Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers:: A meta-analysis of controlled trials

BACKGROUND: There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy. METHODS: A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis. RESULTS: Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44 - 0.80], P = 0.0001) and the risk of emergency surgery (OR 0.66 [0.49 - 0.89], P = 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46 - 1.02], P = 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45 - 2.45] for rebleeding, 0.49 [0.50 - 4.87] for surgery, and 1.28 [0.34 - 4.86] for death) or thermal therapy alone (OR 0.67 [0.40 - 1.20] for rebleeding, 0.89 [0.45 - 1.76] for surgery, and 0.51 [0.24 - 1.10] for death). CONCLUSIONS: Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.