Comparison of Endoscopic Hot Biopsy Forceps Coagulation and Hemostatic Clips for High-Risk Bleeding Peptic Ulcers

Comparison of Endoscopic Hot Biopsy Forceps Coagulation and Hemostatic Clips for High-Risk Bleeding Peptic Ulcers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Endoscopic Hot Biopsy Forceps Coagulation and Hemostatic Clips for High-Risk Bleeding Peptic Ulcers Xiaolan Wang, Tao Cai, Hongwen Tian, Shuang Deng, Yinkui Liu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7601400/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Acute upper gastrointestinal bleeding (AUGIB) remains a major clinical emergency with significant morbidity and mortality, with peptic ulcers being the predominant etiology. Optimizing endoscopic hemostatic strategies for high-risk bleeding ulcers is therefore of critical importance. METHODS This retrospective study evaluated 58 patients with bleeding peptic ulcers classified as Forrest Ia, Ib, IIa, and IIb, who underwent endoscopic hemostasis between 2019 and 2024. Of these, 35 patients received hot biopsy forceps coagulation (Group A), while 23 were treated with hemostatic clips placement (Group B). Clinical outcomes including primary hemostasis success and 7-day rebleeding rates were analyzed. RESULTS The results showed that there was no statistically significant difference (P > 0.05) between the two groups in the success rate of first hemostasis (91.43% vs. 82.61%) and the 7-day rebleeding rate (12.50% vs. 0%), but subgroup analyses revealed a critical threshold effect: for ≥ 1 cm ulcers, the success rate of hemostasis in the hot biopsy forceps coagulation-hemostasis group was significantly superior to that of hemostatic clips (88.24% vs. 33.33%, P = 0.0212), while both reached high efficiency in the < 1cm group (94.44% vs. 100%). Further analysis showed that hot biopsy forceps electrocoagulation hemostasis failure was significantly correlated with bleeding vessel diameter ≥ 2.2mm (4.0mm vs. 2.19mm, P = 0.042), while hemostatic clips failure was positively correlated with ulcer size (1.125cm vs. 0.616cm, P = 0.003). CONCLUSION Hot biopsy forceps coagulation offers a cost-effective and efficient option for managing bleeding ulcers ≥ 1 cm or those involving large-caliber vessels (≤ 2.2mm). Ulcer diameter of 1 cm and vessel diameter of 2.2mm may serve as critical thresholds for stratifying endoscopic hemostatic approaches, providing a foundation for individualized, evidence-based treatment strategies. Ulcers Upper gastrointestinal endoscopy Non-variceal bleeding Figures Figure 1 Figure 2 INTRODUCTION Acute upper gastrointestinal bleeding (AUGIB) remains a common and serious clinical emergency. Although its incidence has declined in recent years, associated mortality rates remain high, ranging from 7.4% to 20.9%[ 1 , 2 ]. Peptic ulcer is the most common cause of non-variceal upper GI bleeding[ 3 ]. For patients with high-risk stigmata of hemorrhage—such as Forrest Ia, Ib, and IIa lesions—endoscopic hemostasis is preferred over pharmacologic therapy as the primary intervention[ 4 , 5 ] . Current endoscopic hemostatic modalities include injection therapy, thermal coagulation (both contact and non-contact methods), mechanical compression (e.g., clips), and topical application of hemostatic powders[ 6 ]. Among these, hot biopsy forceps represent a contact thermal technique using insulated monopolar electrocoagulation. This device enables simultaneous tissue biopsy and coagulation and has been widely applied in the removal of small colonic polyps and treatment of gastrointestinal vascular lesions[ 7 ]. However, clinical evidence on the use of hot biopsy forceps for managing peptic ulcers with high bleeding risk remains limited. Preliminary studies suggest this method may enhance immediate hemostasis, reduce short-term rebleeding, and carry a favorable safety profile. While advanced tools such as monopolar hemostatic forceps and over-the-scope clips offer high efficacy and low rebleeding rates, their high cost may limit widespread use. Therefore, exploring simpler and more cost-effective alternatives remains clinically important. The objective of this study was to assess the efficacy and safety of monopolar electrocoagulation using hot biopsy forceps in the endoscopic management of high-risk bleeding peptic ulcers, with the goal of minimizing the need for emergency interventions and reducing mortality. METHODS Participants Patients presenting with hematemesis and/or melena who were diagnosed with gastric, duodenal, or anastomotic ulcers within 24 hours via emergency gastroscopy were retrospectively enrolled from January 2019 to December 2024. Eligible cases included ulcers classified as Forrest Ia, Ib, or IIa, all of whom underwent urgent endoscopic hemostatic intervention. Exclusion criteria were as follows: inability or unwillingness to provide written informed consent; bleeding secondary to gastric malignancy; pregnancy; coagulopathy (defined as platelet count < 50,000/mm³, prothrombin activity < 30%, or current use of anticoagulant medications); and cases involving multiple bleeding sources. Based on the endoscopic hemostasis modality used, patients were categorized into two groups: Group A (n = 35), treated with monopolar electrocoagulation using hot biopsy forceps, and Group B (n = 23), treated with hemostatic clips placement. All patients and/or their legal guardians provided written informed consent prior to undergoing gastroscopy and endoscopic hemostatic procedures. All interventions were performed by experienced gastroenterologists with expertise in emergency endoscopic hemostasis. The Ethics Committee of Shuangliu District First People's Hospital (Chengdu, China) approved the study. Interventions All procedures were performed using a gastroscope equipped with a water jet function (GIF-H260J; Olympus Optical Co., Japan). In Group A , patients underwent thermal coagulation using hot biopsy forceps. The procedure utilized a high-frequency electrocoagulation generator (AIBO VI0300S+), in conjunction with thermal biopsy forceps (Model HBF-23/2000, Nanjing Microtronics). Under direct visualization, the forceps were applied to the bleeding point or adjacent exposed vessel for coagulation. The electrocoagulation mode was set to soft coagulation at 40–80 W. Coagulation was continued until the target vessel exhibited whitening and bubbling for 2–3 seconds, indicating effective thermal sealing (Fig. 1 ). In Group B , hemostasis was achieved using mechanical clipping with hemostatic clips (Nanjing Minimally Invasive Medical Devices Co., Ltd.). Clip models were selected based on the size of the bleeding lesion. The bleeding site was clearly visualized using water irrigation via the endoscope, and the hemostatic clips were deployed through the endoscope’s working channel to clamp the exposed vessel or bleeding ulcer base. Ulcer and vessel diameters were measured endoscopically. Reference measurements were obtained using the hot biopsy forceps (maximum width: 0.67 cm; jaw diameter: 2.3 mm)(Figure 2 ). In both groups, hypertonic saline epinephrine solution (1:10,000) was injected as needed, depending on the severity and persistence of bleeding. Definition of Rebleeding: Rebleeding within 7 days was defined as the recurrence of hematemesis or melena accompanied by signs of hemodynamic instability (shock) or a drop in hemoglobin of ≥ 2 g/dL, occurring after an initial successful hemostasis and at least 24 hours of clinical stabilization (defined by stable pulse, blood pressure, and hemoglobin levels). Statistical Analysis: Fisher’s exact test was used for categorical