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Lee AY, Cho JY. Advancements in hemostatic strategies for managing upper gastrointestinal bleeding: A comprehensive review. World J Gastroenterol 2024; 30:2087-2090. [PMID: 38681987 PMCID: PMC11045484 DOI: 10.3748/wjg.v30.i15.2087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/20/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
Upper gastrointestinal (GI) hemorrhage presents a substantial clinical challenge. Initial management typically involves resuscitation and endoscopy within 24 h, although the benefit of very early endoscopy (< 12 h) for high-risk patients is debated. Treatment goals include stopping acute bleeding, preventing rebleeding, and using a multimodal approach encompassing endoscopic, pharmacological, angiographic, and surgical methods. Pharmacological agents such as vasopressin, prostaglandins, and proton pump inhibitors are effective, but the increase in antithrombotic use has increased GI bleeding morbidity. Endoscopic hemostasis, particularly for nonvariceal bleeding, employs techniques such as electrocoagulation and heater probes, with concerns over tissue injury from monopolar electrocoagulation. Novel methods such as Hemospray and Endoclot show promise in creating mechanical tamponades but have limitations. Currently, the first-line therapy includes thermal probes and hemoclips, with over-the-scope clips emerging for larger ulcer bleeding. The gold probe, combining bipolar electrocoagulation and injection, offers targeted coagulation but has faced device-related issues. Future advancements involve combining techniques and improving endoscopic imaging, with studies exploring combined approaches showing promise. Ongoing research is crucial for developing standardized and effective hemorrhage management strategies.
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Affiliation(s)
- Ah Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul 06135, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul 06135, Korea
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2
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Amaya-Fragoso E, Hernández-Guerrero A, de la Mora Levy JG, Ramírez-Solís ME, Alonso-Lárraga JO, Beltrán-Galindo LG. Mortality in patients with unresectable gastric cancer complicated with tumor bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:132-139. [PMID: 37170581 DOI: 10.17235/reed.2023.9508/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND gastric cancer (GC) is a gastrointestinal (GI) neoplasia which often complicates with GI bleeding. It is uncertain if bleeding worsens mortality in this group of patients. AIMS to compare 30- and 90-day mortality in patients with unresectable GC (uGC) and tumor bleeding versus patients with the same neoplasia without bleeding. METHODS a retrospective analysis of patients with uGC, with and without tumor bleeding was performed. Survival analysis for 30- and 90-days mortality was performed using Cox regression. Logistic regression was used to identify risk factors associated with mortality and first bleeding episode. RESULTS 202 patients were included in the analysis (105 cases). Mortality at 90 days was 37.14 % for cases and 20.62 % for controls (p = 0.04). There was a significant difference in hazard ratio (HR) at 90 days for cases compared to controls (HR 1.95, 95 % CI 1.14-3.34, p = 0.02). Cases without palliative chemotherapy had the highest 90-days mortality (HR 5.43, 95 % CI 2.12-13.87, p < 0.01), compared to controls treated with chemotherapy. Predictors for first tumor bleeding were clinical stage IV (OR 2.93, 95 % CI 1.04-8.26, p = 0.04), Helicobacter pylori infection (OR 2.80, 95 % CI 1.35-5.80, p < 0.01) and histologic intestinal-subtype (OR 2.14, 95 % CI 1.07-4.30, p = 0.03). CONCLUSIONS tumor bleeding increases 90-days mortality in patients with uGC. Prevention of the first bleeding episode might improve outcome in these patients and the recognition of high-risk patients might help decision-making.
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Chiang HC. The Risk of Polysaccharide Hemostatic Powder for Peptic Ulcer Bleeding. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00952-7. [PMID: 38040275 DOI: 10.1016/j.cgh.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Gibiino G, Binda C, Secco M, Giuffrida P, Coluccio C, Perini B, Fabbri S, Liverani E, Jung CFM, Fabbri C. Endoscopic Management of Bleeding in Altered Anatomy after Upper Gastrointestinal Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1941. [PMID: 38003990 PMCID: PMC10672978 DOI: 10.3390/medicina59111941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023]
Abstract
Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients-up to about 2%. Most cases of intraluminal bleeding are an indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.
