Open Access
CC BY 4.0 · Endosc Int Open 2025; 13: a25367884
DOI: 10.1055/a-2536-7884
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Endoscopic band ligation alone and combined with clipping for colonic diverticular bleeding: Retrospective comparative study

Authors

  • Noritaka Ozawa

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Kenji Yamazaki

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Nae Hasebe

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Kazuki Yamauchi

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Kaori Koide

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Hiroyuki Murase

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Saeka Hayashi

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Takaaki Hino

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Daiki Hirota

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Atsushi Soga

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Kiichi Otani

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Naoya Masuda

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Hiroki Taniguchi

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Shogo Shimizu

    1   Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan (Ringgold ID: RIN68266)
  • Masahito Shimizu

    2   Department of Gastroenterology/Internal Medicine, Gifu University School of Medicine Graduate School of Medicine, Gifu, Japan (Ringgold ID: RIN38225)
 

Abstract

Clipping alone or endoscopic band ligation (EBL) alone are the main endoscopic hemostatic methods for colonic diverticular bleeding (CDB). We have established a novel method combining EBL and clipping (EBL-C) for hemostasis of CDB (Endoscopy E-videos); this study evaluated its usefulness. From March 2019 to July 2024, we endoscopically treated 138 patients for CDB at our institution. We retrospectively compared two groups: those treated with EBL (n = 24) and those treated with EBL-C (n = 56). Risk factors for early rebleeding were also examined in the EBL-C group. The rate of early rebleeding (defined as rebleeding occurring within 30 days) was lower in the EBL-C group than in the EBL group, although this difference was only marginally non-significant (8.9% vs. 25.0%, P = 0.0776). Failure of neck formation was the only independent risk factor for rebleeding (adjusted odds ratio [OR] 0.076; 95% confidence interval [CI] 0.015–0.398; P = 0.0023). Frequency of neck formation was significantly higher in the EBL-C group (EBL-C: 89.3% vs. EBL: 66.7%, P = 0.0235). Undergoing EBL-C was the only independent factor contributing to successful development of neck formation (adjusted OR 7.01; 95%CI 1.41–34.8; P = 0.0095). Previous treatment of the same diverticulum, neck formation failure, and insufficient clipping were risk factors for early rebleeding. Using EBL-C for CDB may be more effective in preventing rebleeding than using EBL alone because it facilitates better ligation of the target diverticulum. Treatment of diverticula that are hard and difficult to manage with suction remains a challenge.


Introduction

Rates of colonic diverticular bleeding (CDB) are increasing in Japan, with patients hospitalized for bloody stools accounting for approximately 60% of cases [1]. Although spontaneous hemostasis is common in this condition and mortality risk is low, the high rebleeding rate remains a clinical concern. Methods of endoscopic hemostasis include clipping, ligation, local injection, and cauterization. However, a recent large-scale Japanese cohort study (CODE BLUE-J Study) has found that, in real-world clinical practice, clipping (57.2%) and ligation (41.0%) are most commonly used [2]. Clipping can be either direct or achieved via a diverticulum closure [3]. Meanwhile, ligation is broadly divided into endoscopic band ligation (EBL) and endoscopic detachable snare ligation [4]. Some recent studies have suggested that EBL may be more effective than clipping at preventing both early (within 30 days) and late (30 days to 1 year) rebleeding [5] [6] [7], especially in cases involving active bleeding and right colon bleeding [2]. Although several previous studies have compared the efficacy of either method alone, combined use of these methods has not been assessed. We have previously reported on combined use of EBL and clipping (EBL-C) for a bleeding diverticulum, which involves hemostasis by direct clipping with a repositionable clip, followed by aspiration and bowel inversion for each clip [8]. Since November 2021, our first-choice method of hemostasis has been EBL-C, except for patients at risk of perforation due to long-term steroid therapy or maintenance dialysis. In this study, we aimed to compare clinical outcomes of EBL-C with those of EBL.


Patients and methods

Patients and study design

From March 2019 to July 2024, we conducted a retrospective review of medical records from 138 patients with CDB definitively diagnosed with stigmata of recent hemorrhage who underwent endoscopic hemostasis procedures at our department. Procedures included clipping (n = 50), EBL (n = 24), EBL-C (n = 56), and over-the-scope clipping (OTSC) (n = 8). We analyzed 80 cases treated with ligation procedures (EBL or EBL-C). EBL and EBL-C involve band ligation, and patients with a risk of perforation associated with ligation (e.g., those on maintenance dialysis or long-term steroid therapy) were excluded. In addition, cases in which diverticulum inversion was technically challenging were excluded due to difficulty of performing ligation. These patients were primarily treated using the clipping method.

