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Scheduled second look endoscopy after endoscopic hemostasis to patients with high risk bleeding peptic ulcers: a Randomized Controlled Trial

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Abstract

Background

The recommendation of second look endoscopy (SLOGD) in selected patients at high risk for rebleeding has been inconclusive. This study aimed to evaluate the benefit of SLOGD in selected patients predicted at high risk of recurrent bleeding.

Methods

From a cohort of 939 patients with bleeding peptic ulcers who underwent endoscopic hemostasis, we derived a 9-point risk score (age > 60, Male, ulcer ≥ 2 cm in size, posterior bulbar or lesser curve gastric ulcer, Forrest I bleeding, haemoglobin < 8 g/dl) to predict recurrent bleeding. We then validated the score in another cohort of 1334 patients (AUROC 0.77). To test the hypothesis that SLOGD in high-risk patients would improve outcomes, we did a randomized controlled trial to compare scheduled SLOGD with observation alone in those predicted at high risk of rebleeding (a score of ≥ 5). The primary outcome was clinical bleeding within 30 days of the index bleed.

Results

Of 314 required, we enrolled 157 (50%) patients (SLOGD n = 78, observation n = 79). Nine (11.8%) in SLOGD group and 14 (18.2%) in observation group reached primary outcome (absolute difference 6.4%, 95% CI − 5.0% to 17.8%). Twenty-one of 69 (30.4%) patients who underwent SLOGD needed further endoscopic treatment. No surgery for bleeding control was needed. There were 6 vs. 3 of 30-day deaths in either group (p = 0.285, log rank). No difference was observed regarding blood transfusion and hospitalization.

Conclusions

In this aborted trial that enrolled patients with bleeding peptic ulcers at high-risk of recurrent bleeding, scheduled SLOGD did not significantly improve outcomes.

ClinicalTrials.gov:NCT02352155.

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References

  1. Lau JY, Barkun A, Fan DM, Kuipers EJ, Yang YS, Chan FK (2013) Challenges in the management of acute peptic ulcer bleeding. Lancet 381:2033–2043

    Article  Google Scholar 

  2. Sung JJ, Chiu PW, Chan FKL, Lau JY, Goh KL, Ho LH, Jung HY, Sollano JD, Gotoda T, Reddy N, Singh R, Sugano K, Wu KC, Wu CY, Bjorkman DJ, Jensen DM, Kuipers EJ, Lanas A (2018) Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 67:1757–1768

    Article  Google Scholar 

  3. Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M (2019) Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the international consensus group. Ann Intern Med 171:805–822

    Article  Google Scholar 

  4. Cook DJ, Guyatt GH, Salena BJ, Laine LA (1992) Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 102:139–148

    Article  CAS  Google Scholar 

  5. Sung JJ, Barkun A, Kuipers EJ, Mossner J, Jensen DM, Stuart R, Lau JY, Ahlbom H, Kilhamn J, Lind T, Peptic Ulcer Bleed Study G (2009) Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med 150:455–464

    Article  Google Scholar 

  6. Leontiadis GI, Sharma VK, Howden CW (2006) Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev 25:CD002094

    Google Scholar 

  7. Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR (2011) Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut 60:1327–1335

    Article  Google Scholar 

  8. El Ouali S, Barkun AN, Wyse J, Romagnuolo J, Sung JJ, Gralnek IM, Bardou M, Martel M (2012) Is routine second-look endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis. Gastrointest Endosc 76:283–292

    Article  Google Scholar 

  9. Park SJ, Park H, Lee YC, Choi CH, Jeon TJ, Park JC, Kim JH, Youn YH, Kim YJ, Kim JH, Lee KJ, Lim SG, Kim H, Bang BW (2018) Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial. Gastrointest Endosc 87:457–465

    Article  Google Scholar 

  10. Kamal F, Khan MA, Lee-Smith W, Sharma S, Imam Z, Henry C, Jowhar D, Khan Z, Petryna E, Iqbal U, Tombazzi C, Ismail MK, Howden CW (2021) Role of routine second-look endoscopy in patients with acute peptic ulcer bleeding: meta-analysis of randomized controlled trials. Gastrointest Endosc 93:1228

