Sung Joseph J Y, Tsoi Kelvin K F, Lai Larry H, Wu Justin C Y, Lau James Y W
Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, NT, Hong Kong.
Gut. 2007 Oct;56(10):1364-73. doi: 10.1136/gut.2007.123976. Epub 2007 Jun 12.
Hemoclips, injection therapy and thermocoagulation (heater probe or electrocoagulation) are the most commonly used types of endoscopic hemostasis for the control of non-variceal gastrointestinal bleeding.
To compare the efficacy of hemoclips versus injection or thermocoagulation in endoscopic hemostasis by pooling data from the literature.
Publications in the English literature (MEDLINE, EMBASE and Cochrane Library) as well as abstracts in major international conferences were searched using the keywords "hemoclips" and "bleeding", and 15 trials fulfilling the search criteria were found. Outcome measures included: initial hemostasis (after endoscopic intervention); recurrent bleeding; definitive hemostasis (no recurrent bleeding until the end of follow-up); the requirement for surgical intervention; and all-cause mortality. The heterogeneity of trials was examined and the effects were pooled by meta-analysis.
Of 1156 patients recruited in the 15 studies, 390 were randomly assigned to receive clips alone, 242 received clips combined with injection, 359 received injection alone, and 165 received thermocoagulation with or without injection. Definitive hemostasis was higher with hemoclips (86.5%) than injection (75.4%; RR 1.14, 95% CI 1.00-1.30), or endoscopic clips with injection (88.5%) compared with injections alone (78.1%; RR 1.13, 95% CI 1.03-1.23), leading to a reduced requirement for surgery but no difference in mortality. Compared with thermocoagulation, there was no improvement in definitive hemostasis with clips (81.5% versus 81.2%; RR 1.00, 95% CI 0.77-1.31). These estimates were robust in sensitivity analyses. There was also no difference between clips and thermocoagulation in rebleeding, the need for surgery and mortality. The reported locations of failed hemoclip applications included posterior wall of duodenal bulb, posterior wall of gastric body and lesser curve of the stomach.
Successful application of hemoclips is superior to injection alone but comparable to thermocoagulation in producing definitive hemostasis. There was no difference in all-cause mortality irrespective of the modalities of endoscopic treatment.
金属夹、注射疗法和热凝术（热探头或电凝术）是内镜下控制非静脉曲张性胃肠道出血最常用的止血方法。
通过汇总文献数据，比较金属夹与注射或热凝术在内镜止血中的疗效。
使用关键词“金属夹”和“出血”检索英文文献（MEDLINE、EMBASE和Cochrane图书馆）以及主要国际会议的摘要，共找到15项符合检索标准的试验。观察指标包括：初始止血（内镜干预后）；再出血；最终止血（随访结束时无再出血）；手术干预需求；以及全因死亡率。检查试验的异质性，并通过荟萃分析汇总效应。
在15项研究招募的1156例患者中，390例被随机分配单独接受金属夹治疗，242例接受金属夹联合注射治疗，359例单独接受注射治疗，165例接受热凝术（有无注射）。金属夹组的最终止血率（86.5%）高于注射组（75.4%；RR 1.14，95%CI 1.00 - 1.30），或金属夹联合注射组（88.5%）高于单独注射组（78.1%；RR 1.13，95%CI 1.03 - 1.23），导致手术需求减少，但死亡率无差异。与热凝术相比，金属夹在最终止血方面无改善（81.5%对81.2%；RR 1.00，95%CI 0.77 - 1.31）。这些估计在敏感性分析中是稳健的。金属夹和热凝术在再出血、手术需求和死亡率方面也无差异。报道的金属夹应用失败部位包括十二指肠球部后壁、胃体后壁和胃小弯。
成功应用金属夹在实现最终止血方面优于单独注射，但与热凝术相当。无论内镜治疗方式如何，全因死亡率均无差异。
