The metallic endoscopic clip was originally
developed for achieving hemostasis of gastrointestinal bleeding.
Introduced approximately 30 years ago, its extensive use was hindered by
poor design, deployment difficulty and low clip-retention rates (Shin et
al.).
But with significant design improvement, clips
have evolved into an invaluable instrument for numerous GI procedures.
Routinely used for the treatment of nonvariceal GI bleeding, its use has
expanded to nonhemostatic applications as well.
Upper GI bleeding results in more than 300,000
hospital admissions annually in the United States, with mortality of 7
percent to 10 percent (ASGE, 2004). Acute nonvariceal GI bleeding is the
most common emergency endoscopists manage. Endoscopic therapy has
generally been recommended as the first line of treatment and has shown
that it can significantly reduce bleeding, mortality, and the need for
surgery.
Traditionally, endoscopic treatment of
non-variceal GI bleeding included injection therapy and thermal
coagulation. Both modalities have high success rates, but tissue injury
complications leading to necrosis and perforation is possible (Kapetanos
et al.).
Metallic clips do not induce tissue injury and
clip application is akin to surgical ligature, resulting in immediate
and complete hemostasis by mechanical compression.
Endoscopic clipping has shown to significantly
improve the clinical outcome of nonvariceal GI bleeding and result in
lower rebleeding rates and shorter hospital stays (ASGE 2006).
Clips can be safely used on patients with
coagulopathy disorders and immediate re-anticoagulation therapy post
placement can generally be advised without significant risk of delayed
post-polypectomy bleeding (Howell et al.).
The largest experience of clip application has
been with peptic ulcer bleeding, which is associated with significant
morbity and mortality. A prospective randomized trial by Cipolletta et
al., compared thermal and mechanical endoscopic methods of achieving
hemostasis in cases of bleeding peptic ulcers and confirmed that
endoclips are safe and effective.
Clip application also showed reduction in
recurrent hemorrhage rates, which positively affected transfusion
requirements and length of hospital stay, potentially with significant
cost savings.
Clips are also safe and effective in the
immediate control of bleeding and prevention of recurrent bleeding of
dieulafoy lesions. These lesions account for five percent of acute upper
GI bleeding and typically affect elderly patients with multiple
comorbidities (Raju G., Gajula L., 2004).
Mallory-Weiss tears, the third-most-common cause
of upper GI bleeding after peptic ulcers and varices, are
vomiting-induced mucosal lacerations in the esophago-gastric junction.
Bleeding stops spontaneously in 90 percent of
these cases and endoscopic therapy is attempted only when active
bleeding stigmata are present. The placement of clips has been found
successful in the control of bleeding and prevention of recurrent
bleeding with these tears and, compared with cautery or sclerotherapy,
is a safer option because of the lack of additional tissue damage (Raju
G., Gajula L., 2004).
Clips are commonly used to control
post-polypectomy bleeding, either immediate or delayed. Placement on the
remnant stalks of polyps will obstruct the feeding vessel (Kapetanos et
al.).
Hemoclips can also be used as a prophylactic
technique to prevent post-polypectomy bleeding by clipping the stalk of
large pedunculated polyps prior to removal with a snare. This technique
is beneficial particularly for patients with impaired hemostatic
function (Kapetanos et al.).
Diverticular disease of the colon is one of the
most common causes of lower GI bleeding. Episodes are usually self
limited, but hemorrhage can occasionally occur. Endoscopic treatment,
though possible, can be difficult due to failure in identifying the
bleeding diverticulum. Studies have shown that clipping appears safe and
effective in controlling diverticular bleeding, but requires caution as
the bowel wall is thin in the diverticulum (Kapetanos D., et al.).
The mouth of the diverticulum can be clipped to
seal it, and clips may serve as fluoroscopic markers to guide arterial
embolism if needed (Raju, G., Gajula, L., 2004).
Most episodes of sphincterotomy bleeding are
self limited, but rapid bleeding may result from cutting the aberrant
branch of the retroduodenal artery. Studies show use of clips to be
superior to epinephrine injections in controlling post sphincterotomy
bleeding. Clips can be placed precisely at the site of bleeding at the
margins of the papillotomy, but care must be taken not to compress the
orifice of the pancreatic or bile duct within the clips prongs
(Kapetanos et al.).