We investigated overall treatment outcomes in patients who underwent ligation procedures (EBL or EBL-C). Subsequently, we compared patient characteristics and treatment outcomes between the EBL-C and EBL groups. Patient characteristics were comparable between both groups, including age, sex, underlying conditions, and medication use (e.g., antiplatelet agents, nonsteroidal anti-inflammatory drugs) ([Table 1]).

Table 1 Characteristics of patients treated with EBL or EBL-C.

EBL (n = 24)

EBL-C (n = 56)

P value

*Recent hemostasis is defined as hemostasis to the same diverticulum within 30 days.

Definitive cases: Treatment history of the same diverticulum was confirmed.

Possible cases: Treatment history of the same diverticulum could not be ruled out.

§Past hemostasis is defined as hemostasis to the same diverticulum more than 30 days prior.

Fisher's exact test.

CT, computed tomography; DAPT, dual antiplatelet therapy; EBL, endoscopic band ligation; EBL-C, endoscopic band ligation plus clipping; NSAID, nonsteroidal anti-inflammatory drug; PEG, polyethylene glycol.

Age ≥ 70 years, n (%)

17 (70.8)

40 (71.4)

1

Sex, male, n (%)

15 (62.5)

27 (48.2)

0.329

Hypertension, n (%)

16 (66.7)

38 (67.9)

1

Antiplatelet agent, n (%)

6 (25)

19 (33.9)

0.599

Anticoagulant, n (%)

2 (8.3)

6 (10.7)

0.266

DAPT, n (%)

1 (4.17)

8 (14.3)

0.266

NSAIDs, n (%)

5 (20.8)

8 (14.3)

0.516

Bowel preparation (use of PEG solution), n (%)

12 (50)

22 (39.3)

0.461

Extravasation on contrast-enhanced CT, n (%)

9/20 (45)

30/49 (61.2)

0.286

Recent hemostasis* (< 30 days)
(definitive cases+ possible cases) n (%)

2 (8.3)

3 (5.4)

0.633

Past hemostasis§ (> 30 days)
(definitive cases + possible cases) n (%)

3 (0)

11 (3.6)

1

Location, left-side colon, n (%)

9 (26.8)

15 (36)

0.426

Use of long attachment cap, n (%)

22 (91.7)

53 (94.6)

0.633


Methods and devices

Identifying the responsible diverticulum is crucial. Therefore, performing bowel preparation within 24 hours and conducting the examination using a long hood attachment are recommended [9] [10] [11]. In addition, the identification rate increases when contrast-enhanced computed tomography (CT) shows evidence of extravasation [12] [13]. Therefore, our hospital prioritizes performing contrast-enhanced CT whenever CDB is suspected. We recommend endoscopic examination after bowel preparation with polyethylene glycol within 24 hours. However, when extravasation is clearly visible on contrast-enhanced CT scans or the patient is hemodynamically unstable, emergency endoscopy may be conducted without bowel preparation at the attending physician’s discretion.

We used a water-jet scope, fitted with a long attachment cap, a SureClip (Micro-Tech Co., Nanjing, China), and an EBL device (Sumitomo Bakelite Co., Ltd., Tokyo, Japan).


EBL-C procedure

EBL-C was conducted as follows ([Fig. 1]) ([Video 1]).

  1. Fit the long attachment cap. Once the bleeding diverticulum is identified, perform hemostasis by direct clipping (SureClip; Micro-Tech Co).

  2. Withdraw the scope, fit the EBL device (Sumitomo Bakelite Co., Ltd.), and reinsert it. Suction the bleeding diverticulum containing the clip as far as possible, then release the O-ring. If suction and inversion are sufficient, ligation with the O-ring will have caused formation of a neck, indicating effective ligation ([Fig. 2]).

Zoom
Fig. 1 Schema of the EBL-C method.
Endoscopic hemostasis of colonic diverticular bleeding by combining endoscopic band ligation (EBL) and clipping.Video 1

Zoom
Fig. 2 Success and failure of the EBL-C procedure.