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Affiliation(s)
- Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Matteo Secco
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Paolo Giuffrida
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Barbara Perini
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, 35128 Padua, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Elisa Liverani
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
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Su DS, Li CK, Gao C, Qi XS. Hemostatic powder for acute upper gastrointestinal bleeding: Recent research advances. Shijie Huaren Xiaohua Zazhi 2023; 31:249-255. [DOI: 10.11569/wcjd.v31.i7.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is a clinically common emergency condition. The common causes of AUGIB are peptic ulcer and esophagogastric variceal bleeding. Despite continuous improvements in endoscopic hemostasis techniques, endoscopic treatment is still unsuccessful in 5%-15% of patients. Hemostatic powder, a new drug for endoscopic hemostasis that is sprayed on the bleeding site with the assistance of an air pump, can absorb water to promote clotting substance aggregation and then adhere over the lesion, forming a mechanical barrier and then achieving hemostasis. It is convenient to spray hemostatic powder under endoscopy, where precise positioning is not warranted. The immediate hemostasis rate of hemostatic powder is often high, and it can be used as a remedy after the failure of conventional hemostasis. However, until now, there have been no recommendations in China regarding the use of hemostatic powder for the treatment of AUGIB. This article summarizes the mechanism, clinical applicability, and side effects of five major types of hemostatic powder by reviewing the existing evidence, with an aim to strengthen endoscopists' understanding of this drug.
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Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010143. [PMID: 36676767 PMCID: PMC9863809 DOI: 10.3390/medicina59010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.
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Jiang SX, Chahal D, Ali-Mohamad N, Kastrup C, Donnellan F. Hemostatic powders for gastrointestinal bleeding: a review of old, new, and emerging agents in a rapidly advancing field. Endosc Int Open 2022; 10:E1136-E1146. [PMID: 36238531 PMCID: PMC9552790 DOI: 10.1055/a-1836-8962] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/20/2022] [Indexed: 10/26/2022] Open
Abstract
Background and study aims Hemostatic powders are increasingly used to address limitations in conventional endoscopic techniques for gastrointestinal bleeding. Various agents exist with different compositions, characteristics, efficacy, and adverse events (AEs). We sought to review existing hemostatic powders, from preclinical to established agents. Methods A literature review on hemostatic powders for gastrointestinal bleeding was undertaken through a MEDLINE search from 2000-2021 and hand searching of articles. Relevant literature was critically appraised and reviewed for mechanism of action, hemostasis and rebleeding rate, factors associated with hemostatic failure, and AEs. Results The most established agents are TC-325 (Hemospray), EndoClot, and Ankaferd Blood Stopper (ABS). These agents have been successfully applied to a variety of upper and lower gastrointestinal bleeding etiologies, in the form of primary, combination, salvage, and bridging therapy. Few AEs have been reported, including visceral perforation, venous embolism, and self-limited abdominal pain. Newer agents include CEGP-003 and UI-EWD, which have shown results similar to those for the older agents in initial clinical studies. All aforementioned powders have high immediate hemostasis rates, particularly in scenarios not amenable to conventional endoscopic methods, but are limited by significant rates of rebleeding. Other treatments include TDM-621 (PuraStat) consisting of a liquid hemostatic agent newly applied to endoscopy and self-propelling thrombin powder (CounterFlow Powder), a preclinical but promising agent. Conclusions Rapid development of hemostatic powders and growing clinical expertise has established these agents as a valuable strategy in gastrointestinal bleeding. Further research will continue to refine the efficacy and applicability of these agents.
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Affiliation(s)
- Shirley X. Jiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daljeet Chahal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, United States
| | - Nabil Ali-Mohamad
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christian Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada,Blood Research Institute, Versiti, Milwaukee, Wisconsin, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
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Cha B, Lee D, Shin J, Park JS, Kwon GS, Kim H. Hemostatic efficacy and safety of the hemostatic powder UI-EWD in patients with lower gastrointestinal bleeding. BMC Gastroenterol 2022; 22:170. [PMID: 35392821 PMCID: PMC8991611 DOI: 10.1186/s12876-022-02247-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
Background and aims Acute lower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. Recently, a novel endoscopic hemostatic powder (UI-EWD/Nexpowder™, Nextbiomedical, Incheon, South Korea) was developed and applied for the control of LGIB. The aim of this study was to evaluate the hemostatic efficacy and long-term safety of UI-EWD in LGIB. Patients and methods We conducted a retrospective cohort study of LGIB at a single tertiary center in south Korea. One hundred and sixty-seven consecutive patients with LGIB who were initially successful in endoscopic hemostasis were included and divided into the conventional treatment group (n = 112) and the UI-EWD therapy group (n = 55; 38 patients with conventional treatment and 17 patients with UI-EWD alone). The success rate of hemostasis, adverse events related to UI-EWD, and re-bleeding rate were evaluated. Results The incidence of endoscopic hemostasis applied to the hepatic flexure (7.3% vs. 0%, p = 0.011) and larger than 4 cm (25.5% vs. 8.0%, p = 0.002) were significantly higher in the UI-EWD group than in the conventional therapy group. The cumulative rebleeding rate within 28 days in the UI-EWD group was 5.5% (3/55), which was significantly lower than that in the conventional treatment group (17.0% [19/112]; p = 0.039). No UI-EWD-related adverse events were recorded. Conclusion Based on our results, application of UI-EWD in LGIB showed promising results for the prevention of re-bleeding, especially in locations where it is difficult to approach or cases with more bleeding. There were no significant complications, such as perforation or embolism. In particular, UI-EWD should be considered first for anatomical or technical impediments to endoscopic access in LGIB.