data analysis. A p-value < 0.05 was considered statistically significant. The comparison of two independent samples was performed using the nonparametric Mann-Whitney U test. Outcomes 2.1 Comparative Analysis of Clinical Characteristics Between the Hot Biopsy Forceps Electrocoagulation Group and the hemostatic clips Group The comparative analysis revealed that the mean ulcer diameter in the hot biopsy forceps electrocoagulation group (Group A) was significantly larger than that in the hemostatic clip group (Group B) (1.1 cm [range: 0.6–1.5] vs. 0.7 cm [range: 0.4–1.0], P = 0.0052). However, there were no statistically significant differences between the two groups in baseline clinical characteristics, including age, sex, ulcer type (gastric, duodenal, or anastomotic), Forrest classification, presence of hemorrhagic shock, or the volume of blood transfusion required (P > 0.05 for all). Furthermore, there were no significant differences between the groups in secondary clinical outcomes, such as rates of conversion to surgical intervention, incidence of perforation, or 30-day mortality. Regarding hemostatic efficacy, the initial hemostasis success rate did not differ significantly between Group A and Group B (91.43% vs. 82.61%, P > 0.05). Similarly, the 7-day rebleeding rate showed no statistically significant difference between the two groups (12.50% vs. 0%, P > 0.05) (Table 1 ). Table 1 Baseline information of patients. diagnostic trait Hot Biopsy Forceps Hemostatic Clips P-value Age, years, M (IQR) 59.17 (51.00–74.00) 60.43(53.00–74.00) 0.7721 Female, n (%) 6 (17.14%) 2 (8.70%) 0.4582 duodenal ulcer 23 (65.71%) 13 (56.52%) 0.5831 peptic ulcer 11 (31.43%) 9 (39.13%) 0.5826 anastomotic ulcer 1 (2.86%) 1 (4.35%) > 0.9999 Mean diameter of ulcers (cm) 1.1 (0.6–1.5) 0.704 (0.4-1.0) 0.0052 Bare vessel diameter (mm) 2.34 (2.0–3.0) 2.043 (1.0–3.0) 0.2731 First successful hemostasis. 32 (91.43%) 19 (82.61%) 0.4184 Rebleeding rate within 7 days 4 (12.50%) 0 (0.00%) 0.2835 Surgical hemostasis 1 (2.86%) 1 (4.35%) > 0.9999 Forrest Ia 5 (14.29%) 3 (13.04%) > 0.9999 Forrest Ib 15 (33.33%) 13 (56.52%) 0.0755 Forrest IIa 13 (37.14%) 7 (30.43%) 0.7785 Forrest IIb 2 (5.71%) 0 (0.00%) 0.513 Death within 30 days 2 (5.71%) 1 (4.35%) > 0.9999 Perforated (n%) 1 (2.86%) 0 (0.00%) > 0.9999 Combined with shock (n%) 15 (42.86%) 7 (30.43%) 0.4132 Average blood transfusion 6.043 (0-9.5) 5.500 (0-8.5) 0.8136 2.2 Enhanced Hemostatic Efficacy of Hot Biopsy Forceps Electrocoagulation in Ulcers ≥ 1 cm in Diameter Subgroup analysis demonstrated a significant hemostatic advantage of thermal biopsy forceps electrocoagulation in patients with larger ulcers. Among patients with ulcer diameters ≥ 1 cm, the initial hemostasis success rate was significantly higher in the hot biopsy forceps group compared to the hemostatic clip group (88.24% vs. 33.33%, P = 0.0212). In contrast, for ulcers 0.9999) (Table 2 ). Table 2 Subgroup analysis of ulcer diameter for first successful hemostasis Ulcer diameter grouping Endoscopic Hot Biopsy (success/total) Hemostatic Clip (success/total) P-value ≥ 1cm group 15 (88.24%) 2 (33.33%) 0.0212 0.9999 2.3 Factors Influencing Initial Hemostasis Success and Rebleeding in the Hot Biopsy Forceps Electrocoagulation Group Analysis within the hot biopsy forceps electrocoagulation group revealed that the diameter of the exposed vessel was a key determinant of both initial hemostasis success and risk of rebleeding. Patients in whom initial hemostasis failed had significantly larger exposed vessel diameters compared to those with successful hemostasis (4.0 mm vs. 2.19 mm, P = 0.042) (Table 3 ). Similarly, rebleeding within 7 days was strongly associated with larger vessel diameter; patients who experienced rebleeding had significantly greater vessel diameters than those who did not (4.0 mm [2.5–5.0] vs. 1.92mm [1.0–2.0], P = 0.0048) (Table 4 ). Table 3 Analysis of factors influencing the success or failure of first hemostasis in the electrocoagulation group diagnostic trait successes fail (e.g. experiments) P-value Age, years, M (IQR) 58.19 (51.00-72.25) 69.67 (29.00–92.00) 0.3117 Mean diameter of ulcers (cm) 1.059 (0.60-1.00) 1.667 (0.5–2.5) 0.4715 Bare vessel diameter (mm) 2.188 (1.25–2.75) 4.0 (2.0–5.0) 0.0419 Table 4 Analysis of factors affecting rebleeding in the hot biopsy forceps electrocoagulation group diagnostic trait successes fail (e.g. experiments) P-value Age, years, M (IQR) 57.29 (50.25-69.00) 64.50 (53.25–73.75) 0.4642 Mean diameter of ulcers (cm) 0.9893 (0.60-1.0) 1.550 (0.60–2.75) 0.683 Bare vessel diameter (mm) 1.929 (1.0–2.0) 4.0 (2.5-5.0) 0.0048 2.4 Factors Influencing the Success or Failure of Initial Hemostasis in the Hemostatic Clip Group In the metal hemostatic clip group, the success of initial hemostasis was significantly associated with ulcer size. The mean ulcer diameter in cases of hemostatic failure was nearly twice that observed in successful cases (1.125 cm vs. 0.616 cm, P = 0.003). While the diameter of exposed vessels was also greater in the failed group compared to the successful group (2.75 mm vs. 1.895 mm), this difference did not reach statistical significance ( P = 0.084). This non-significant trend may be attributable to confounding factors such as limited sample size or variation in vessel location, which could affect the technical feasibility of clip placement (Table 5 ). Table 5 Factors influencing the success or failure of first hemostasis in the metal hemostatic clip group diagnostic trait successes fail (e.g. experiments) P-value Age, years, M (IQR) 61.58 (53.00–74.00) 55.00 (34.00-71.50) 0.4889 Mean diameter of ulcers (cm) 0.6158 (0.40–0.80) 1.125 (1.0-1.375) 0.0027 Bare vessel diameter (mm) 1.895 (1.0–2.0) 2.750 (2.0-3.750) 0.0841 C–D: A gastric antrum ulcer (diameter: 0.6 cm) featuring an exposed vessel (~ 2.0 mm) was treated with hot biopsy forceps coagulation. E–F: Thermal coagulation using hot biopsy forceps controlled bleeding in a gastric angulus ulcer (diameter: 1.0 cm) with an exposed vessel (~ 2.0 mm). Discussion In this study, we retrospectively analyzed the efficacy of endoscopic hemostasis in patients with high bleeding risk peptic ulcers (Forrest Ia, Ib, IIa, and IIb) and revealed the stratified superiority of hot biopsy forceps electrocoagulation versus metal hemostatic clips for hemostasis in different ulcer characteristics. The results showed that hot biopsy forceps electrocoagulation demonstrated significant superiority in cases with ≥ 1 cm ulcers and vessel diameters ≤ 2.2 mm, whereas metal hemostatic clips were more suitable for small ulcers (< 1 cm). This finding complements previous studies and provides a new evidence-based rationale for individualized hemostatic strategies. The choice of endoscopic hemostatic technique needs to be based on ulcer morphology, vascular characteristics and operational feasibility. In this study, we confirmed that the success rate of hemostasis with metal hemostatic clips was negatively correlated with ulcer diameter (ulcer diameter in the failure group: 1.125 cm vs. 0.616 cm, P = 0.003), which is consistent with the findings of the (RCT)by Jung et al. that hemostatic clips are effective for hemostasis of small, superficial lesions but are prone to failure in large ulcers due to tissue edema or limited field of view. or limited field of view prone to failure[ 8 ]. In larger or fibrotic ulcers, standard hemostatic clips may not provide sufficient tissue grasping capacity, resulting in poor hemostasis[ 9 ] .In certain locations, such as the posterior wall of the duodenal bulb, the posterior wall of the gastric corpus, and the lesser