The use of cap-mounted clips as a primary hemostatic modality in nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis of randomized trials

Abstract

Background:
Cap-mounted-clips, especially Over-The-Scope-Clip (OTSC™), are recommended for recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB). There has been recent interest in their use as an initial hemostatic modality. We performed a systematic review of randomized controlled trials (RCTs) assessing cap-mounted clips’ efficacy as a primary hemostatic modality in NVUGIB.


Methods:
A literature search of MEDLINE, EMBASE, and ISI Web of Science databases up to April 2024 identified RCTs comparing cap-mounted clips to standard endoscopic therapy (SET) as a primary hemostatic modality in NVUGIB. The primary endpoint was the composite outcome of further bleeding (persistent or recurrent) at 30 days. Secondary outcomes included persistent bleeding at index endoscopy and 30-day rebleeding, individually. Other pertinent outcomes were also recorded. A meta-analysis was performed to determine pooled risk ratios (RRs), comparing cap-mounted clip to SET. Out of 516 citations, five RCTs (n = 555), all assessing OTSC™, were included.


Results:
The composite outcome of further bleeding was lower with cap-mounted clip versus SET (RR = 0.33 [95% confidence interval {CI}: 0.20–0.54]). There was no difference in persistent bleeding at initial endoscopy (RR = 0.30 [95% CI: 0.07–1.30]), but 30-day rebleeding was lower with cap-mounted clip (RR = 0.38 [95% CI: 0.21–0.70]). There were no differences in other outcomes. Grading of the evidence ranged from very low to moderate, mainly due to risk of bias and imprecision.


Conclusions:
Cap-mounted clips may be an efficacious primary hemostatic modality, associated with a lower further bleeding at 30 days compared to SET in NVUGIB. However, due to limitations in existing evidence, further research must better characterize an optimal subgroup of patients benefiting most from this approach before adopting its routine use.