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Affiliation(s)
- Boram Cha
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Donghyun Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Jongbeom Shin
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea.
| | - Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Gye-Suk Kwon
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Hyungkil Kim
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
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Propensity score matching analysis to evaluate efficacy of polyethylene oxide adhesive on preventing delayed bleeding after gastric endoscopic submucosal dissection. Sci Rep 2022; 12:4538. [PMID: 35297400 PMCID: PMC8927376 DOI: 10.1038/s41598-022-08499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/07/2022] [Indexed: 02/07/2023] Open
Abstract
Regardless of technical advancements, delayed bleeding is still a common adverse event after gastric endoscopic submucosal dissection (ESD), often occurring in the early postoperative phase. This study aimed to evaluate the efficacy of a newly designed polyethylene oxide (PEO) adhesive for preventing delayed gastric bleeding. Patients who underwent gastric ESD between December 2017 and December 2020 at three Chinese institutions were retrospectively reviewed. Patients receiving PEO application on gastric post-ESD ulcers were included in the PEO group, and patients without this procedure were included in the control group. To minimize potential bias, propensity score matching was performed, and sex, age, lesion size, lesion morphology, ulceration, localization, procedure time, frequency of major intraoperative bleeding, resected specimen size, lesion histopathology, submucosal invasion and the taking of antithrombotic drugs were included as matching factors. The incidence of delayed bleeding and time to bleeding were compared between both groups. After propensity score matching, 270 patients (135 per group) were included in the analysis. The delayed bleeding rate in the PEO group was significantly lower than that in the control group (1.5%, 2/135 vs. 8.9%, 12/135, P = 0.006). The median time (range) to bleeding was 4.5 (4–5) days in the PEO group and 2 (1–15) days in the control group, with no significant difference (P = 0. 198). PEO demonstrated a significant effect in reducing the rate of delayed bleeding. Further study is warranted to confirm the efficacy of PEO for bleeding that occurs in the early phase after gastric ESD.
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Orpen-Palmer J, Stanley AJ. Update on the management of upper gastrointestinal bleeding. BMJ MEDICINE 2022; 1:e000202. [PMID: 36936565 PMCID: PMC9951461 DOI: 10.1136/bmjmed-2022-000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/15/2022] [Indexed: 11/04/2022]
Abstract
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
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Jung DH, Moon HS, Park CH, Park JC. Polysaccharide hemostatic powder to prevent bleeding after endoscopic submucosal dissection in high risk patients: a randomized controlled trial. Endoscopy 2021; 53:994-1002. [PMID: 33200808 DOI: 10.1055/a-1312-9420] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND : Bleeding after endoscopic submucosal dissection (ESD) is a severe adverse event. Several methods to prevent post-ESD bleeding (PEB) have been introduced; however, they have not been widely used because of technical difficulties. We aimed to investigate whether polysaccharide hemostatic powder (PHP), which is very easy to apply, can prevent early post-ESD bleeding, especially in patients with a high risk of post-ESD bleeding. METHODS : This was a prospective, multicenter, randomized, open-label, controlled trial. Patients with a high risk for post-ESD bleeding were enrolled. Patients with gastric neoplasms in whom the resected specimen size was expected to be > 40 mm and those who were regularly taking antithrombotic agents were defined as high risk patients. Patients were randomly assigned to the PHP or control groups. RESULTS: Between May 2017 and September 2018, 143 patients were enrolled (PHP group, 73; control group, 70). The total post-ESD bleeding rate was 6.3 % (PHP group, 5.5 % vs. control group, 7.1 %; P = 0.74). There was no bleeding within 7 days after ESD in the PHP group. Continued antithrombotic use was an independent risk factor for post-ESD bleeding. In subgroup analysis excluding the patients who continued to take antithrombotic agents (n = 129) during ESD, the rate of post-ESD bleeding tended to be lower in the PHP group than in the control group (0 % vs. 6.3 %; P = 0.06). CONCLUSION : PHP did not demonstrate a significant effect on the prevention of post-ESD bleeding in this study. Further larger scale, randomized controlled trials are needed to confirm this.