Statistical analysis

We used Fisher’s exact test for comparisons of categorical variables and a Mann–Whitney U test of the comparisons of continuous variables between groups. The association between endoscopic treatment and clinical outcomes was analyzed using univariate and multivariate logistic regression models. P < 0.05 was considered statistically significant. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan).


Definition of terms

We focused on presence or absence of treatment history for the same diverticulum.

In cases of early rebleeding (within 30 days), identifying the same diverticulum was often possible based on evidence of prior procedures, such as residual clips or ulcers formed by EBL.

Conversely, identifying the same diverticulum after a longer period is often more challenging, but anatomical landmarks like the appendix or Bauhin's valve, as well as scarring, could aid determination. In addition, contrast-enhanced CT or endoscopy sometimes confirmed bleeding at a different site, ruling out involvement of the same diverticulum. Thus, we distinguished between definitive cases, in which treatment history of the same diverticulum was confirmed, and possible cases, in which involvement of the same diverticulum could not be ruled out.



Results

Among patients who underwent ligation procedures (EBL or EBL-C) (n = 80), 11 cases (13.6%) experienced early rebleeding (within 30 days). In multivariate analysis of risk factors for early rebleeding, failure of neck formation was the only independent risk factor for rebleeding (adjusted odds ratio [OR] 0.076; 95% confidence interval [CI] 0.015–0.398; P = 0.0023) ([Table 2]). Neck formation was achieved in 66 cases (82.5%) and undergoing EBL-C was the only independent factor contributing to successful development of neck formation (adjusted OR 7.01; 95% CI 1.41–34.8; P = 0.0095) ([Table 3]).

Table 2 Early rebleeding risks after ligation therapy on logistic regression analyses.

Early rebleeding
(n = 11)

No rebleeding
(n = 69)

Crude OR
(95%CI)

P value

Adjusted OR
(95%CI)

P value

CI, confidence interval; DAPT, dual antiplatelet therapy; EBL-C, endoscopic band ligation plus clipping; NSAID, nonsteroidal anti-inflammatory drug; OR, odds ratio.

Age ≥ 70 years, n (%)

9 (81.8)

48(69.6)

1.97
(0.39–9.91)

0.411

Sex, female, n (%)

3 (27.3)

3(27.3)

2.75
(0.67–11.2)

0.16

1.92
(0.31–11.7)

0.48

Hypertension, n (%)

9 (81.8)

45(65.2)

2.4
(0.48–12.0)

0.287

Diabetes, n (%)

1 (9.1)

14(20.1)

0.393
(0.04–3.33)

0.392

Antiplatelet agent, n (%)

3 (27.3)

22(31.9)

0.801
(0.19–3.32)

0.76

Anticoagulant, n (%)

2 (18.2)

6(8.7)

2.38
(0.41–13.4)

0.342

DAPT, n (%)

1 (9.1)

8(11.6)

0.763
(0.09–6.77)

0.808

NSAIDs, n (%)

3 (27.3)

10(14.5)

2.21
(0.5–9.78)

0.295

Bowel preparation, n (%)

3 (27.3)

31(44.9)

0.46
(0.11–1.88)

0.28

Recent hemostasis (< 30 days) (definitive + possible), n (%)

2 (18.2)

3(4.3)

4.89
(0.72–33.3)

0.105

4.22
(0.25–72.7)

0.322

Past hemostasis (> 30 days) (definitive + possible), n (%)

2 (18.2)

12(17.4)

1.06
(0.2–5.52)

0.949

Location, left-side colon, n (%)

5 (45.5)

19(27.5)

2.19
(0.59–8.04)

0.236

Use of long attachment cap, n (%)

9 (81.8)

66(95.7)

4.89
(0.72–33.3)

0.105

1.93
(0.17–22.4)

0.597

Neck formation (+), n (%)

4 (36.4)

62(89.9)

0.0645
(0.015–0.277)

0.000225

0.076
(0.015–0.398)

0.00227

EBL-C, n (%)

5 (45.5)

51(73.9)

0.294
(0.079–1.08)

0.0656

0.59
(0.12–2.82)

0.509

Table 3 Factors associated with neck formation after ligation therapy on logistic regression analyses.

Neck formation (+)
(n = 66)

Neck formation (-)
(n = 14)

Crude OR
(95%CI)

P value

Adjusted OR
(95%CI)

P value

DAPT, dual antiplatelet therapy; EBL-C, endoscopic band ligation plus clipping; NSAID, nonsteroidal anti-inflammatory drug; OR, odds ratio.