curvature of the stomach, application of hemostatic clips may be difficult, compromising their effectiveness and success[ 10 ]. On the contrary, thermal biopsy forceps electrocoagulation showed a high hemostatic success rate of 88.24% in larger ulcers (≥ 1 cm) by direct coagulation of exposed vessels, which may be related to the sealing effect of electrocoagulation on the deeper blood vessels and its property of not being limited by the hardness of the ulcer base. This single-center retrospective study observed that for exposed vessels with a diameter ≤ 2.2 mm (previously considered to carry a risk of electrocoagulation failure when > 1 mm[ 11 , 12 ]) and ulcers averaging 1.1 cm, the success rate of endoscopic electrocoagulation for hemostasis reached 91.43%. This suggests electrocoagulation may have a broader applicability than previously recognized. Although the ESGE guidelines recommend OTSC (over-the-scope clip) as the first choice for vessels > 2 mm, this study found that in primary healthcare settings (especially when OTSC is unavailable), electrocoagulation still demonstrated reliable efficacy for vessels ≤ 2.2 mm. However, as these conclusions stem from single-center retrospective data, their generalizability requires validation through multicenter prospective studies.Coagulation of large vessels requires higher energy and more precise manipulation, whereas gentle coagulation modes may result in incomplete vessel closure due to insufficient energy, increasing the risk of hemostatic failure and rebleeding. Similarly, Ishida et al. showed that monopolar coagulation in ESD needs to be adjusted to strong coagulation mode in vessels > 2 mm in diameter to reduce rebleeding rates[ 13 ]. In contrast, hemostatic clips, which block blood flow by mechanical compression, are theoretically more effective for immediate hemostasis in large vessels, but there was no significant correlation between the diameter of the exposed vessel and the success rate in the titanium clip group in the present study, which may be due to the sample size limitation or the location of the vessel (e.g., meandering of ulcer margins) affecting the clip closure effect[ 14 ] . Efficient hemostasis (100% success rate) with metal clips in small ulcers (< 1 cm) reduces repeat operations and hospitalization time. The advantages of thermal biopsy forceps electrocoagulation are the lower cost of the instrument (about a fraction of the cost of another thermal coagulation tool, the monopolar hemostatic forceps) and its suitability for large ulcers (≥ 1 cm), which avoids the waste of resources due to repeated failure of hemostatic clips. There was no difference in the complication rate between the two groups in this study (perforation: 1 vs. 0), which is consistent with previous reports of the extremely low risk of perforation with thermal biopsy forceps in intestinal polypectomy applications[ 15 ]. Notably, the risk of delayed perforation with thermal biopsy forceps suggests the need for increased postoperative surveillance, especially in elderly patients with combined gastric wall weakness. The present study fills a gap in the previous literature by providing the first systematic comparison of the stratified efficacy of thermal biopsy forceps electrocoagulation with hemostatic clips in high-risk ulcers.Soon et al. previously reported that the success rate of hemostasis with monopolar electrocoagulation in high-risk ulcers (89%) was close to the results of the present study (91.43%), but the effect of lesion characteristics was not further analyzed[ 16 ]. In addition, guidelines such as ESGE emphasize the importance of combined therapy, whereas the present study demonstrates that efficient hemostasis can be achieved in specific subgroups with thermal biopsy forceps electrocoagulation alone, providing a rationale for simplifying the procedure[ 6 ]. However, the hemostatic efficacy of hemostatic clips alone has room for improvement compared with the current "epinephrine combined with a new type of hemostatic clips" regimen, suggesting that a sequential combination of thermal coagulation and hemostatic clips could be explored in the future. Limitations of the study First, retrospective design and selection bias: non-randomized subgroups may have led to differences in baseline characteristics (e.g., larger ulcer diameter in group A), and the effect of confounders could not be completely excluded despite correction by the school of statistics. Second, sample size limitations. Summary and outlook This study provides an important threshold for hemostatic strategies in high-risk peptic ulcers (1-cm ulcer, 2.2-mm vessel) and confirms the unique benefits of thermal biopsy-clamp electrocoagulation in large lesions. Future multicenter randomized controlled trials are needed to accurately assess vessel characteristics in conjunction with ultrasound endoscopy and to explore the synergistic effects of the combined thermal coagulation-titanium clamp protocol. Meanwhile, the development of an intelligent electrocoagulation energy regulation system may further improve the efficiency of sealing large vessels and reduce the difficulty of operation and the risk of complications. Declarations Funding This work was supported by the the Youth Innovation Project of Sichuan Medical Association (Q21018), and Chengdu Medical Research Projects (2022516; 2023666). Authors' contributions Xiaolan Wang, Tao Cai: Conceptualization, patient recruitment, endoscopic procedures, data collection, manuscript drafting. Hongwen Tian：Clinical data validation, data collection, manuscript drafting. Shuang Deng，Yinkui Liu，Ting Zhang: Literature review, follow-up data acquisition, database management. Xin Zhang and Xia Tong: Writing – original draft, Methodology, Conceptualization，Funding acquisition. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Human Ethics and Consent to Participate Declarations Ethical approval was granted by the Medical Ethics Committee of Shuangliu District First People's Hospital (Chengdu, China), following the Declaration of Helsinki, and written informed consent was obtained from each participant. Clinical trial number Not applicable Consent for publication All authors consented for publication. Availability of data and material The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding authors. References Rotondano, G., Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding. Gastroenterol Clin North Am, 2014. 43 (4): p. 643-63. Straube, S., et al., Mortality with upper gastrointestinal bleeding and perforation: effects of time and NSAID use. BMC Gastroenterol, 2009. 9 (1471-230X (Electronic)): p. 41. Oakland, K., Changing epidemiology and etiology of upper and lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol, 2019. 42-43 (1532-1916 (Electronic)): p. 101610. Laine, L. and K.R. McQuaid, Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol, 2009. 7 (1): p. 33-47; quiz 1-2. Barkun, A.N., et al., Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc, 2009. 69 (4): p. 786-99. Gralnek, I.M., et al., Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy, 2021. 53 (3): p. 300-332. Gilbert, D.A., et al., Status evaluation: hot biopsy forceps. American Society for Gastrointe stinal Endoscopy. Technology Assessment Committee. Gastrointestinal endoscopy, 1992. 38 (6): p. 753-6. Jung, D.H., et al., Comparison of a Polysaccharide Hemostatic Powder and Conventional Therapy for Peptic Ulcer Bleeding. Clin Gastroenterol Hepatol, 2023. 21 (11): p. 2844-2853 e5. Meier, B., et al., Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut, 2022. 