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Affiliation(s)
- Da Hyun Jung
- Department of Gastroenterology, Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jun Chul Park
- Department of Gastroenterology, Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Jung DH, Park JC. Strategies that Reduce Post-endoscopic Submucosal Dissection Bleeding. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Bleeding after endoscopic submucosal dissection (ESD), one of the most common postprocedural adverse events, is the main cause of increased readmission rates and hospital costs. Generally, the incidence of post-ESD bleeding is estimated to be about 5%. However, the incidence of bleeding is particularly increased in high-risk patients. In particular, it has an incidence of over 50% in patients that use antithrombotic agents. The well-known risk factors for post-ESD bleeding include antithrombotic therapy, lesions in the proximal stomach, specimen size >4 cm, and concomitant renal disease. Currently, the number of patients at a high risk of post-ESD bleeding has been increasing. This may be due to the aging society and the increase in the usage of antithrombotic agents. Therefore, several strategies have been employed to prevent post-ESD bleeding. These strategies include acid inhibition therapy, preventive hemostasis using Doppler endoscopic ultrasound and artery-selective clipping, second look endoscopy, the closings method, and the shield methods. However, these methods are technically demanding, which hinders their wide usage in clinical practice. Recently, several hemostatic powders have been developed and clinically used in the treatment of gastrointestinal bleeding. In this article, we review the risk factors for post-ESD bleeding and the recently introduced prevention methods. Moreover, we aimed to explore realistic and appropriate strategies for the prevention of post-ESD bleeding.
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Branchi F, Klingenberg-Noftz R, Friedrich K, Bürgel N, Daum S, Buchkremer J, Sonnenberg E, Schumann M, Treese C, Tröger H, Lissner D, Epple HJ, Siegmund B, Stroux A, Adler A, Veltzke-Schlieker W, Autenrieth D, Leonhardt S, Fischer A, Jürgensen C, Pape UF, Wiedenmann B, Möschler O, Schreiner M, Strowski MZ, Hempel V, Huber Y, Neumann H, Bojarski C. PuraStat in gastrointestinal bleeding: results of a prospective multicentre observational pilot study. Surg Endosc 2021; 36:2954-2961. [PMID: 34129089 PMCID: PMC9001238 DOI: 10.1007/s00464-021-08589-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 06/02/2021] [Indexed: 11/28/2022]
Abstract
Background A recently developed haemostatic peptide gel for endoscopic application has been introduced to improve the management of gastrointestinal bleeding. The aim of this pilot study was to evaluate the feasibility, safety, efficacy and indication profiles of PuraStat in a clinical setting. Methods In this prospective observational multicentre pilot study, patients with acute non-variceal gastrointestinal bleeding (upper and lower) were included. Primary and secondary application of PuraStat was evaluated. Haemoglobin, prothrombin time, platelets and transfusion behaviour were documented before and after haemostasis. The efficacy of PuraStat was assessed during the procedure, at 3 days and 1 week after application. Results 111 patients with acute gastrointestinal bleeding were recruited into the study. 70 percent (78/111) of the patients had upper gastrointestinal bleeding and 30% (33/111) had lower gastrointestinal bleeding. After primary application of PuraStat, initial haemostatic success was achieved in 94% of patients (74/79, 95% CI 88–99%), and in 75% of the patients when used as a secondary haemostatic product, following failure of established techniques (24/32, 95% CI 59–91%). The therapeutic success rates (absence of rebleeding) after 3 and 7 days were 91% and 87% after primary use, and 87% and 81% in all study patients. Overall rebleeding rate at 30 day follow-up was 16% (18/111). In the 5 patients who finally required surgery (4.5%), PuraStat allowed temporary haemostasis and stabilisation. Conclusions PuraStat expanded the therapeutic toolbox available for an effective treatment of gastrointestinal bleeding sources. It could be safely applied and administered without complications as a primary or secondary therapy. PuraStat may additionally serve as a bridge to surgery in order to achieve temporary haemostasis in case of refractory severe bleeding, possibly playing a role in preventing immediate emergency surgery. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08589-6.
