Second-look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: a meta-analysis.

BACKGROUND AND AIMS In the management of peptic ulcer bleeding, the benefits of second-look endoscopic treatment with thermal coagulation or injections in controlling recurrent bleeding is unsure. This study set out to compare efficacy of routine second-look endoscopy with treatment using either thermal coagulation or injections versus single endoscopy by pooling data from published work. METHODS Full publications in the English-language published work as well as abstracts in major international conferences were searched over the past 10 years, and six trials fulfilling the search criteria were found. Outcome measurements included: (i) recurrent bleeding; (ii) requirement of surgical intervention; and (iii) mortality. We examined heterogeneity of trials and pooled the effects by meta-analysis. The quality of studies was graded according to the prospective randomization, methods of patient allocation, the list of exclusion criteria, outcome definitions and the predefined salvage procedures for uncontrolled bleeding. RESULTS Among 998 patients recruited in these five randomized trials, 119 received routine second-look endoscopy with thermal coagulation, and 374 received second-look with endoscopic injection and 505 had single endoscopic therapy. Less recurrent bleeding was reported after thermal coagulation (4.2%) than single endoscopy (15.7%) (relative risk [RR] = 0.29; 95% confidence interval [CI] = 0.11-0.73), but no reduction was reported for the requirement of surgical intervention and all-cause mortality. Injection therapy did not reduce re-bleeding (17.6%) when compared to single endoscopy (20.8%; RR = 0.85; 95% CI = 0.63-1.14), requirement for surgery and mortality. CONCLUSION Routine second-look endoscopy with thermal coagulation, but not injection therapy, reduced recurrent peptic ulcer bleeding. There is no proven benefit in reducing surgical intervention and overall mortality.