71 (7): p. 1251-1258. Sung, J.J., et al., Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut, 2007. 56 (10): p. 1364-73. Lau, J.Y., et al., Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med, 1999. 340 (10): p. 751-6. Swain, C.P., et al., Nature of the bleeding vessel in recurrently bleeding gastric ulcers. Gastroenterology, 1986. 90 (3): p. 595-608. Ishida, T., et al., Efficacy of forced coagulation with low high-frequency power setting during endoscopic submucosal dissection. World J Gastroenterol, 2017. 23 (29): p. 5422-5430. Mullady, D.K., A.Y. Wang, and K.A. Waschke, AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. Gastroenterology, 2020. 159 (3): p. 1120-1128. Wadas, D.D. and R.A. Sanowski, Complications of the hot biopsy forceps technique. Gastrointest Endosc, 1988. 34 (1): p. 32-7. Soon, M.S., et al., Monopolar coagulation versus conventional endoscopic treatment for high-risk peptic ulcer bleeding: a prospective, randomized study. Gastrointest Endosc, 2003. 58 (3): p. 323-9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7601400","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516184090,"identity":"f5108127-cc0d-4746-84aa-98e98af2a06e","order_by":0,"name":"Xiaolan Wang","email":"","orcid":"","institution":"Hospital Sichuan University (The First Peo ple’s Hospital of Shuangliu District","correspondingAuthor":false,"prefix":"","firstName":"Xiaolan","middleName":"","lastName":"Wang","suffix":""},{"id":516184091,"identity":"d87154d7-711c-457c-9ef5-a07d27cd819b","order_by":1,"name":"Tao Cai","email":"","orcid":"","institution":"Hospital Sichuan 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13:12:55","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63733,"visible":true,"origin":"","legend":"","description":"","filename":"8afdc691d17c4335a4b48b51851677171structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7601400/v1/286a79b7c06e70fc2c0a7b9d.xml"},{"id":92086692,"identity":"14b3a64c-ea56-48da-8abc-0f3ae606a165","added_by":"auto","created_at":"2025-09-24 13:04:55","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70166,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7601400/v1/58d14dbf5eec5322374c2f7a.html"},{"id":92086690,"identity":"aeaeaf90-5ccb-4953-aa3a-c126a03a9d61","added_by":"auto","created_at":"2025-09-24 13:04:55","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":204043,"visible":true,"origin":"","legend":"\u003cp\u003eA–B: Under white light endoscopy, hemostasis was successfully achieved in a duodenal bulb ulcer (diameter: 2.0 cm) with an exposed vessel (diameter: ~5.0 mm) using thermal coagulation with hot biopsy forceps.\u003cbr\u003e\nC–D: A gastric antrum ulcer (diameter: 0.6 cm) featuring an exposed vessel (~2.0 mm) was treated with hot biopsy forceps coagulation.\u003cbr\u003e\nE–F: Thermal coagulation using hot biopsy forceps controlled bleeding in a gastric angulus ulcer (diameter: 1.0 cm) with an exposed vessel (~2.0 mm).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7601400/v1/f324483c106e01b8d06482d1.jpeg"},{"id":92086691,"identity":"c1e68d85-1b12-419a-8879-10db2cf7e1b4","added_by":"auto","created_at":"2025-09-24 13:04:55","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":952099,"visible":true,"origin":"","legend":"\u003cp\u003eFigA. Endoscopic scaling with fully opened hot biopsy forceps (6.7 mm span) for ulcer measurement.Fig B. Vessel caliber assessment using forceps jaws (2.3 mm diameter) as reference.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7601400/v1/81d7597fd1648fdd2b287f04.jpeg"},{"id":92664880,"identity":"f0082391-0aee-4630-a055-98da0d235aec","added_by":"auto","created_at":"2025-10-02 16:01:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2146924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7601400/v1/c766222c-a157-48b9-b53f-e69e00b9e33c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Endoscopic Hot Biopsy Forceps Coagulation and Hemostatic Clips for High-Risk Bleeding Peptic Ulcers","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAcute upper gastrointestinal bleeding (AUGIB) remains a common and serious clinical emergency. Although its incidence has declined in recent years, associated mortality rates remain high, ranging from 7.4% to 20.9%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Peptic ulcer is the most common cause of non-variceal upper GI bleeding[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For patients with high-risk stigmata of hemorrhage\u0026mdash;such as Forrest Ia, Ib, and IIa lesions\u0026mdash;endoscopic hemostasis is preferred over pharmacologic therapy as the primary intervention[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eCurrent endoscopic hemostatic modalities include injection therapy, thermal coagulation (both contact and non-contact methods), mechanical compression (e.g., clips), and topical application of hemostatic powders[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Among these, hot biopsy forceps represent a contact thermal technique using insulated monopolar electrocoagulation. This device enables simultaneous tissue biopsy and coagulation and has been widely applied in the removal of small colonic polyps and treatment of gastrointestinal vascular lesions[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, clinical evidence on the use of hot biopsy forceps for managing peptic ulcers with high bleeding risk remains limited. Preliminary studies suggest this method may enhance immediate hemostasis, reduce short-term rebleeding, and carry a favorable safety profile. While advanced tools such as monopolar hemostatic forceps and over-the-scope clips offer high efficacy and low rebleeding rates, their high cost may limit widespread use. Therefore, exploring simpler and more cost-effective alternatives remains clinically important.\u003c/p\u003e\u003cp\u003eThe objective of this study was to assess the efficacy and safety of monopolar electrocoagulation using hot biopsy forceps in the endoscopic management of high-risk bleeding peptic ulcers, with the goal of minimizing the need for emergency interventions and reducing mortality.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003ePatients presenting with hematemesis and/or melena who were diagnosed with gastric, duodenal, or anastomotic ulcers within 24 hours via emergency gastroscopy were retrospectively enrolled from January 2019 to December 2024. Eligible cases included ulcers classified as Forrest Ia, Ib, or IIa, all of whom underwent urgent endoscopic hemostatic intervention. Exclusion criteria were as follows: inability or unwillingness to provide written informed consent; bleeding secondary to gastric malignancy; pregnancy; coagulopathy (defined as platelet count \u0026lt; 50,000/mm³, prothrombin activity \u0026lt; 30%, or current use of anticoagulant medications); and cases involving multiple bleeding sources. Based on the endoscopic hemostasis modality used, patients were categorized into two groups: Group A (n = 35), treated with monopolar electrocoagulation using hot biopsy forceps, and Group B (n = 23), treated with hemostatic clips placement. All patients and/or their legal guardians provided written informed consent prior to undergoing gastroscopy and endoscopic hemostatic procedures. All interventions were performed by experienced gastroenterologists with expertise in emergency endoscopic hemostasis.