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Affiliation(s)
- Federica Branchi
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Rolf Klingenberg-Noftz
- DRK-Krankenhaus Grevesmühlen, Gastroenterologie und Allgemeine Innere Medizin, Klützer Straße 13-15, 23936, Grevesmühlen, Germany
| | - Kristina Friedrich
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Nataly Bürgel
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Severin Daum
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Juliane Buchkremer
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Elena Sonnenberg
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Michael Schumann
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christoph Treese
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Hanno Tröger
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Donata Lissner
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Hans-Jörg Epple
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Britta Siegmund
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Andrea Stroux
- Institut für Biometrie und Klinische Epidemiologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Andreas Adler
- Campus Virchow Klinikum, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Winfried Veltzke-Schlieker
- Campus Virchow Klinikum, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Daniel Autenrieth
- Campus Virchow Klinikum, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Silke Leonhardt
- Campus Virchow Klinikum, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Fischer
- Campus Virchow Klinikum, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Jürgensen
- Campus Mitte, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Virchowweg 10, 10117, Berlin, Germany
| | - Ulrich-Frank Pape
- Campus Mitte, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Virchowweg 10, 10117, Berlin, Germany
| | - Bertram Wiedenmann
- Campus Virchow Klinikum, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Campus Mitte, Medizinische Klinik mit Schwerpunkt Gastroenterologie und Hepatologie, Virchowweg 10, 10117, Berlin, Germany
| | - Oliver Möschler
- Niels-Stensen-Kliniken, Marienhospital Osnabück GmbH, Bischhofstraße 1, 49074, Osnabrück, Germany
| | - Maximilian Schreiner
- Bundeswehrkrankenhaus Berlin, Klinik für Innere Medizin, Scharnhorststraße 13, 10115, Berlin, Germany
| | - Mathias Z Strowski
- Park-Klinik Weißensee, Gastroenterologie und Onkologie, Klinik für Innere Medizin, Schönstr. 80, 13086, Berlin, Germany
| | - Volkmar Hempel
- Klinikum Mittleres Erzgebirge gGmbH, Klinik für Innere Medizin, Alte Marienberger Straße 52, 09405, Zschopau, Germany
| | - Yvonne Huber
- I. Medizinische Klinik Und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Helmut Neumann
- I. Medizinische Klinik Und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Christian Bojarski
- Campus Benjamin Franklin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
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14
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Feasibility and safety of a new endoscopic synthetic sealant nebulizing device over gastric endoscopic submucosal dissections. Surg Endosc 2021; 35:4048-4054. [PMID: 33851265 PMCID: PMC8195911 DOI: 10.1007/s00464-021-08480-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/28/2021] [Indexed: 11/16/2022]
Abstract
Background Endoscopic Submucosal Dissection (ESD) is the treatment of choice of superficial neoplastic gastrointestinal lesions. Delayed bleedings and perforations are still current clinical concerns. Glubran 2 is a synthetic cyanoacrylate-derived glue nowadays already widely used as an effective tissue adhesive. ENDONEB is a novel device thought for enabling the sealant nebulization over a specific targeted surface during laparotomy, laparoscopy, and thoracotomy. The aim of this single-center preclinical animal trial is to evaluate the feasibility and safety of the same nebulization technique during ESD in the perspective that further clinical studies would demonstrate the efficacy of Glubran 2 in preventing post-ESD adverse events. Methods Four live Landrace pigs were enrolled. Two approximately 30-mm-wide gastric ESDs were performed in each pig (experimental ESD and control ESD). About 0.5 mL of Glubran 2 was nebulized on the experimental ESDs. Subjective perception of the feasibility of the Glubran 2 nebulization was reported. Pigs were clinically monitored at follow-up and upper GI endoscopy was performed at 24 and 48 hours, when animals were euthanized to perform a macroscopic and histological analysis of the specimens. Results No peri-procedural adverse events were reported. Glubran 2 nebulization over experimental ESDs showed to be technically easy and time-effective. Clinical and endoscopic animal monitoring was negative at follow-up. At 24 hours, the Glubran 2 film was clearly visible on the eschar of the ESDs and signs of initial hydrolysis were discernable at 48 hours. No signs of peritoneal reaction were observed at the macroscopic examination. Equal transmural inflammation was described at the histological examination of both types of ESDs. Conclusions Safety and feasibility profiles of Glubran 2 nebulizing ENDONEB device over ESD surfaces were excellent. Further evidences and human trials are needed to investigate its effectiveness in ESDs’ eschars sealing and, thus, in delayed micro-perforations and bleedings prevention and treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08480-4.