Age ≥ 70 years, n (%)

45 (68.1)

12 (85.7)

0.357
(0.073–1.74)

0.203

0.297
(0.039–2.24)

0.238

Sex, female, n (%)

35 (53.0)

3 (21.4)

0.242
(0.062–0.95)

0.0414

0.3
(0.048–1.86)

0.195

Hypertension, n (%)

41 (62.1)

13 (92.9)

0.126
(0.0156–1.02)

0.0526

0.0682
(0.0031–1.49)

0.0879

Diabetes, n (%)

13 (19.7)

2 (14.3)

1.47
(0.29–7.40)

0.639

Antiplatelet agent, n (%)

18 (27.3)

7 (50)

0.375
(0.115–1.22)

0.103

0.794
(0.14–4.55)

0.796

Anticoagulant, n (%)

5 (7.6)

3 (21.4)

0.301
(0.063–1.44)

0.133

0.183
(0.022–1.51)

0.114

DAPT, n (%)

8 (12.1)

1 (7.1)

1.79
(0.206–15.6)

0.597

NSAIDs, n (%)

11 (16.7)

2 (14.3)

1.2
(0.24–6.13)

0.827

Bowel preparation, n (%)

29 (43.9)

5 (35.7)

1.41
(0.43–4.67)

0.573

Recent hemostasis (< 30 days)
(definitive + possible), n (%)

2 (3.0)

3 (21.4)

0.115
(0.017–0.77)

0.0254

0.126
(0.0086–1.85)

0.131

Past hemostasis (> 30 days)
(definitive + possible), n (%)

13 (19.7)

1 (7.1)

3.19
(0.38–26.6)

0.284

Location, left-side colon, n (%)

20 (30.3)

4 (28.6)

1.09
(0.304–3.88)

0.898

Use of long attachment cap, n (%)

3 (4.5)

2 (14.3)

0.286
(0.043–1.90)

0.195

0.394
(0.0387–4.01)

0.431

EBL-C, n (%)

50 (75.6)

6 (42.9)

4.17
(1.26–13.8)

0.0196

7.01
(1.41–34.8)

0.0095

The early rebleeding rate (rebleeding within 30 days) was lower in the EBL-C group than in the EBL group, although this difference was only marginally non-significant (8.9% vs. 25.0%, P = 0.0776). Over the 1-year follow-up period, the late rebleeding rate (rebleeding between 30 days and 1 year) was also lower in the EBL-C group than in the EBL group, but the difference was non-significant (2.4% vs. 8.3%, P = 0.0549). Conversely, the frequency of neck formation, considered a factor potentially reducing rebleeding risk, was significantly higher in the EBL-C group (EBL-C: 89.3% vs. EBL: 66.7%, P = 0.0235). There were no significant differences in use of red blood cell transfusion, treatment time, or hospitalization duration ([Table 4]).

Table 4 Outcomes of patients treated with EBL or EBL-C.

EBL
(n = 24)

EBL-C
(n = 56)

P value

*Early rebleeding: rebleeding that occurs within 30 days following the initial hemostasis.

Late rebleeding: rebleeding that occurs between 30 days and 1 year (or 2 years) following initial hemostasis.

Time to hemostasis was defined as time to hemostasis complete after identifying the bleeding site.

§EBL procedure time was defined as time to hemostasis complete after initial clipping.

Fisher's exact test.

††Mann–Whitney U test.

EBL, endoscopic band ligation; EBL-C, endoscopic band ligation plus clipping.

Neck formation, n (%)

16 (66.7)

50 (89.3)

0.0235

Early rebleeding*, n (%)

6 (25)

5 (8.9)

0.0776

Late rebleeding within 2 years, n (%)

2/24 (8.3)

1/27 (3.7)

0.187

Late rebleeding within 1 year, n (%)

2/24 (8.3)

1/41 (2.4)

0.0549

Time to hemostasis, median (range), min

20 (7–46)

21 (7–47)

0.871††

EBL procedure time§, median (range), min

15 (7–25)

15 (4–42)

0.617††

Transfusion, n (%)

11 (45.8)

29 (51.8)

0.808

Length of hospital stay after hemostasis, median (range), day

6 (4–23)

5 (1–14)

0.208††

Complications, n (%)

0 (0)

0 (0)

NA

Rebleeding risk was examined in the EBL-C group. A definitive history of treatment for the same diverticulum over 30 days prior was significantly associated with higher risk of rebleeding. No other background factors were found to be significant ([Table 5]).

