Endoscopic treatment modalities for colonic diverticular bleeding: A systematic review with direct and network meta-analyses.

Background: Colonic diverticular bleeding (CDB) is a leading cause of lower gastrointestinal hemorrhage that has a high risk of recurrence. The endoscopic clipping and endoscopic band ligation (EBL) methods are widely used for hemostasis in patients with CDB. Endoscopic detachable snare ligation (EDSL) has also become an increasingly common treatment option. The data remain inconsistent regarding the comparative efficacy of these endoscopic therapies in achieving initial hemostasis and reduction of early and late rebleeding rates.

Aim: To study the effectiveness and complications of endoscopic clipping, EBL, and EDSL for CDB.

Methods: We conducted a systematic search of PubMed/MEDLINE, Scopus, Web of Science, Embase, Google Scholar, and the Cochrane database for clinical trials to find studies that reported CDB and endoscopic clipping, EBL, or EDSL as treatment methods. The pooled estimates of initial hemostasis, early and late rebleeding, and the need for transarterial embolization or surgery between these groups were calculated.

Results: We analyzed 28 studies with 5224 patients. Of these, 4526 had active CDB and required one of the three endoscopic interventions. The pooled prevalence of early rebleeding was 23.5%, 10.7%, and 10.6% in the endoscopic clipping, EBL, and EDSL groups, respectively. Patients who underwent endoscopic clipping had a significantly higher rate of early rebleeding compared to those who received EBL [odds ratio (OR) = 3.76 (95%CI: 2.13-6.63)] and EDSL (OR = 3.30, 95%CI: 1.28-8.53). There was no difference in the initial hemostasis between the three groups. The pooled prevalence of late rebleeding was 27.2% in the clipping, followed by 13.8% in the EBL and 2.7% in the EDSL group. Compared to 2.6% in the EBL group, 4.0% of patients who received endoscopic clipping subsequently underwent surgery or transarterial embolization. These results were consistent in the network meta-analysis. Based on the ranking of the indirect comparison of modalities, the snare technique was better at achieving initial hemostasis and had a lower late rebleeding rate.

Conclusion: The findings of this direct and indirect pairwise comparison suggest that EDSL is superior to endoscopic clipping and EBL in achieving initial hemostasis and lowering the rate of late rebleeding in patients with CDB.