\u003c/p\u003e\u003cp\u003e The Ethics Committee of Shuangliu District First People's Hospital (Chengdu, China) approved the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eAll procedures were performed using a gastroscope equipped with a water jet function (GIF-H260J; Olympus Optical Co., Japan). \u003cb\u003eIn Group A\u003c/b\u003e, patients underwent thermal coagulation using hot biopsy forceps. The procedure utilized a high-frequency electrocoagulation generator (AIBO VI0300S+), in conjunction with thermal biopsy forceps (Model HBF-23/2000, Nanjing Microtronics). Under direct visualization, the forceps were applied to the bleeding point or adjacent exposed vessel for coagulation. The electrocoagulation mode was set to soft coagulation at 40–80 W. Coagulation was continued until the target vessel exhibited whitening and bubbling for 2–3 seconds, indicating effective thermal sealing (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). \u003cb\u003eIn Group B\u003c/b\u003e, hemostasis was achieved using mechanical clipping with hemostatic clips (Nanjing Minimally Invasive Medical Devices Co., Ltd.). Clip models were selected based on the size of the bleeding lesion. The bleeding site was clearly visualized using water irrigation via the endoscope, and the hemostatic clips were deployed through the endoscope’s working channel to clamp the exposed vessel or bleeding ulcer base. Ulcer and vessel diameters were measured endoscopically. Reference measurements were obtained using the hot biopsy forceps (maximum width: 0.67 cm; jaw diameter: 2.3 mm)(Figure\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In both groups, hypertonic saline epinephrine solution (1:10,000) was injected as needed, depending on the severity and persistence of bleeding.\u003c/p\u003e\n\u003ch3\u003eDefinition of Rebleeding:\u003c/h3\u003e\n\u003cp\u003eRebleeding within 7 days was defined as the recurrence of hematemesis or melena accompanied by signs of hemodynamic instability (shock) or a drop in hemoglobin of ≥ 2 g/dL, occurring after an initial successful hemostasis and at least 24 hours of clinical stabilization (defined by stable pulse, blood pressure, and hemoglobin levels).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003eFisher’s exact test was used for categorical data analysis. A p-value \u0026lt; 0.05 was considered statistically significant. The comparison of two independent samples was performed using the nonparametric Mann-Whitney U test.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003e2.1 Comparative Analysis of Clinical Characteristics Between the Hot Biopsy Forceps Electrocoagulation Group and the\u003c/b\u003e hemostatic clips \u003cb\u003eGroup\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe comparative analysis revealed that the mean ulcer diameter in the hot biopsy forceps electrocoagulation group (Group A) was significantly larger than that in the hemostatic clip group (Group B) (1.1 cm [range: 0.6–1.5] vs. 0.7 cm [range: 0.4–1.0], P = 0.0052). However, there were no statistically significant differences between the two groups in baseline clinical characteristics, including age, sex, ulcer type (gastric, duodenal, or anastomotic), Forrest classification, presence of hemorrhagic shock, or the volume of blood transfusion required (P \u0026gt; 0.05 for all).\u003c/p\u003e\u003cp\u003eFurthermore, there were no significant differences between the groups in secondary clinical outcomes, such as rates of conversion to surgical intervention, incidence of perforation, or 30-day mortality. Regarding hemostatic efficacy, the initial hemostasis success rate did not differ significantly between Group A and Group B (91.43% vs. 82.61%, P \u0026gt; 0.05). Similarly, the 7-day rebleeding rate showed no statistically significant difference between the two groups (12.50% vs. 0%, P \u0026gt; 0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline information of patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediagnostic trait\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHot Biopsy Forceps\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHemostatic Clips\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years, M (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e59.17 (51.00–74.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60.43(53.00–74.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.7721\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (17.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (8.70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4582\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eduodenal ulcer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23 (65.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (56.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.5831\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epeptic ulcer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (31.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (39.13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.5826\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eanastomotic ulcer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (4.35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 0.9999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean diameter of ulcers (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.1 (0.6–1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.704 (0.4-1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0052\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBare vessel diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.34 (2.0–3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.043 (1.0–3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.2731\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst successful hemostasis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32 (91.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19 (82.61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4184\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRebleeding rate within 7 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (12.50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.2835\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical hemostasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (4.35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 0.9999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForrest Ia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (13.04%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 0.9999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForrest Ib\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (33.33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (56.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0755\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForrest IIa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (37.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (30.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.7785\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForrest IIb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (5.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath within 30 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (5.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (4.35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 0.9999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerforated (n%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 0.9999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCombined with shock (n%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (42.86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (30.