Meta‐analysis: Over‐the‐scope clips in patients at high risk of re‐bleeding following upper gastrointestinal tract bleeding

Summary Background Acute non‐variceal upper gastrointestinal bleeding (UGIB) is challenging in patients at high risk of re‐bleeding in whom standard endoscopic treatment (ST) has limited effectiveness. Over‐the‐scope clips (OTSC) have shown promise in these patients although their precise role remains uncertain. Aims To confirm the role of OTSC in patients with UGIB at high risk of re‐bleeding. Methods We systematically searched CENTRAL, MEDLINE and Embase from January 1st, 1970 to April 24, 2024 for randomised controlled trials (RCTs) comparing OTSC and ST in acute non‐variceal UGIB with high re‐bleeding risk. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. Results We analysed four RCTs (319 patients); pooled risk ratio (RR) for clinical success at initial endoscopy favoured OTSC (RR = 1.30, 95% CI = 1.08–1.56, p = 0.006, I2 = 58%, moderate certainty of evidence). TSA showed the desired sample size was 410 and the cumulative Z curve crossing the trial sequential monitoring boundary. The pooled RR for re‐bleeding within 30 days favoured OTSC (RR = 0.53, 95% CI = 0.30–0.94, p = 0.03, I2 = 0%, moderate certainty of evidence). There was no significant difference in 30‐day mortality, or length of hospital or ICU stay. Conclusions Moderate certainty evidence supports OTSC as a superior initial treatment for acute non‐variceal UGIB with high re‐bleeding risk. Further large‐scale studies are needed to confirm OTSCs’ role by exploring other prognostic outcomes and assessing cost‐effectiveness and potential complications. Moderate‐certainty evidence supports OTSC as a superior initial treatment for acute non‐variceal UGIB with high re‐bleeding risk. TSA strengthens the reliability of this conclusion. Further large‐scale studies are needed to confirm OTSC's role, by exploring other prognosis outcomes and assessing cost‐effectiveness and potential complications