Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 7, 2016; 22(41): 9162-9171
Published online Nov 7, 2016. doi: 10.3748/wjg.v22.i41.9162
First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: A single-center experience with 100 cases
Hans-Jürgen Richter-Schrag, Torben Glatz, Christine Walker, Andreas Fischer, Robert Thimme
Hans-Jürgen Richter-Schrag, Christine Walker, Andreas Fischer, Robert Thimme, Center of Interdisciplinary Gastrointestinal Endoscopy, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
Torben Glatz, Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
Author contributions: Richter-Schrag HJ designed the research and wrote the paper; Glatz T performed and analyzed the data; Walker C and Fischer A contributed to the evaluation; Thimme R critically revised the manuscript.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board and the Ethics Committee of Albert-Ludwigs-University-Freiburg, Germany.
Informed consent statement: All study participants, or their legal guardians, provided informed written consent prior to study enrollment and treatment. The identity of all subjects, including all details, was anonymized.
Conflict-of-interest statement: The authors declare that there is no conflict of interest with the paper presented.
Data sharing statement: No additional data are available. Informed consent for data sharing was not obtained, but the present data are anonymized, and the risk of identification is low. Questions regarding the technical aspects and data set are available from the corresponding author at
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Hans-Jürgen Richter-Schrag, MD, Professor of Medicine, Center of Interdisciplinary Gastrointestinal Endoscopy, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Street 55, D-79106 Freiburg, Germany.
Telephone: +49-761-27032020 Fax: +49-761-27027750
Received: June 18, 2016
Peer-review started: June 21, 2016
First decision: July 12, 2016
Revised: August 1, 2016
Accepted: September 28, 2016
Article in press: September 28, 2016
Published online: November 7, 2016

To evaluate rebleeding, primary failure (PF) and mortality of patients in whom over-the-scope clips (OTSCs) were used as first-line and second-line endoscopic treatment (FLET, SLET) of upper and lower gastrointestinal bleeding (UGIB, LGIB).


A retrospective analysis of a prospectively collected database identified all patients with UGIB and LGIB in a tertiary endoscopic referral center of the University of Freiburg, Germany, from 04-2012 to 05-2016 (n = 93) who underwent FLET and SLET with OTSCs. The complete Rockall risk scores were calculated from patients with UGIB. The scores were categorized as < or ≥ 7 and were compared with the original Rockall data. Differences between FLET and SLET were calculated. Univariate and multivariate analysis were performed to evaluate the factors that influenced rebleeding after OTSC placement.


Primary hemostasis and clinical success of bleeding lesions (without rebleeding) was achieved in 88/100 (88%) and 78/100 (78%), respectively. PF was significantly lower when OTSCs were applied as FLET compared to SLET (4.9% vs 23%, P = 0.008). In multivariate analysis, patients who had OTSC placement as SLET had a significantly higher rebleeding risk compared to those who had FLET (OR 5.3; P = 0.008). Patients with Rockall risk scores ≥ 7 had a significantly higher in-hospital mortality compared to those with scores < 7 (35% vs 10%, P = 0.034). No significant differences were observed in patients with scores < or ≥ 7 in rebleeding and rebleeding-associated mortality.


Our data show for the first time that FLET with OTSC might be the best predictor to successfully prevent rebleeding of gastrointestinal bleeding compared to SLET. The type of treatment determines the success of primary hemostasis or primary failure.

Keywords: Gastrointestinal bleeding, Rockall risk score, Over-the-scope clip, First-line endoscopic treatment, Second-line endoscopic treatment

Core tip: In the present study, the over-the-scope clip (OTSC) was evaluated for first-line and second-line endoscopic treatment (FLET, SLET) of high-risk upper and lower gastrointestinal bleeding. One hundred OTSCs were applied in 93 patients. Primary hemostasis and clinical success was achieved in 88% and 78%, respectively. Statistical analysis shows no significant influence of anticoagulants on the rebleeding rate. The total mortality was 21.5%. Primary failure was significantly reduced by the use of OTSC as FLET (4.9% vs 23.1%, P = 0.008). This largest single-center data of OTSC-placement in high-risk GI bleeding published to date shows, for the first time, that FLET is a significant predictor of reduced rebleeding (OR = 5.2; P = 0.009).