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4132\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAverage blood transfusion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.043 (0-9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.500 (0-8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.8136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.2 Enhanced Hemostatic Efficacy of Hot Biopsy Forceps Electrocoagulation in Ulcers ≥ 1 cm in Diameter\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSubgroup analysis demonstrated a significant hemostatic advantage of thermal biopsy forceps electrocoagulation in patients with larger ulcers. Among patients with ulcer diameters ≥ 1 cm, the initial hemostasis success rate was significantly higher in the hot biopsy forceps group compared to the hemostatic clip group (88.24% vs. 33.33%, P = 0.0212). In contrast, for ulcers \u0026lt; 1 cm in diameter, both groups achieved high success rates with no statistically significant difference (94.44% vs. 100%, P \u0026gt; 0.9999) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSubgroup analysis of ulcer diameter for first successful hemostasis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUlcer diameter grouping\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEndoscopic Hot Biopsy (success/total)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHemostatic Clip (success/total)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≥ 1cm group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (88.24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (33.33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0212\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 1cm group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (94.44%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.3 Factors Influencing Initial Hemostasis Success and Rebleeding in the Hot Biopsy Forceps Electrocoagulation Group\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAnalysis within the hot biopsy forceps electrocoagulation group revealed that the diameter of the exposed vessel was a key determinant of both initial hemostasis success and risk of rebleeding. Patients in whom initial hemostasis failed had significantly larger exposed vessel diameters compared to those with successful hemostasis (4.0 mm vs. 2.19 mm, P = 0.042) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Similarly, rebleeding within 7 days was strongly associated with larger vessel diameter; patients who experienced rebleeding had significantly greater vessel diameters than those who did not (4.0 mm [2.5–5.0] vs. 1.92mm [1.0–2.0], P = 0.0048) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of factors influencing the success or failure of first hemostasis in the electrocoagulation group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediagnostic trait\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esuccesses\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003efail (e.g. experiments)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years, M (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58.19 (51.00-72.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69.67 (29.00–92.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.3117\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean diameter of ulcers (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.059 (0.60-1.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.667 (0.5–2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4715\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBare vessel diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.188 (1.25–2.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.0 (2.0–5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0419\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of factors affecting rebleeding in the hot biopsy forceps electrocoagulation group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediagnostic trait\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esuccesses\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003efail (e.g. experiments)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years, M (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.29 (50.25-69.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.50 (53.25–73.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4642\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean diameter of ulcers (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.9893 (0.60-1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.550 (0.60–2.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBare vessel diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.929 (1.0–2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.0 (2.5-5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0048\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.4 Factors Influencing the Success or Failure of Initial Hemostasis in the Hemostatic Clip Group\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn the metal hemostatic clip group, the success of initial hemostasis was significantly associated with ulcer size. The mean ulcer diameter in cases of hemostatic failure was nearly twice that observed in successful cases (1.125 cm vs. 0.616 cm, \u003cem\u003eP\u003c/em\u003e = 0.003). While the diameter of exposed vessels was also greater in the failed group compared to the successful group (2.75 mm vs. 1.895 mm), this difference did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e = 0.084). This non-significant trend may be attributable to confounding factors such as limited sample size or variation in vessel location, which could affect the technical feasibility of clip placement (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"−\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors influencing the success or failure of first hemostasis in the metal hemostatic clip group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediagnostic trait\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esuccesses\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003efail (e.g. experiments)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years, M (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61.58 (53.00–74.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c3\"\u003e\u003cp\u003e55.00 (34.00-71.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.4889\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean diameter of ulcers (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.6158 (0.40–0.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c3\"\u003e\u003cp\u003e1.125 (1.0-1.375)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0027\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBare vessel diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.895 (1.0–2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c3\"\u003e\u003cp\u003e2.750 (2.0-3.750)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0841\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eC–D: A gastric antrum ulcer (diameter: 0.6 cm) featuring an exposed vessel (~ 2.0 mm) was treated with hot biopsy forceps coagulation.\u003c/p\u003e\u003cp\u003eE–F: Thermal coagulation using hot biopsy forceps controlled bleeding in a gastric angulus ulcer (diameter: 1.0 cm) with an exposed vessel (~ 2.0 mm).