Indications for endoscopic clipping have
expanded to include closure of perforations, fistulas and anastomotic
leaks. They have also been used to secure catheters, feeding tubes and
stents to the GI wall to prevent migration and as markers for
fluoroscopic guided therapy.
Several designs of endoscopic clips are now
available and indications are rapidly expanding. Retention rate at the
site of application is important, especially when long-term attachment
of clips is necessary, such as for tumor marking for radiation therapy
or anchoring feeding tubes or stents. A comparative study of retention
rates of endoscopic clips using the Resolution® Clip (Boston
Scientific), the TriClip® (Cook Endoscopy), and the HX-5l Clip (Olympus)
concluded that the Resolution Clip had the longest duration of retention
at the site of application—more than four to five weeks, and should be
preferred when long-term clip attachment is necessary (Shin E.J., Ko,
C.W. et al.).
Another study by Adler et al. compared a new
reopenable endoclip with traditional clipping devices. The Resolution
Clip, compared in a randomized, prospective basis, was found to remain
on the lesions significantly longer than the other clips remained. Also,
fewer clips were used to achieve hemostasis in each treatment, as
forceps-like functionality offers the ability to correct placement.
To prevent complications—heat, burning and
torque of the clips—Scout X-rays should be done on all patients who have
had clips placed in the GI tract prior to MRI (Gastrointestinal
Endoscopy, 2006).
Despite the advantages of secure and permanent
hemostasis and lack of complications, endo clips are not useful for all
types of bleeding and cannot always replace other hemostatic methods.
Limitations include inaccessible lesions, diffuse bleeding, large
visible vessels and fibrotic ulcers. Recognizing such limitations and
employing alternative methods of hemostasis is crucial to positive
patient outcomes (Soehendra et al.).
Barbara Zuccala, RN, BSN, MSN, CGRN, is a GI
educator at Valley Hospital in Ridgewood, N.J.
References
Adler, Papanikolaou, Veltzke-Schlieker,
Wiedenmann, and Roesch (2008). Prospective Clinical Study on the Use of
a New Reopenable Endoclip in Comparison with Traditional Clipping
Systems.
American Society of Gastrointestinal Endoscopy
(2004). ASGE guideline: the role of endoscopy in acute non-variceal
upper-GI hemorrhage. Gastrointestinal Endoscopy, 60(4), 497-504.
American Society for Gastrointestinal Endoscopy
(2006). Endoscopic Clip Application Devices. Gastrointestinal Endoscopy,
63(6), 746-750.
Cipolletta et al. (2001) Cipolletta, L., Bianco,
M. A., Marmo, R., Rotondano, G., Piscopo, R., Vingiani, A. M., et al.
(2001). Endoclips versusheater probe in preventingearly recurrent
bleeding from peptic ulcer: a prospective and randomized trial.
Gastrointestinal Endoscopy, 53(2), 147-151.
Howell, D. A., Eswaran, S. L., Loew, B. J.,
Sanders, M. K., Erkkinen, J. F., Bernadino, K. P., et al. (2006). Use of
Hemostatic Clips in Patients Undergoing Colonoscopy in the Setting of
Coumadin Anticoagulation Therapy. Gastrointestinal Endoscopy, 63(5).
Kapetanos, D., Beltsis, A., Chatzimavroudis, G.,
& Katsinelos, P. (2009). The Use of Endoclips in the Treatment of
Nonvariceal Gastrointestinal Bleeding. Surg Laparosc Endosc Percutan
Tech, 19(1), 2-10.
Raju, G. S., & Gajula, L. (2004). Endoclips for
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Shin et al. (2007) Shin, E. J., Ko, C., Magno,
P., Giday, S. A., Clarke, J. O., Buscaglia, J. M., et al. (2007).
Gastrointestinal Endoscopy. Comparative Study of Endoscopic
Clips:Duration of Attachmentat the Clip Application, 66(4), 757-761.
Soehendra, N., Sriram, P. V., Ponchon, T., &
Chung, S. C. (2001). Hemostatic Clip in Gastrointestinal Bleeding.
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