The triclip - more research is mandatory: reply to Dr. Lin

 

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We appreciate the observations by Dr. Lin et al. [1] which revealed clinical limitations of a particular hemoclipping device, adding further knowledge to our understanding of the clinical results of using these devices.

The letter from Dr. Lin outlined one of the major problems of clip application in hemostasis, which is the challenging application of the procedure in difficult-to-approach sites, confirming previous findings [2]. Despite this drawback, hemoclip therapy has been established as a valuable procedure for the endoscopic management of gastrointestinal bleeding [3]. Nevertheless, experimental data on clip application, elucidating the factors related to overall success and failure, are rare. The main target of our experimental studies was therefore to evaluate the efficacy of different clip devices [4] in a defined experimental setting in an attempt to establish homogeneous and reproducible results as far as possible. We showed that the two clipping devices used (hemoclip and triclip) have comparable efficacy in terms of hemostatic capacity, but also that other factors (e. g. the experience of the endoscopist) influenced the results of this endoscopic intervention. Dr. Lin correctly pointed out that the experimental setting used in our study [4] might not have been able to detect particular weaknesses of a clipping device, such as the difficult approach. However, several other variables can contribute to the success or failure of clip application, such as the size of an ulcer, the consistency of the tissue, underlying coagulation disorders, and poor visualization.

This is the difference between the experimental setting and the clinical situation and may explain the differences in the two trials. Additionally, the influence of the long experience of using the established two-pronged Olympus system is not negligible in comparison with the new three-pronged triclip system, which sometimes requires a different endoscopic approach, and this could represent a bias in the clinical study of Dr. Lin et al.

In principle, the findings of Lin et al. and our own findings convincingly show that endoscopy is in need of both experimental and clinical research, resulting in complementary observations, to substantiate our understanding of a device. The consequence of such a dual approach is an improvement in patient care. Not that we should forget technical research, which may help us to overcome another limitation of clipping, the necessity for multiple clipping [5], by providing multiple-clipping devices without the need for reloading. Other new devices have been introduced [6] and more will follow in the near future. Further experimental and clinical trials to investigate the efficacy of each device are therefore mandatory.

Competing interests: None

References

• 1 Lin H J, Lo W C, Cheng Y C, Perng C L. Endoscopic hemoclip versus triclip placement in patients with high-risk peptic ulcer bleeding.  Am J Gastroenterol. 2006;  Nov 13 (Epub ahead of print)
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• 2 Gevers A M, de Goede E, Simoens M. et al . A randomized trial comparing injection therapy with hemoclip and with injection combined with hemoclip for bleeding ulcers.  Gastrointest Endosc. 2002;  55 466-469
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• 3 Raju G S, Gajula L. Endoclips for GI endoscopy.  Gastrointest Endosc. 2004;  59 267-279
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• 4 Maiss J, Dumser C, Zopf Y. et al . ”Hemodynamic efficacy“ of two endoscopic clip devices used in the treatment of bleeding vessels, tested in an experimental setting using the compact Erlangen Active Simulator for Interventional Endoscopy (compactEASIE) training model.  Endoscopy. 2006;  38 575-580
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• 5 Chung I K, Ham J S, Kim H S. et al . Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers.  Gastrointest Endosc. 1999;  49 13-18
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• 6 Maiss J, Baumbach C, Zopf Y. et al . Hemodynamic efficacy of the new resolution clip-device in comparison with high-volume injection therapy in spurting bleeding: a prospective experimental trial using the compactEASIE simulator.  Endoscopy. 2006;  38 808-812
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J. Maiss,MD 

Department of Medicine I

University Erlangen-Nuremberg

Ulmenweg 18

D-91054 Erlangen

Germany

Fax: +49-9133-602618

Email: juergen.maiss@med1.imed.uni-erlangen.de