Efficacy and safety of novel hemostatic gel in endoscopic sphincterotomy or endoscopic papillectomy: A multicenter, randomized controlled clinical trial

Advancement of haemostatic self-assembling peptides in the treatment of gastrointestinal bleeding: What role for PuraStat®?

PuraStat^® is a novel self-assembling peptide (SAP) used as a haemostatic agent in endoscopy, with widespread application in surgical settings. While the current evidence, though deserving further expansion, demonstrates a good haemostatic performance profile for this substance, there remains significant heterogeneity among studies, and an analysis of this SAP as monotherapy is not always available. The recent study by Bellester et al in the World Journal of Gastrointestinal Endoscopy provided an optimal effectiveness profile of this SAP in 45 patients treated for gastrointestinal (GI) bleeding, particularly highlighting data on its use as monotherapy in upper GI bleeding. This invited article outlines the current evidence on PuraStat^® and offers a commentary on the recently published study.

Efficacy of Polysaccharide Hemostatic Powder on Blood Oozing Among Patients With Postendoscopic Sphincterotomy Bleeding: A Randomized Controlled Trial

INTRODUCTION

Postendoscopic sphincterotomy (EST) bleeding presents challenges for endoscopists using side-viewing duodenoscopes. Recently, polysaccharide hemostatic powder (PHP) has shown promising results in managing gastrointestinal hemorrhage. Given the established efficacy of endoscopic clips in addressing post-EST bleeding, we aim to evaluate the efficacy of PHP and its noninferiority to endoscopic clips in patients with nonpulsatile post-EST bleeding.

METHODS

Patients with nonpulsatile post-EST bleeding were randomized to receive either PHP or endoscopic clips. The primary end point was the immediate hemostasis rate, with secondary end points including delayed bleeding rate, overall treatment success rate, mean hemostasis time, and other major complications.

RESULTS

A total of 104 patients with nonpulsatile post-EST bleeding were included. Immediate hemostasis was achieved in 100% of the PHP group and 92.3% in the endoscopic clip group (risk difference, 7.7%, 95% confidence interval (CI) = 0.5%-15.0%, P = 0.022). Four patients in the endoscopic clip group experienced immediate hemostasis failure. Hemostasis time was shorter in the PHP group (50.77 vs 62.81 seconds, P = 0.011). One delayed bleeding case (2.1%) occurred in the clip group, whereas none were observed in the PHP group. The overall treatment success rate was higher in the PHP group compared with the endoscopic clip group (100% vs 90.4%; P = 0.022). No differences were observed in adverse events.

DISCUSSION

PHP is not inferior to endoscopic clip and could be of use in immediate hemostasis for nonpulsatile post-EST bleeding, with the added advantage of ease of use. Further research is needed to assess its efficacy in preventing delayed bleeding ( chictr.org.cn , ChiCTR2400092280).

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Efficacy of hemostatic powder monotherapy versus conventional endoscopic treatment for nonvariceal GI bleeding: a meta-analysis and trial sequential analysis

BACKGROUND AND AIMS

Hemostatic powder (HP) is a novel hemostasis modality for nonvariceal GI bleeding. This meta-analysis was performed to evaluate the efficacy of HP monotherapy versus conventional endoscopic treatment (CET) for nonvariceal GI bleeding.

METHODS

PubMed, EMBASE, and Cochrane Library databases were systematically searched from inception to October 16, 2023. The primary outcomes were the initial hemostatic rate and the 30-day recurrent bleeding rate. After the meta-analysis, a trial sequential analysis (TSA) was also conducted to decrease the risk of random errors and validate the result.

RESULTS

The meta-analysis included 8 studies, incorporating 653 patients in total. Given significant heterogeneity, all analyses were segregated into malignancy-related and nonmalignancy-related GI bleeding lesions. For the former, HP monotherapy significantly improved the initial hemostasis rate and 30-day recurrent bleeding rate compared with CET (relative risk [RR], 1.50; 95% confidence interval [CI], 1.28-1.75; P < .001; RR, .32; 95% CI, .12-.86; P = .02, respectively), and TSA supported the results. For nonmalignancy-related GI bleeding, HP monotherapy and CET have similar initial hemostasis and 30-day recurrent bleeding rates (RR, 1.08; 95% CI, .98-1.19; P = .11; RR, 1.15; 95% CI, .46-2.90; P = .76, respectively), but the TSA failed to confirm the results.

CONCLUSIONS

HP monotherapy surpassed CET in terms of the initial hemostasis rate and 30-day recurrent bleeding rate for patients with malignancy-related GI bleeding. However, their relative efficacy for nonmalignancy-related GI bleeding remains unresolved.

Bleeding after endoscopic papillectomy and its risk factors: A single center experience of 196 cases

BACKGROUND

Endoscopic papillectomy (EP) is an effective method to remove an ampulla of Vater (AoV) adenoma with minimal invasiveness. We reviewed the clinical outcomes and prognosis of patients undergoing EP, including tumor recurrence and adverse events.

METHODS

A total of 196 patients who underwent EP from January 2004 to December 2017 were included. Clinical information was collected through electronic medical records, and risk factors to predict post-procedural bleeding were analyzed using a multivariate logistic regression model.

RESULTS

A total of 93.9% patients (184/196) underwent complete resection. During the follow-up period, 14.7% patients (27/184) experienced tumor recurrence, and two of seven surgically resected tumors were malignant. A total of 45.4% patients (89/196) experienced adverse events related to EP. Delayed bleeding occurred in 16.3% of the patients (32/196), and they were all successfully treated with endoscopic hemostasis and conservative management. The most frequent site of delayed bleeding was the distal end of the papillary orifice, and 56.3% (18/32) patients of delayed bleeding were classified as having mild severity, the others had moderate severity. Familial adenomatous polyposis (FAP) [odds ratio (OR) = 3.80, 95% confidence interval (CI): 1.01-14.29; P < 0.05] and male sex (OR = 2.82, 95% CI: 1.04-7.63; P = 0.04) showed statistical significance in predicting delayed post-EP bleeding.

CONCLUSIONS

EP for AoV adenoma was a highly effective and safe procedure. The risk of post-EP delayed bleeding was increased in patients with FAP syndrome and male patients, and post-EP bleeding occurred most commonly in the distal part of the AoV.

Effectiveness and safety of a new clip for delivery using a duodenoscope for bleeding after endoscopic sphincterotomy

Background and study aims Hemostasis for post-endoscopic sphincterotomy (post-EST) bleeding involves no standard strategy. New clips designed for delivery using the duodenoscope (SureClip, Micro-Tech, Nanjing, China) have been utilized for gastrointestinal bleeding hemostasis and bleeding prevention after polypectomy and papillectomy. We retrospectively analyzed the effectiveness and safety of SureClip for post-EST bleeding. Patients and methods Of 608 patients with endoscopic sphincterotomy (EST), 41 cases (6.7%) experienced post-EST bleeding from 2019 to 2023. Of these patients, 24 underwent hemostasis by SureClip, and the success rate of complete hemostasis and complication by hemostasis by SureClip was analyzed. Results In 12 and 12 patients with urgent and delayed bleeding, 11 (91.7%) and 11 (91.7%) had successful hemostasis, respectively. In addition, missed patients achieved complete hemostasis with additional transcatheter arterial embolization and balloon compression, respectively. No complications were observed, including perforation, pancreatitis, and clipping bile duct and pancreatic duct by mistake. Conclusions Hemostasis with SureClip is safe, effective, and not expensive for post-EST bleeding. It could be the first choice for hemostasis in patients with post-EST bleeding refractory to balloon compression.