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15
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Lee DH, Ko W. Hemostatic materials in non-variceal upper gastrointestinal hemorrhage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii190015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
- Utah-Inha DDS and Advanced Therapeutics Research Center, Incheon, Korea
| | - Weonjin Ko
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
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16
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Naseer M, Lambert K, Hamed A, Ali E. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World J Gastrointest Endosc 2020; 12:1-16. [PMID: 31942229 PMCID: PMC6939122 DOI: 10.4253/wjge.v12.i1.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/28/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Maliha Naseer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Karissa Lambert
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Ahmed Hamed
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Eslam Ali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
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17
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Alzoubaidi D, Hussein M, Rusu R, Napier D, Dixon S, Rey JW, Steinheber C, Jameie-Oskooei S, Dahan M, Hayee B, Gulati S, Despott E, Murino A, Subramaniam S, Moreea S, Boger P, Hu M, Duarte P, Dunn J, Mainie I, McGoran J, Graham D, Anderson J, Bhandari P, Goetz M, Kiesslich R, Coron E, Lovat L, Haidry R. Outcomes from an international multicenter registry of patients with acute gastrointestinal bleeding undergoing endoscopic treatment with Hemospray. Dig Endosc 2020; 32:96-105. [PMID: 31365756 DOI: 10.1111/den.13502] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/28/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. PATIENTS AND METHODS Prospective data (Jan 2016-May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5 min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post-therapy. RESULTS Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8-14) and median complete Rockall score (RS) was 7 (IQR: 6-8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314 = 53%) and Forrest Ib the most common bleed type in PUD (100/167 = 60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven-day and 30-day all-cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. CONCLUSIONS These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Mohamed Hussein
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Radu Rusu
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust Hospitals, London, UK
| | - Duncan Napier
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust - Cheltenham General Hospital, Cheltenham, UK
| | - Selena Dixon
- Department of Gastroenterology, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Johannes W Rey
- Department of Gastroenterology, Clinic Osnabruck, Osnabruck, Germany
| | - Cora Steinheber
- Department of Gastroenterology, Tubingen University Hospital, Tubingen, Germany
| | | | - Martin Dahan
- Department of Gastroenterology, University Hospital Centre, Nantes, France
| | - Bu Hayee
- Department of Gastroenterology, Kings College London, London, UK
| | - Shraddha Gulati
- Department of Gastroenterology, Kings College London, London, UK
| | - Edward Despott
- Department of Gastroenterology, The Royal Free Hospital, London, UK
| | - Alberto Murino
- Department of Gastroenterology, The Royal Free Hospital, London, UK
| | | | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Phil Boger
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Maxworth Hu
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Patricia Duarte
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Jason Dunn
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust Hospitals, London, UK
| | - Inder Mainie
- Department of Gastroenterology, Belfast Trust, Belfast, UK
| | - John McGoran
- Department of Gastroenterology, Belfast Trust, Belfast, UK
| | - David Graham
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust - Cheltenham General Hospital, Cheltenham, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Martin Goetz
- Department of Gastroenterology, Tubingen University Hospital, Tubingen, Germany
| | | | - Emmanuel Coron
- Department of Gastroenterology, University Hospital Centre, Nantes, France
| | - Laurence Lovat
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Department of Gastroenterology, University College London Hospital (UCLH), London, UK
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18
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Management of Bleeding from Unresectable Gastric Cancer. Biomedicines 2019; 7:biomedicines7030054. [PMID: 31344824 PMCID: PMC6784219 DOI: 10.3390/biomedicines7030054] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Bleeding from unresectable gastric cancer (URGC) is not a rare complication. Two major ways in which the management of this issue differs from the management of benign lesions are the high rate of rebleeding after successful hemostasis and that not only endoscopic therapy (ET) and transcatheter arterial embolization (TAE) but palliative radiotherapy (PRT) can be applied in the clinical setting. However, there are no specific guidelines concerning the management of URGC with bleeding. We herein discuss strategies for managing bleeding from URGC. A high rate of initial hemostasis for active bleeding is expected when using various ET modalities properly. If ET fails in patients with hemostatic instability, emergent TAE is considered in order to avoid a life-threating condition due to massive bleeding. Early PRT, especially, regimens with a high biologically effective dose (BED) of ≥39 Gy should be considered not only for patients with hemostatic failure but also for those with successful hemostasis and inactive hemorrhage, as longer duration of response with few complications can be expected. Further prospective, comparative studies considering not only the hemostatic efficacy of these modalities but the patients' quality of life are needed in order to establish treatment strategies for bleeding from URGC.
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19
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Vitali F, Naegel A, Atreya R, Zopf S, Neufert C, Siebler J, Neurath MF, Rath T. Comparison of Hemospray ® and Endoclot ™ for the treatment of gastrointestinal bleeding. World J Gastroenterol 2019; 25:1592-1602. [PMID: 30983819 PMCID: PMC6452236 DOI: 10.3748/wjg.v25.i13.1592] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal (GI) bleeding is a common indication for endoscopy. For refractory cases, hemostatic powders (HP) represent “touch-free” agents.
AIM To analyze short term (ST-within 72 h-) and long-term (LT-within 30 d-) success for achieving hemostasis with HP and to directly compare the two agents Hemospray (HS) and Endoclot (EC).
METHODS HP was applied in 154 consecutive patients (mean age 67 years) with GI bleeding. Patients were followed up for 1 mo (mean follow-up: 3.2 mo).
RESULTS Majority of applications were in upper GI tract (89%) with following bleeding sources: peptic ulcer disease (35%), esophageal varices (7%), tumor bleeding (11.7%), reflux esophagitis (8.7%), diffuse bleeding and erosions (15.3%). Overall ST success was achieved in 125 patients (81%) and LT success in 81 patients (67%). Re-bleeding occurred in 27% of all patients. In 72 patients (47%), HP was applied as a salvage hemostatic therapy, here ST and LT success were 81% and 64%, with re-bleeding in 32%. As a primary hemostatic therapy, ST and LT success were 82% and 69%, with re-bleeding occurring in 22%. HS was more frequently applied for upper GI bleeding (P = 0.04)
CONCLUSION Both HP allow for effective hemostasis with no differences in ST, LT success and re-bleeding.