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\n"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we retrospectively analyzed the efficacy of endoscopic hemostasis in patients with high bleeding risk peptic ulcers (Forrest Ia, Ib, IIa, and IIb) and revealed the stratified superiority of hot biopsy forceps electrocoagulation versus metal hemostatic clips for hemostasis in different ulcer characteristics. The results showed that hot biopsy forceps electrocoagulation demonstrated significant superiority in cases with ≥ 1 cm ulcers and vessel diameters ≤ 2.2 mm, whereas metal hemostatic clips were more suitable for small ulcers (\u0026lt; 1 cm). This finding complements previous studies and provides a new evidence-based rationale for individualized hemostatic strategies.\u003c/p\u003e\u003cp\u003eThe choice of endoscopic hemostatic technique needs to be based on ulcer morphology, vascular characteristics and operational feasibility. In this study, we confirmed that the success rate of hemostasis with metal hemostatic clips was negatively correlated with ulcer diameter (ulcer diameter in the failure group: 1.125 cm vs. 0.616 cm, P = 0.003), which is consistent with the findings of the (RCT)by Jung et al. that hemostatic clips are effective for hemostasis of small, superficial lesions but are prone to failure in large ulcers due to tissue edema or limited field of view. or limited field of view prone to failure[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In larger or fibrotic ulcers, standard hemostatic clips may not provide sufficient tissue grasping capacity, resulting in poor hemostasis[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] .In certain locations, such as the posterior wall of the duodenal bulb, the posterior wall of the gastric corpus, and the lesser curvature of the stomach, application of hemostatic clips may be difficult, compromising their effectiveness and success[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. On the contrary, thermal biopsy forceps electrocoagulation showed a high hemostatic success rate of 88.24% in larger ulcers (≥ 1 cm) by direct coagulation of exposed vessels, which may be related to the sealing effect of electrocoagulation on the deeper blood vessels and its property of not being limited by the hardness of the ulcer base. This single-center retrospective study observed that for exposed vessels with a diameter ≤ 2.2 mm (previously considered to carry a risk of electrocoagulation failure when \u0026gt; 1 mm[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]) and ulcers averaging 1.1 cm, the success rate of endoscopic electrocoagulation for hemostasis reached 91.43%. This suggests electrocoagulation may have a broader applicability than previously recognized. Although the ESGE guidelines recommend OTSC (over-the-scope clip) as the first choice for vessels \u0026gt; 2 mm, this study found that in primary healthcare settings (especially when OTSC is unavailable), electrocoagulation still demonstrated reliable efficacy for vessels ≤ 2.2 mm. However, as these conclusions stem from single-center retrospective data, their generalizability requires validation through multicenter prospective studies.Coagulation of large vessels requires higher energy and more precise manipulation, whereas gentle coagulation modes may result in incomplete vessel closure due to insufficient energy, increasing the risk of hemostatic failure and rebleeding. Similarly, Ishida et al. showed that monopolar coagulation in ESD needs to be adjusted to strong coagulation mode in vessels \u0026gt; 2 mm in diameter to reduce rebleeding rates[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In contrast, hemostatic clips, which block blood flow by mechanical compression, are theoretically more effective for immediate hemostasis in large vessels, but there was no significant correlation between the diameter of the exposed vessel and the success rate in the titanium clip group in the present study, which may be due to the sample size limitation or the location of the vessel (e.g., meandering of ulcer margins) affecting the clip closure effect[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eEfficient hemostasis (100% success rate) with metal clips in small ulcers (\u0026lt; 1 cm) reduces repeat operations and hospitalization time. The advantages of thermal biopsy forceps electrocoagulation are the lower cost of the instrument (about a fraction of the cost of another thermal coagulation tool, the monopolar hemostatic forceps) and its suitability for large ulcers (≥ 1 cm), which avoids the waste of resources due to repeated failure of hemostatic clips. There was no difference in the complication rate between the two groups in this study (perforation: 1 vs. 0), which is consistent with previous reports of the extremely low risk of perforation with thermal biopsy forceps in intestinal polypectomy applications[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Notably, the risk of delayed perforation with thermal biopsy forceps suggests the need for increased postoperative surveillance, especially in elderly patients with combined gastric wall weakness.\u003c/p\u003e\u003cp\u003eThe present study fills a gap in the previous literature by providing the first systematic comparison of the stratified efficacy of thermal biopsy forceps electrocoagulation with hemostatic clips in high-risk ulcers.Soon et al. previously reported that the success rate of hemostasis with monopolar electrocoagulation in high-risk ulcers (89%) was close to the results of the present study (91.43%), but the effect of lesion characteristics was not further analyzed[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, guidelines such as ESGE emphasize the importance of combined therapy, whereas the present study demonstrates that efficient hemostasis can be achieved in specific subgroups with thermal biopsy forceps electrocoagulation alone, providing a rationale for simplifying the procedure[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the hemostatic efficacy of hemostatic clips alone has room for improvement compared with the current \"epinephrine combined with a new type of hemostatic clips\" regimen, suggesting that a sequential combination of thermal coagulation and hemostatic clips could be explored in the future.\u003c/p\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003eFirst, retrospective design and selection bias: non-randomized subgroups may have led to differences in baseline characteristics (e.g., larger ulcer diameter in group A), and the effect of confounders could not be completely excluded despite correction by the school of statistics. Second, sample size limitations.\u003c/p\u003e"},{"header":"Summary and outlook","content":"\u003cp\u003eThis study provides an important threshold for hemostatic strategies in high-risk peptic ulcers (1-cm ulcer, 2.2-mm vessel) and confirms the unique benefits of thermal biopsy-clamp electrocoagulation in large lesions. Future multicenter randomized controlled trials are needed to accurately assess vessel characteristics in conjunction with ultrasound endoscopy and to explore the synergistic effects of the combined thermal coagulation-titanium clamp protocol. Meanwhile, the development of an intelligent electrocoagulation energy regulation system may further improve the efficiency of sealing large vessels and reduce the difficulty of operation and the risk of complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the the Youth Innovation Project of Sichuan Medical Association (Q21018), and Chengdu Medical Research Projects (2022516; 2023666).