Dual Therapy Versus Monotherapy in the Endoscopic Treatment of High-Risk Bleeding Ulcers: A Meta-Analysis

Abstract

Background & Aims: Endoscopic therapy improves the outcome of patients with peptic ulcer and high-risk stigmata. Epinephrine injection is the most popular therapeutic method, albeit the least effective. There is no definite recommendation on the use of dual endoscopic therapy and its effects on morbidity, surgery rates, and mortality is still controversial. The aim of this study was to perform a systematic review and meta-analysis to determine whether the use of two hemostatic procedures improves patient outcomes compared to monotherapies. Methods: An extensive search for randomized trials comparing dual therapy (i.e. epinephrine injection plus other injection or thermal or mechanical hemostatic method) vs. endoscopic monotherapy (injection or thermal or mechanical alone) was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2004. Selected articles were reviewed separately by 2 of the authors, and those fulfilling the inclusion criteria were included in a meta-analysis. Main comparisons contrasted epinephrine injection vs. epinephrine injection plus thermal or mechanical method; mechanical and thermal plus injection vs thermal or mechanical method alone. Primary outcomes variables was further bleeding, emergency surgery and mortality. Overall effect and subanalysis for each strata was performed to examine the efficacy of the different techniques. Peto odds ratios, Rate Difference and 95% confidence intervals were used for comparisons. Prior to meta-analysis, the heterogeneity of results was assessed by means of a Q test. Results: Twenty-three of 1135 studies including 2478 patients met inclusion criteria. Dual therapy reduced the further bleeding rate by 5% (random RR 0.67, 95% CI: 0.46-0.97) and emergency surgery by 3% (RR: 0.69, 95% CI: 0.51-0.92). There was a 2% reduction in mortality (RR: 0.59, 95% CI: 0.39-0.89). Sub-analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered. There was no significant or clinically relevant therapeutic gain of dual therapy over thermal or mechanical monotherapy which showed equivalent efficacy. Conclusions: Dual endoscopic therapy is significantly better than epinephrine injection alone, whether has no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding. Epinephrine injection alone should no longer be considered sufficient. Background & Aims: Endoscopic therapy improves the outcome of patients with peptic ulcer and high-risk stigmata. Epinephrine injection is the most popular therapeutic method, albeit the least effective. There is no definite recommendation on the use of dual endoscopic therapy and its effects on morbidity, surgery rates, and mortality is still controversial. The aim of this study was to perform a systematic review and meta-analysis to determine whether the use of two hemostatic procedures improves patient outcomes compared to monotherapies. Methods: An extensive search for randomized trials comparing dual therapy (i.e. epinephrine injection plus other injection or thermal or mechanical hemostatic method) vs. endoscopic monotherapy (injection or thermal or mechanical alone) was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2004. Selected articles were reviewed separately by 2 of the authors, and those fulfilling the inclusion criteria were included in a meta-analysis. Main comparisons contrasted epinephrine injection vs. epinephrine injection plus thermal or mechanical method; mechanical and thermal plus injection vs thermal or mechanical method alone. Primary outcomes variables was further bleeding, emergency surgery and mortality. Overall effect and subanalysis for each strata was performed to examine the efficacy of the different techniques. Peto odds ratios, Rate Difference and 95% confidence intervals were used for comparisons. Prior to meta-analysis, the heterogeneity of results was assessed by means of a Q test. Results: Twenty-three of 1135 studies including 2478 patients met inclusion criteria. Dual therapy reduced the further bleeding rate by 5% (random RR 0.67, 95% CI: 0.46-0.97) and emergency surgery by 3% (RR: 0.69, 95% CI: 0.51-0.92). There was a 2% reduction in mortality (RR: 0.59, 95% CI: 0.39-0.89). Sub-analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered. There was no significant or clinically relevant therapeutic gain of dual therapy over thermal or mechanical monotherapy which showed equivalent efficacy. Conclusions: Dual endoscopic therapy is significantly better than epinephrine injection alone, whether has no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding. Epinephrine injection alone should no longer be considered sufficient.