopic haemostasis. The design of clips, which can be delivered through flexible endoscopes, is reviewed with experimental and clinical data of their efficacy. The need for improvements in clip design is stressed. Experimental studies and preliminary clinical data where available on a variety of other mechanical methods of haemostasis are presented, including band ligation, endoloops, sewing machines, stapling machines, ulcer clamps, corkscrews, balloon tamponade and ferromagnetic tamponade. New, less invasive, surgical methods which might have a place in ulcer haemostasis, including transgastric endoluminal surgery and flexible endoscopic ulcer excision with wound closure, are discussed. Mechanical methods offer the best prospect for improvements in security of endoscopic haemostasis for bleeding peptic ulcer. More development is required if the results are to improve.
Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery
2000, Surgical Clinics of North America
Citation Excerpt :
Meta-analysis of a laser trial shows highly significant improvement in endpoints, such as rebleeding rates, need for urgent surgery, and risk for mortality, but some investigators have found no difference among therapies for bleeding peptic ulcers, such as microwaves or heater probes, lasers, and alcohol injection.83 Well-known, fatal complications of injection therapy exist,39,67,87,112 and although recurrent bleeding after endoscopic therapy still seems to occur in approximately 20% to 25% of cases, the fairly low mortality rate (as low as 5%) seems to be consistent with the impression that the need for emergency surgery, and upper gastrointestinal tract bleeding is decreased.88,142,150 A new therapy using clips applied to bleeding variceal vessels by an endoscope has been performed by two groups.76
Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers
1999, Gastrointestinal Endoscopy
Background: The endoscopic hemoclip method is a safe and effective hemostatic method for managing bleeding peptic ulcers. We compared the hemostatic efficacy of the endoscopic hemoclip method with that of hypertonic saline–epinephrine (HSE) injection and a combined method in the management of bleeding peptic ulcers. Methods: From July 1994 to July 1997, we conducted a randomized clinical trial of endoscopic hemostasis involving 124 patients with actively bleeding or visible vessels at endoscopic inspection. Results: Patients were randomly assigned to hemoclip (41 patients), HSE (41 patients), and combined treatment groups (42 patients). Initial hemostasis was achieved in 97.6%, 95.1%, and 97.6% of cases, respectively. Recurrent bleeding developed in 2.4%, 14.6%, and 9.5% of cases. Emergency operations were performed in 4.9%, 14.6%, and 2.3% of cases. The hemostasis rate was 71.4%, 50%, and 66.7% for spurting hemorrhage in each group. Permanent hemostasis was achieved in 95.1%, 85.4%, and 95.2% of cases. Three patients had complications, all in the HSE group. Conclusions: The hemoclip method is an effective hemostatic procedure and is safer than HSE injection. The combined method does not provide substantial advantage over use of the hemoclip method alone in the hemostatic management of bleeding peptic ulcers. (Gastrointest Endosc 1999;49:13-8.)
New and alternative hemostatic techniques
1997, Gastrointestinal Endoscopy Clinics of North America
In upper gastrointestinal bleeding, endoscopic management does reduce rates of rebleeding, surgery, and mortality. In active bleeding, however, early recurrence still occurs in around 20% despite successful initial hemostasis. Several new techniques or modifications of endoscopic hemostatic methods have been invented to improve the results. They include ligating devices, biological injection agents, argon plasma coagulation, and hemoclips. Hemoclips and injection therapy using fibrin glue do not cause relevant tissue damage and appear to have better results in terms of lower rebleeding rates. Fibrin glue seems to be effective only if injected repeatedly. Due to limited experience, no final conclusion can be made at this stage. Further clinical investigation is warranted.

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Randomized comparison of endoscopic microwave coagulation and endoscopic sclerosis in the treatment of bleeding peptic ulcers

Lancet

Lancet

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

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Gastroenterology

Endoscopic hemostasis by local injection of epinephrine and polidocanol in bleeding ulcer. A prospective randomized trial

Endoscopy