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXiaolan Wang, Tao Cai: Conceptualization, patient recruitment, endoscopic procedures, data collection, manuscript drafting. Hongwen Tian：Clinical data validation, data collection, manuscript drafting. \u0026nbsp;Shuang Deng，Yinkui Liu，Ting Zhang: \u0026nbsp;Literature review, follow-up data acquisition, database management. Xin Zhang and Xia Tong: Writing \u0026ndash; original draft, Methodology, Conceptualization，Funding acquisition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Medical Ethics Committee of Shuangliu District First People\u0026apos;s Hospital (Chengdu, China), following the Declaration of Helsinki, and written informed consent was obtained from each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consented for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRotondano, G., \u003cem\u003eEpidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding.\u003c/em\u003e Gastroenterol Clin North Am, 2014. \u003cstrong\u003e43\u003c/strong\u003e(4): p. 643-63.\u003c/li\u003e\n\u003cli\u003eStraube, S., et al., \u003cem\u003eMortality with upper gastrointestinal bleeding and perforation: effects of time and NSAID use.\u003c/em\u003e BMC Gastroenterol, 2009. \u003cstrong\u003e9\u003c/strong\u003e(1471-230X (Electronic)): p. 41.\u003c/li\u003e\n\u003cli\u003eOakland, K., \u003cem\u003eChanging epidemiology and etiology of upper and lower gastrointestinal bleeding.\u003c/em\u003e Best Pract Res Clin Gastroenterol, 2019. \u003cstrong\u003e42-43\u003c/strong\u003e(1532-1916 (Electronic)): p. 101610.\u003c/li\u003e\n\u003cli\u003eLaine, L. and K.R. McQuaid, \u003cem\u003eEndoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials.\u003c/em\u003e Clin Gastroenterol Hepatol, 2009. \u003cstrong\u003e7\u003c/strong\u003e(1): p. 33-47; quiz 1-2.\u003c/li\u003e\n\u003cli\u003eBarkun, A.N., et al., \u003cem\u003eEndoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses.\u003c/em\u003e Gastrointest Endosc, 2009. \u003cstrong\u003e69\u003c/strong\u003e(4): p. 786-99.\u003c/li\u003e\n\u003cli\u003eGralnek, I.M., et al., \u003cem\u003eEndoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021.\u003c/em\u003e Endoscopy, 2021. \u003cstrong\u003e53\u003c/strong\u003e(3): p. 300-332.\u003c/li\u003e\n\u003cli\u003eGilbert, D.A., et al., \u003cem\u003eStatus evaluation: hot biopsy forceps. American Society for Gastrointe stinal Endoscopy. Technology Assessment Committee.\u003c/em\u003e Gastrointestinal endoscopy, 1992. \u003cstrong\u003e38\u003c/strong\u003e(6): p. 753-6.\u003c/li\u003e\n\u003cli\u003eJung, D.H., et al., \u003cem\u003eComparison of a Polysaccharide Hemostatic Powder and Conventional Therapy for Peptic Ulcer Bleeding.\u003c/em\u003e Clin Gastroenterol Hepatol, 2023. \u003cstrong\u003e21\u003c/strong\u003e(11): p. 2844-2853 e5.\u003c/li\u003e\n\u003cli\u003eMeier, B., et al., \u003cem\u003eOver-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2).\u003c/em\u003e Gut, 2022. \u003cstrong\u003e71\u003c/strong\u003e(7): p. 1251-1258.\u003c/li\u003e\n\u003cli\u003eSung, J.J., et al., \u003cem\u003eEndoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis.\u003c/em\u003e Gut, 2007. \u003cstrong\u003e56\u003c/strong\u003e(10): p. 1364-73.\u003c/li\u003e\n\u003cli\u003eLau, J.Y., et al., \u003cem\u003eEndoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers.\u003c/em\u003e N Engl J Med, 1999. \u003cstrong\u003e340\u003c/strong\u003e(10): p. 751-6.\u003c/li\u003e\n\u003cli\u003eSwain, C.P., et al., \u003cem\u003eNature of the bleeding vessel in recurrently bleeding gastric ulcers.\u003c/em\u003e Gastroenterology, 1986. \u003cstrong\u003e90\u003c/strong\u003e(3): p. 595-608.\u003c/li\u003e\n\u003cli\u003eIshida, T., et al., \u003cem\u003eEfficacy of forced coagulation with low high-frequency power setting during endoscopic submucosal dissection.\u003c/em\u003e World J Gastroenterol, 2017. \u003cstrong\u003e23\u003c/strong\u003e(29): p. 5422-5430.\u003c/li\u003e\n\u003cli\u003eMullady, D.K., A.Y. Wang, and K.A. Waschke, \u003cem\u003eAGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review.\u003c/em\u003e Gastroenterology, 2020. \u003cstrong\u003e159\u003c/strong\u003e(3): p. 1120-1128.\u003c/li\u003e\n\u003cli\u003eWadas, D.D. and R.A. Sanowski, \u003cem\u003eComplications of the hot biopsy forceps technique.\u003c/em\u003e Gastrointest Endosc, 1988. \u003cstrong\u003e34\u003c/strong\u003e(1): p. 32-7.\u003c/li\u003e\n\u003cli\u003eSoon, M.S., et al., \u003cem\u003eMonopolar coagulation versus conventional endoscopic treatment for high-risk peptic ulcer bleeding: a prospective, randomized study.\u003c/em\u003e Gastrointest Endosc, 2003. \u003cstrong\u003e58\u003c/strong\u003e(3): p. 323-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ulcers, Upper gastrointestinal endoscopy, Non-variceal bleeding","lastPublishedDoi":"10.21203/rs.3.rs-7601400/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7601400/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e\u003cp\u003eAcute upper gastrointestinal bleeding (AUGIB) remains a major clinical emergency with significant morbidity and mortality, with peptic ulcers being the predominant etiology. Optimizing endoscopic hemostatic strategies for high-risk bleeding ulcers is therefore of critical importance.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e\u003cp\u003eThis retrospective study evaluated 58 patients with bleeding peptic ulcers classified as Forrest Ia, Ib, IIa, and IIb, who underwent endoscopic hemostasis between 2019 and 2024. Of these, 35 patients received hot biopsy forceps coagulation (Group A), while 23 were treated with hemostatic clips placement (Group B). Clinical outcomes including primary hemostasis success and 7-day rebleeding rates were analyzed.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e\u003cp\u003eThe results showed that there was no statistically significant difference (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) between the two groups in the success rate of first hemostasis (91.43% vs. 82.61%) and the 7-day rebleeding rate (12.50% vs. 0%), but subgroup analyses revealed a critical threshold effect: for \u0026ge;\u0026thinsp;1 cm ulcers, the success rate of hemostasis in the hot biopsy forceps coagulation-hemostasis group was significantly superior to that of hemostatic clips (88.24% vs. 33.33%, P\u0026thinsp;=\u0026thinsp;0.0212), while both reached high efficiency in the \u0026lt;\u0026thinsp;1cm group (94.44% vs. 100%). Further analysis showed that hot biopsy forceps electrocoagulation hemostasis failure was significantly correlated with bleeding vessel diameter\u0026thinsp;\u0026ge;\u0026thinsp;2.2mm (4.0mm vs. 2.19mm, P\u0026thinsp;=\u0026thinsp;0.042), while hemostatic clips failure was positively correlated with ulcer size (1.125cm vs. 0.616cm, P\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e\u003cp\u003eHot biopsy forceps coagulation offers a cost-effective and efficient option for managing bleeding ulcers\u0026thinsp;\u0026ge;\u0026thinsp;1 cm or those involving large-caliber vessels (\u0026le;\u0026thinsp;2.2mm). Ulcer diameter of 1 cm and vessel diameter of 2.2mm may serve as critical thresholds for stratifying endoscopic hemostatic approaches, providing a foundation for individualized, evidence-based treatment strategies.\u003c/p\u003e","manuscriptTitle":"Comparison of Endoscopic Hot Biopsy Forceps Coagulation and Hemostatic Clips for High-Risk Bleeding Peptic Ulcers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 13:04:51","doi":"10.21203/rs.3.rs-7601400/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2227d844-031b-4fbb-b94a-7f5e0a4a866d","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-02T15:53:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 13:04:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7601400","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7601400","identity":"rs-7601400","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}