    Article  Google Scholar 

  11. Saeed ZA, Cole RA, Ramirez FC, Schneider FE, Hepps KS, Graham DY (1996) Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial. Endoscopy 28:288–294

    Article  CAS  Google Scholar 

  12. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C (2015) Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 47:a1-46

    Article  Google Scholar 

  13. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Curdia Goncalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE (2021) Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 53:300–332

    Article  Google Scholar 

  14. Lau JY, Sung JJ, Lam YH, Chan AC, Ng EK, Lee DW, Chan FK, Suen RC, Chung SC (1999) Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 340:751–756

    Article  CAS  Google Scholar 

  15. Lau JYW, Pittayanon R, Wong KT, Pinjaroen N, Chiu PWY, Rerknimitr R, Holster IL, Kuipers EJ, Wu KC, Au KWL, Chan FKL, Sung JJY (2019) Prophylactic angiographic embolisation after endoscopic control of bleeding to high-risk peptic ulcers: a randomised controlled trial. Gut 68:796–803

    Article  CAS  Google Scholar 

  16. Levy I, Gralnek IM (2016) Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy. Best Pract Res Clin Gastroenterol 30:705–718

    Article  Google Scholar 

  17. Schmidt A, Golder S, Goetz M, Meining A, Lau J, von Delius S, Escher M, Hoffmann A, Wiest R, Messmann H, Kratt T, Walter B, Bettinger D, Caca K (2018) Over-the-scope clips are more effective than standard endoscopic therapy for patients with recurrent bleeding of peptic ulcers. Gastroenterology 155:674-686 e676

    Article  Google Scholar 

  18. Brandler J, Baruah A, Zeb M, Mehfooz A, Pophali P, Wong Kee Song L, AbuDayyeh B, Gostout C, Mara K, Dierkhising R, Buttar N (2018) Efficacy of over-the-scope clips in management of high-risk gastrointestinal bleeding. Clin Gastroenterol Hepatol 16:690-696 e691

    Article  Google Scholar 

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Acknowledgements

The authors would like to thank fellows of Gastroenterology at King Chulalongkorn Memorial Hospital, Bangkok, Thailand who were in training between 2015 and 2020 for their kind contribution in data collection.

Funding

This study was funded by the Health and Medical Research Fund (HMRF12130501), the Hong Kong SAR Government.

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Authors and Affiliations

  1. Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand

    Rapat Pittayanon, Natanong Kongtub & Rungsun Rerknimitr

  2. Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong

    Bing-Yee Suen, Yee-kit Tse & James Y. W. Lau

  3. Department of Surgery, Prince of Wales Hospital, Room 64026, Lui Chee Woo Clinical Science Building, 32 Ngan Shing Street, Shatin, NT, Hong Kong SAR, China

    James Y. W. Lau

Authors
  1. Rapat Pittayanon
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  2. Bing-Yee Suen
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  3. Natanong Kongtub
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  4. Yee-kit Tse
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  5. Rungsun Rerknimitr
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  6. James Y. W. Lau
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Contributions

Conception and design of the study, JYWL; collecting data, RP, B-YS and NK; interpreting data, RP, B-YS, YT and JYWL; drafting the manuscript, RP, and JYWL; Facilitating the study, RR and JYWL. All authors have approved the final draft submitted.

Corresponding author

Correspondence to James Y. W. Lau.

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Disclosures

Dr. Rapat Pittayanon, Miss Bing-Yee Suen, Miss Natanong Kongtub, Mr. Yee-kit Tse, Dr. Rungsun Rerknimitr and Dr. James YW Lau have no conflicts of interest or financial ties to disclose.

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Pittayanon, R., Suen, BY., Kongtub, N. et al. Scheduled second look endoscopy after endoscopic hemostasis to patients with high risk bleeding peptic ulcers: a Randomized Controlled Trial. Surg Endosc 36, 6497–6506 (2022). https://doi.org/10.1007/s00464-021-09004-w

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  • DOI: https://doi.org/10.1007/s00464-021-09004-w

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