Band ligation or clipping for diverticular bleeding: quite the quandary

In their recent article, Kobayashi et al. [1] analyzed the retrospective multicenter data from the CODE BLUE-J trial and reported higher efficacy of endoscopic band ligation (EBL) in colonic diverticular hemorrhage (CDH) compared with endoscopic clipping. EBL was associated with significantly lower early and late rebleeding rates, ultimately reducing the need for interventional radiology. While the present study adds to the limited literature on the use of EBL for CDH, a few issues need to be addressed.

The study, being a retrospective analysis, has a risk of selection and attrition bias. It is unclear how patients were selected for EBL versus clipping. Also, there was a significant difference in the characteristics between the patients who underwent EBL and clipping. A higher proportion of the patients in the clipping group had a systolic blood pressure ≤ 100 mmHg and hemoglobin (Hb) < 12 g/dL. The use of antiplatelet agents and corticosteroids was also higher in the clipping group. Previous studies have shown the presence of hypotension [2] [3], low Hb (≤ 11 g/dL) at admission [2], and the use of antiplatelet drugs [4] to be independent predictors of rebleeding after CDH. The significantly higher proportion of these factors in the clipping group therefore makes them susceptible to a higher risk of rebleeding. In addition, patients in the clipping group seem to have had a greater severity of bleeding, which would have contributed to their prolonged hospital stay. The use of a propensity score-matched analysis would have helped in better estimating the effects of these treatments on outcomes.

Overall, we would like to congratulate the authors for conducting this multicenter study with a large sample size. EBL seems to be a promising alternative therapy for the management of CDH, mostly in hemodynamically stable patients. Further randomized studies are needed before recommending EBL over clipping for CDH.

Publication History

Article published online:
24 February 2022

• References

• 1 Kobayashi K, Nagata N, Furumoto Y. et al. Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: a large-scale multicenter cohort study. Endoscopy 2021; DOI: 10.1055/a-1705-0921.
• 2 Joaquim N, Caldeira P, Antunes AG. et al. Risk factors for severity and recurrence of colonic diverticular bleeding. Rev Esp Enferm Dig 2017; 109: 3-9
• 3 Kitagawa T, Katayama Y, Kobori I. et al. Predictors of 90-day colonic diverticular recurrent bleeding and readmission. Intern Med 2019; 58: 2277-2282
• 4 Niikura R, Nagata N, Yamada A. et al. Recurrence of colonic diverticular bleeding and associated risk factors. Colorectal Dis 2012; 14: 302-305