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Affiliation(s)
- Francesco Vitali
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Andreas Naegel
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Raja Atreya
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Steffen Zopf
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Clemens Neufert
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Juergen Siebler
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Markus F Neurath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Timo Rath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
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20
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Jung K, Moon W. Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review. World J Gastrointest Endosc 2019; 11:68-83. [PMID: 30788026 PMCID: PMC6379746 DOI: 10.4253/wjge.v11.i2.68] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/02/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.
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Affiliation(s)
- Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
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21
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Alzoubaidi D, Lovat LB, Haidry R. Management of non-variceal upper gastrointestinal bleeding: where are we in 2018? Frontline Gastroenterol 2019; 10:35-42. [PMID: 30651955 PMCID: PMC6319149 DOI: 10.1136/flgastro-2017-100901] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/10/2018] [Accepted: 01/21/2018] [Indexed: 02/04/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient's management. However, in order to continue to improve patient's outcomes, further developments are needed.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK
- GI Services, University College London Hospital, London, UK
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22
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Cho YS. New endoscopic techniques in treating gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Cipolletta L, Cipolletta F, Granata A, Ligresti D, Barresi L, Tarantino I, Traina M. What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding? ACTA ACUST UNITED AC 2018; 16:363-375. [PMID: 30229463 DOI: 10.1007/s11938-018-0192-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients. RECENT FINDINGS Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.
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Affiliation(s)
- Livio Cipolletta
- Endoscopy Unit, Ruesch Clinic, Via San Domenico, 24, 80127, Naples, Italy.
| | - Fabio Cipolletta
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
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Park JC, Kim YJ, Kim EH, Lee J, Yang HS, Kim EH, Hahn KY, Shin SK, Lee SK, Lee YC. Effectiveness of the polysaccharide hemostatic powder in non-variceal upper gastrointestinal bleeding: Using propensity score matching. J Gastroenterol Hepatol 2018; 33:1500-1506. [PMID: 29415371 DOI: 10.1111/jgh.14118] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/29/2017] [Accepted: 01/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Recently, the application of hemostatic powder to the bleeding site has been used to treat active upper gastrointestinal bleeding (UGIB). We aimed to assess the effectiveness of the polysaccharide hemostatic powder (PHP) in patients with non-variceal UGIB. METHODS We reviewed prospectively collected 40 patients with UGIB treated with PHP therapy between April 2016 and January 2017 (PHP group) and 303 patients with UGIB treated with conventional therapy between April 2012 and October 2014 (conventional therapy group). We compared the rate of successful hemostasis and the rebleeding between the two groups after as well as before propensity score matching using the Glasgow-Blatchford score and Forrest classification. RESULTS Thirty patients treated with the PHP and 60 patients treated with conventional therapy were included in the matched groups. Baseline patient characteristics including comorbidities, vital signs, and bleeding scores were similar in the matched groups. The rate of immediate hemostasis and 7-day and 30-day rebleeding were also similar in the two groups before and after matching. In the subgroup analysis, no significant differences in immediate hemostasis or rebleeding rate were noted between PHP in monotherapy and PHP combined with a conventional hemostatic method. At 30 days after the therapy, there were no significant PHP-related complications or mortality. CONCLUSIONS Given its safety, the PHP proved feasible for endoscopic treatment of UGIB, having similar effectiveness as that of conventional therapy. The PHP may become a promising hemostatic method for non-variceal UGIB.
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Affiliation(s)
- Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yeong Jin Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Su Yang
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Yeon Hahn
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Peptic ulcer bleeding remains an important medical emergency. Important recent advances are reviewed. These include further support for a more restrictive transfusion strategy aiming for a target haemoglobin of 70-90 g/L. The Glasgow-Blatchford score remains the most useful assessment score for identifying the lowest risk patients suitable for outpatient management and predicting the need for intervention. Newer scores such as the AIMS65 and Progetto Nazionale Emorragia Digestive score (PNED) may be more accurate in predicting mortality. Pre-endoscopy erythromycin improves outcomes and is underused. A new disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Over-the-scope clips and haemostatic powders appear to have some role as endoscopic salvage therapies. Non- H. pylori, non-aspirin/non-steroidal anti-inflammatory drug (NSAID) ulcers contribute to an increasing percentage of bleeding peptic ulcers and are associated with a high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian LP Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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Martínez-Alcalá A, Mönkemüller K. Emerging Endoscopic Treatments for Nonvariceal Upper Gastrointestinal Hemorrhage. Gastrointest Endosc Clin N Am 2018; 28:307-320. [PMID: 29933777 DOI: 10.1016/j.giec.2018.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite major improvements in endoscopic devices and therapeutic endoscopy, rebleeding rates and mortality have remained the same for several decades. Therefore, much interest has been paid to emerging therapeutic devices, such as the over-the-scope clip and hemostatic sprays. Other emerging technologies, such as radiofrequency ablation, endoscopic suturing devices, and ultrasound-guided angiotherapy, are also being investigated to improve therapeutic outcomes in specific situations. This narrative review details the technical aspects, clinical applications, outcomes, and potential limitations of these devices in the context of nonvariceal upper gastrointestinal hemorrhage.