Table 5 Patient-related risk factors for early rebleeding after EBL-C on Fisher‘s exact test.

Early rebleeding
(n = 5)

No rebleeding
(n = 51)

P value*

*Fisher’s exact text.

CT, computed tomography; DAPT, dual antiplatelet therapy; EBL-C, endoscopic band ligation plus clipping; NSAID, nonsteroidal anti-inflammatory drug.

Age ≥ 70 years, n (%)

4 (80)

36 (70.6)

1

Sex, male, n (%)

3 (60)

20 (39.2)

1

Hypertension, n (%)

5 (100)

33 (64.7)

0.164

Diabetes, n (%)

0 (0)

12 (23.5)

0.574

Antiplatelet agent, n (%)

2 (40)

17 (33.3)

1

Anticoagulant, n (%)

2 (40)

4 (7.8)

0.0836

DAPT, n (%)

1 (20)

7 (13.7)

0.522

NSAIDs, n (%)

1 (20)

7 (13.7)

0.552

Bowel preparation, n (%)

1 (20)

21 (41.2)

0.638

Early colonoscopy, n (%)

3 (60)

36 (70.6)

0.634

Extravasation on contrast-enhanced CT, n (%)

4/5 (80)

26/44 (59.1)

0.636

Use of long attachment cap, n (%)

4 (80)

49 (96.1)

0.249

Recent hemostasis (definitive), n (%)

0 (0)

3 (5.9)

1

Recent hemostasis (definitive + possible), n (%)

0 (0)

3 (5.9)

1

Past hemostasis (definitive), n (%)

2 (40)

0 (0)

0.00649

Past hemostasis (definitive + possible), n (%)

2 (40)

9 (17.6)

0.251

Location, right-side colon, n (%)

3 (60)

38 (74.5)

0.602

Among procedure-related factors, rates of no neck formation and insufficient clipping were higher in the early rebleeding group than in the comparison group ([Table 6]).

Table 6 Procedure-related risk factors for early rebleeding after EBL-C on Fisher’s exact test.

Early rebleeding
(n = 5)

No rebleeding
(n = 51)

P value

*Cases of insufficient hemostasis with initial clipping.

Fisher's exact test.

EBL-C, endoscopic band ligation plus clipping.

Neck formation (-), n (%)

3 (60)

3 (5.9)

0.00661 *

Insufficient clipping)†, n (%)

3 (60)

4 (7.8)

0.0112 *

Among the EBL-C patients (n = 56), 44 (78.6%) successfully achieved both clip hemostasis and neck formation, with none experiencing early rebleeding (0/44). However, 11 patients (19.6%) had either unsuccessful clip hemostasis or neck formation, and early rebleeding occurred in four of them (36.4%). In addition, one patient (1.8%) had both unsuccessful clip hemostasis and neck formation and experienced early rebleeding. No complications occurred in either group.

Regarding rebleeding cases, rebleeding from the same diverticulum was observed in eight cases in the EBL group (early: 6, late: 2) and six in the EBL-C group (early: 5, late: 1). Methods of hemostasis for rebleeding EBL cases were as follows: for the six early rebleeding cases, one was treated with EBL-C, three with clipping, one achieved spontaneous hemostasis, and one was treated with OTSC. For the two late rebleeding cases, one was treated with EBL and one achieved spontaneous hemostasis. For rebleeding EBL-C cases, hemostasis methods were as follows: for the five early rebleeding cases, four were treated with OTSC and one with clipping. For the one late rebleeding case, EBL-C was performed. None of the five rebleeding cases treated with OTSC experienced rebleeding again.

In this study, there were seven definitive cases of treatment history in the same diverticulum.

There were five definitive cases of recent treatment history (within 30 days), including four treated with clipping and one with EBL. Among the clipping cases, the clips had dislodged in two cases and remained in place in two cases. The bands had dislodged, resulting in ulcer formation. There were two definitive cases of past treatment history (over 30 days prior), including one treated with EBL and one with EBL-C. In both definitive cases of past treatment history (over 30 days prior), clips and bands had dislodged, and although scarring was observed, the diverticulum itself remained. Both cases were treated with EBL-C, but early rebleeding occurred in both cases.


