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Comparison of a Hemostatic Powder and Standard Treatment in the Control of Active Bleeding From Upper Nonvariceal Lesions

TO THE EDITOR: Lau and colleagues (1) have shown that power-sprayed hemostatic powder is not inferior to standard endoscopic treatment in actively bleeding lesions. However, a few points warrant closer consideration. First, Lau and colleagues' study reports that the standard endoscopic treatment group had a much higher incidence of failure to control bleeding at 30 days (1 of 5 patients) than would be expected in a cohort where most lesions were Forrest 1b ulcers. These ulcers are known to have a very low risk for failure of endoscopic therapy (0% to 5%) (2, 3). Second, all methods of endoscopic therapy were not fully explored for the management of bleeding from ulcers in the standard endoscopic treatment group. Ulcers larger than 2 cm, which carry a high risk for failure of endoscopic therapy, were seen in 17.6% of patients. Use of over-the-scope clips may have been a better choice in these patients because these clips are large and have a greater compression force on the tissue (4). They achieve primary hemostasis in 97% to 100% of patients and have a low rate of rebleeding (0% to 22%) (5). Moreover, the major difference in hemostasis at 30 days between the standard endoscopic treatment and TC-325 groups (35.8% percentage points) was seen in patients with gastrointestinal tumors. Bleeding from these tumors is often in the form of diffuse ooze and is difficult to control using standard endoscopic treatment, which is better suited for bleeding from a point. This difference had the maximum effect on the primary outcome, with no significant difference in hemostasis between other endoscopic findings. Finally, Lau and colleagues' study included a higher proportion of patients with gastrointestinal tumors than in other studies, and a higher proportion of these patients were in the TC-325 group. This finding raises a possibility of bias during inclusion. More data are thus needed before power-sprayed hemostatic powder is accepted as a standard treatment method for endoscopic hemostasis in active nonvariceal bleeding.