Can the triclip be successfully applied in clinical practice?

We read with interest the article by Maiss et al. [1], ”‘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.” In this study, Maiss et al. compared two disposable clip devices (Olympus HX-200L-135 vs. Wilson-Cook Tri-clip) in an experimental setting using the compactEASIE training model. Four investigators with different levels of endoscopic experience applied clipping devices to the spurting vessels located over the anterior wall of the gastric corpus. No significant difference was found between the two clipping devices with respect to their hemostatic effect.

Endoscopic placement of metallic clips (hemoclips) to a bleeder is an appealing therapeutic modality that minimizes the possibility of tissue injury. Moreover, it is effective in achieving hemostasis, with a low rebleeding rate [2] [3]. There is now a new device with three prongs in one clip (the triclip), but there has been only one case report describing its placement [4].

We conducted a study that involved 100 peptic ulcer patients with active bleeding or nonbleeding visible vessels who received endoscopic therapy with either hemoclip placement (n = 50) or triclip placement (n = 50) between May 2005 and April 2006 [5]. Primary hemostasis was achieved in 38 patients in the triclip group (76 %) and in 47 patients in the hemoclip group (94 %) (P = 0.011). Rebleeding occurred in 11 patients in the triclip group (28.9 %) and in seven patients in the hemoclip group (14.9 %) (P = 0.1625).

We found that triclip placement was limited in some patients. In bleeders located over the antrum, duodenum, and gastrojejunal anastomosis (n = 31 in the triclip group and n = 35 in the hemoclip group), primary hemostasis was obtained in 22/31 triclip patients (71 %) and in 34/35 hemoclip patients (97.1 %) (P = 0.0036). For bleeders located over difficult-to-approach sites (the posterior wall or lesser curvature of the gastric body and the posterior wall of the duodenum), primary hemostasis was achieved in 6/16 patients in the triclip group (37.5 %) and in 13/15 patients in the hemoclip group (86.7 %) (P < 0.01).

One drawback of the triclip might explain its inferior hemostatic effect: when the distal end of the endoscope was located at the antrum or duodenum, pushing the triclip outside the endoscopic sheath was a bit difficult because of bending of the triclip. This did not occur in the hemoclip group. In the Maiss study, the bleeders were fixed to the anterior wall of the gastric body, so a clinical comparison is required. In addition, if we take the cost factor into consideration (i. e. one hemoclip 8.4 USD/piece vs. one triclip 123 USD/piece), hemoclips are still the better option in clinical practice.

Competing interests: None

References

• 1 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
• 2 Lin H J, Hsieh Y H, Tseng G Y. et al . A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding.  Am J Gastroenterol. 2002;  97 2250-2254
• 3 Lo C C, Hsu P I, Lo G H. et al . Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers.  Gastrointest Endosc. 2006;  63 767-773
• 4 Gheorghe C. Endoscopic clipping focused on triclip for bleeding Dieulafoy’s lesion in the colon.  Roman J Gastroenterol. 2005;  14 79-82
• 5 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;  101 1-5 (Epub ahead of print)