Discussion

Unsuccessful neck formation was a risk factor for early rebleeding in ligation procedures. In EBL-C, which involves performing EBL after placing a clip, the rate of neck formation was higher compared with EBL alone, suggesting a potential reduction in rebleeding risk.

EBL-C is a simple procedure with several advantages. First, it involves hemostasis at two different parts of the vessel using different methods: clipping the exposed part of the vessel and using EBL on the non-exposed part. This dual approach enhances the hemostatic force, potentially increasing the effectiveness of rebleeding prevention.

Conventional EBL involves marking the vicinity of the bleeding diverticulum, which may prove difficult to identify while placing the EBL device and reinserting the scope. In EBL-C, because the bleeding diverticulum itself is clipped, there is no chance that it will be misidentified or overlooked, and EBL can be conducted with confidence.

In addition, in conventional EBL, after the vicinity of the diverticulum is marked with a clip, it continues to bleed while the scope is being temporarily withdrawn to place the EBL device before reinserting the scope, which can cause hemodynamic fluctuations and obscure the visual field. In EBL-C, because the bleeding diverticulum itself is clipped to stop the bleeding, hemostasis is usually achieved, and thus, the operator can continue the procedure without feeling under pressure.

Depending on the location of the responsible diverticulum, obtaining a frontal view may be difficult. With conventional EBL, the surrounding mucosa may be aspirated, making it challenging to invert the diverticulum. By performing EBL after clipping, we have managed multiple cases in which the clip acted as an axis, making it easier to identify the diverticulum center and perform aspiration. These experiences formed the basis for developing the EBL-C method.

Some concerns involve risk that presence of a clip within the diverticulum in EBL-C might make it difficult to fully pull the diverticulum into the EBL device during suction. However, in this study, the EBL-C group showed a significantly higher rate of neck formation (EBL-C 89.3% vs. EBL 66.7%, P = 0.0235). In practice, we seldom had the impression during the procedure that the diverticulum could not be fully pulled into the device. This suggests that presence of the clip may support sufficient suction by aligning the axis of aspiration.

Although we used maximum suction strength, we have not experienced a case in which the clip was dislodged by this suction. This procedure may require use of clips with a strong gripping force, such as a SureClip. Evidence from comparative studies involving other clips is required.

EBL-C patients who developed rebleeding had insufficient clipping and unsuccessful neck formation. Early rebleeding did not occur in any patients without these characteristics, and their risk of rebleeding can be regarded as extremely low. Conversely, if either of these characteristics is present, risk of rebleeding is high, and additional preventive treatment should be considered. Furthermore, both patients with definitive histories of past hemostasis for the same diverticulum experienced rebleeding. Absence of neck formation and a history of past hemostasis for the same diverticulum may both reflect hardness of the diverticulum.

EBL is considered challenging to perform when the diverticulum is hard because it makes suction and inversion difficult. In such cases, OTSC (Ovesco Endoscopy, Tübingen, Germany) reportedly is effective [14] [15]. In this study, we conducted hemostasis using OTSC for patients who developed early rebleeding after ligation procedures (either EBL or EBL-C), with good outcomes. Data on use of OTSC for CDB are scarce and OTSC is associated with risk of complications, high cost, and extended treatment time. Further studies are required to verify whether OTSC should be recommended for all patients with risk factors for rebleeding.

There are many reports evaluating risk of rebleeding based on patient characteristics and diverticular features before treatment [16] [17] [18] [19]. However, few studies have assessed risk of rebleeding according to procedure-related factors, such as post-ligation morphology. The only report examining complete eversion as a risk factor for bleeding showed a trend toward lower frequency of complete eversion in the rebleeding group, although no statistically significant differences were observed [20]. If the rebleeding risk could be assessed immediately after the procedure, this would be significant for CDB treatment, which has a higher risk of rebleeding and hemodynamic instability compared with other conditions.

Limitations of this study include a retrospective single-center design and small sample size. In addition, this study may be affected by sampling bias because treatment methods varied across different time periods. To further prove its efficacy, it will be necessary to conduct multicenter, randomized, controlled trials and accumulate evidence.


Conclusions

In conclusion, EBL-C for CDB may be more effective in preventing rebleeding than EBL alone because it facilitates better ligation of the target diverticulum.



Conflict of Interest

The authors declare that they have no conflict of interest.

  • References

  • 1 Nagata N, Kobayashi K, Yamauchi A. et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J Study. Am J Gastroenterol 2021; 116: 2222-2234
  • 2 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 2022; 54: 735-744
  • 3 Kishino T, Nagata N, Kobayashi K. et al. Endoscopic direct clipping versus indirect clipping for colonic diverticular bleeding: A large multicenter cohort study. United European Gastroenterol J 2022; 10: 93-103
  • 4 Akutsu D, Narasaka T, Wakayama M. et al. Endoscopic detachable snare ligation: A new treatment method for colonic diverticular hemorrhage. Endoscopy 2015; 47: 1039-1042
  • 5 Nakano K, Ishii N, Ikeya T. et al. Comparison of long-term outcomes between endoscopic band ligation and endoscopic clipping for colonic diverticular hemorrhage. Endosc Int Open 2015; 3: E529-E533
  • 6 Nagata N, Ishii N, Kaise M. et al. Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping. Gastrointest Endosc 2018; 88: 841-853.e4
  • 7 Tsuruoka N, Takedomi H, Sakata Y. et al. Recent trends in treatment for colonic diverticular bleeding in Japan. Digestion 2020; 101: 12-17
  • 8 Ozawa N, Yamazaki K, Koizumi H. et al. Novel method combining endoscopic band ligation and clipping for hemostasis of colonic diverticular bleeding. Endoscopy 2023; 55: E887-E888
  • 9 Niikura R, Nagata N, Aoki T. et al. Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding. J Clin Gastroenterol 2015; 49: e24-e30
  • 10 Pasha SF, Shergill A, Acosta RD. et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79: 875-885
  • 11 Kobayashi M, Akiyama S, Narasaka T. et al. Multicenter propensity score-matched analysis comparing short versus long cap-assisted colonoscopy for acute hematochezia. JGH Open 2023; 7: 487-496
  • 12 Sugiyama T, Hirata Y, Kojima Y. et al. Efficacy of contrast-enhanced computed tomography for the treatment strategy of colonic diverticular bleeding. Intern Med 2015; 54: 2961-2967
  • 13 Nakatsu S, Yasuda H, Maehata T. et al. Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Intern Med 2015; 54: 553-558
  • 14 Kawano K, Takenaka M, Kawano R. et al. Efficacy of over-the-scope clip method as a novel hemostatic therapy for colonic diverticular bleeding. J Clin Med 2021; 10: 2891
  • 15 Yamazaki K, Maruta A, Taniguchi H. et al. Endoscopic treatment of colonic diverticular bleeding with an over-the-scope clip after failure of endoscopic band ligation. VideoGIE 2020; 5: 252-254
  • 16 Yamauchi A, Ishii N, Yamada A. et al. Outcomes and recurrent bleeding risks of detachable snare and band ligation for colonic diverticular bleeding: a multicenter retrospective cohort study. Gastrointest Endosc 2023; 98: 1
  • 17 Yamauchi A, Kou T, Kishimoto T. et al. Risk factor analysis for early rebleeding after endoscopic treatment for colonic diverticular bleeding with stigmata of recent hemorrhage. JGH Open 2021; 5: 573-579
  • 18 Nishikawa H, Maruo T, Tsumura T. et al. Risk factors associated with recurrent hemorrhage after the initial improvement of colonic diverticular bleeding. Acta Gastroenterol Belg 2013; 76: 20-24
  • 19 Kawanishi K, Kato J, Kakimoto T. et al. Risk of colonic diverticular rebleeding according to endoscopic appearance. Endosc Int Open 2018; 6: E36-E42
  • 20 Ikeya T, Ishii N, Nakano K. et al. Risk factors for early rebleeding after endoscopic band ligation for colonic diverticular hemorrhage. Endosc Int Open 2015; 3: E523-E528

Correspondence

Kenji Yamazaki
Department of Gastroenterology, Gifu Prefectural General Medical Center
4-6-1, Noishiki
500-8717 Gifu
Japan   

Publikationsverlauf

Eingereicht: 03. Juli 2024

Angenommen nach Revision: 21. Januar 2025

Accepted Manuscript online:
10. Februar 2025

Artikel online veröffentlicht:
14. März 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Bibliographical Record
Noritaka Ozawa, Kenji Yamazaki, Nae Hasebe, Kazuki Yamauchi, Kaori Koide, Hiroyuki Murase, Saeka Hayashi, Takaaki Hino, Daiki Hirota, Atsushi Soga, Kiichi Otani, Naoya Masuda, Hiroki Taniguchi, Shogo Shimizu, Masahito Shimizu. Endoscopic band ligation alone and combined with clipping for colonic diverticular bleeding: Retrospective comparative study. Endosc Int Open 2025; 13: a25367884.
DOI: 10.1055/a-2536-7884
  • References

  • 1 Nagata N, Kobayashi K, Yamauchi A. et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J Study. Am J Gastroenterol 2021; 116: 2222-2234
  • 2 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 2022; 54: 735-744
  • 3 Kishino T, Nagata N, Kobayashi K. et al. Endoscopic direct clipping versus indirect clipping for colonic diverticular bleeding: A large multicenter cohort study. United European Gastroenterol J 2022; 10: 93-103
  • 4 Akutsu D, Narasaka T, Wakayama M. et al. Endoscopic detachable snare ligation: A new treatment method for colonic diverticular hemorrhage. Endoscopy 2015; 47: 1039-1042
  • 5 Nakano K, Ishii N, Ikeya T. et al. Comparison of long-term outcomes between endoscopic band ligation and endoscopic clipping for colonic diverticular hemorrhage. Endosc Int Open 2015; 3: E529-E533
  • 6 Nagata N, Ishii N, Kaise M. et al. Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping. Gastrointest Endosc 2018; 88: 841-853.e4
  • 7 Tsuruoka N, Takedomi H, Sakata Y. et al. Recent trends in treatment for colonic diverticular bleeding in Japan. Digestion 2020; 101: 12-17
  • 8 Ozawa N, Yamazaki K, Koizumi H. et al. Novel method combining endoscopic band ligation and clipping for hemostasis of colonic diverticular bleeding. Endoscopy 2023; 55: E887-E888
  • 9 Niikura R, Nagata N, Aoki T. et al. Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding. J Clin Gastroenterol 2015; 49: e24-e30
  • 10 Pasha SF, Shergill A, Acosta RD. et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79: 875-885
  • 11 Kobayashi M, Akiyama S, Narasaka T. et al. Multicenter propensity score-matched analysis comparing short versus long cap-assisted colonoscopy for acute hematochezia. JGH Open 2023; 7: 487-496
  • 12 Sugiyama T, Hirata Y, Kojima Y. et al. Efficacy of contrast-enhanced computed tomography for the treatment strategy of colonic diverticular bleeding. Intern Med 2015; 54: 2961-2967
  • 13 Nakatsu S, Yasuda H, Maehata T. et al. Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Intern Med 2015; 54: 553-558
  • 14 Kawano K, Takenaka M, Kawano R. et al. Efficacy of over-the-scope clip method as a novel hemostatic therapy for colonic diverticular bleeding. J Clin Med 2021; 10: 2891
  • 15 Yamazaki K, Maruta A, Taniguchi H. et al. Endoscopic treatment of colonic diverticular bleeding with an over-the-scope clip after failure of endoscopic band ligation. VideoGIE 2020; 5: 252-254
  • 16 Yamauchi A, Ishii N, Yamada A. et al. Outcomes and recurrent bleeding risks of detachable snare and band ligation for colonic diverticular bleeding: a multicenter retrospective cohort study. Gastrointest Endosc 2023; 98: 1
  • 17 Yamauchi A, Kou T, Kishimoto T. et al. Risk factor analysis for early rebleeding after endoscopic treatment for colonic diverticular bleeding with stigmata of recent hemorrhage. JGH Open 2021; 5: 573-579
  • 18 Nishikawa H, Maruo T, Tsumura T. et al. Risk factors associated with recurrent hemorrhage after the initial improvement of colonic diverticular bleeding. Acta Gastroenterol Belg 2013; 76: 20-24
  • 19 Kawanishi K, Kato J, Kakimoto T. et al. Risk of colonic diverticular rebleeding according to endoscopic appearance. Endosc Int Open 2018; 6: E36-E42
  • 20 Ikeya T, Ishii N, Nakano K. et al. Risk factors for early rebleeding after endoscopic band ligation for colonic diverticular hemorrhage. Endosc Int Open 2015; 3: E523-E528

Zoom
Fig. 1 Schema of the EBL-C method.
Zoom
Fig. 2 Success and failure of the EBL-C procedure.