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Affiliation(s)
| | - Klaus Mönkemüller
- Department of Visceral Surgery, Division of Endoscopy, Frankenwaldklinik, Kronach, Germany.
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Kim YJ, Park JC, Kim EH, Shin SK, Lee SK, Lee YC. Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy. Endosc Int Open 2018; 6:E700-E705. [PMID: 29868635 PMCID: PMC5979193 DOI: 10.1055/a-0593-5884] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Despite use of various endoscopic therapies in patients with tumor-related bleeding, various rates of successful immediate hemostasis and short-term rebleeding have been reported. We aimed to evaluate preliminary results of use of the EndoClot polysaccharide hemostatic system (PHS) in patients with acute upper gastrointestinal bleeding (UGIB) from a gastric malignancy. PATIENTS AND METHODS We retrospectively analyzed data from a prospectively collected database of 12 patients with acute UGIB from a gastric malignancy who had been treated with EndoClot PHS. The EndoClot air compressor was used to propel 2 g of absorbable modified polymer particles onto the bleeding site. We checked successful immediate hemostasis, rebleeding events and mortality within 30 days. RESULTS Twelve patients were enrolled in the study. The median patient age was 72.5 years (range, 57 - 89). The initial median hemoglobin level was 6.75 g/dL (range, 5.4 - 8.9). The median systolic blood pressure was 114 mmHg (range, 86 - 153). Eleven patients had advanced gastric cancer and one patient had a gastrointestinal stromal tumor. The lower body of the stomach was the most common tumor location (58.3 %), and the median tumor size was 40 mm (range, 15 - 100). Immediate hemostasis was achieved in all patients, and rebleeding developed in 2 of 12 patients (16 %), 3 and 5 days after treatment. There were no significant Endoclot PHS-related adverse events, and there was no all-cause mortality at 30 days after the intervention. CONCLUSIONS Endoclot PHS represents a new alternative, complementary, and promising therapy for patients with an acute UGIB from a gastric malignancy.
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Affiliation(s)
- Yeong Jin Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea,Corresponding author Jun Chul Park, MD, Associate professor Division of GastroenterologyDepartment of Internal MedicineYonsei University College of Medicine50, Yonsei-ro, Seodaemun-guSeoul,Korea+82-2-2227-7877
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Hahn KY, Park JC, Lee YK, Shin SK, Lee SK, Lee YC. Efficacy of hemostatic powder in preventing bleeding after gastric endoscopic submucosal dissection in high-risk patients. J Gastroenterol Hepatol 2018; 33:656-663. [PMID: 28910851 DOI: 10.1111/jgh.13990] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/29/2017] [Accepted: 09/08/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM The prevention of post-endoscopic submucosal dissection (ESD) bleeding in high-risk patients is an important problem. This study evaluated the efficacy of polysaccharide hemostatic powder in preventing post-ESD bleeding in high-risk patients. METHODS Patients at high risk for post-ESD bleeding were prospectively enrolled between December 2015 and July 2016. A high risk of post-ESD bleeding was considered if the patients were taking antithrombotic agents or had undergone a large resection (specimen size ≥ 40 mm). The endpoints were Forrest classification of the post-ESD ulcer on second-look endoscopy 2 days after the procedure and bleeding rates within 48 h and at 4 weeks. RESULTS Forty-four patients underwent gastric ESD and treatment with hemostatic powder. Among them, 33 patients (70.5%) underwent large resection (≥ 40 mm) without antithrombotic therapy, and 13 patients (29.5%) received antithrombotic therapy. The mean resected specimen size was 55.3 ± 13.9 mm. The proportion of high-risk delayed bleeding lesions (Forrest IIa) at second-look endoscopy was 4.5% (2/44). The overall bleeding rate was 9.1% (4/44). There was no early bleeding event. The median (interquartile range) timing of bleeding after the procedure was 12.5 (interquartile range 10.3-15.5) days. The bleeding rate in the large resection (≥ 40 mm) group without antithrombotic therapy and the antithrombotic therapy group was 3.2% (1/33) and 23.1% (3/13), respectively. CONCLUSIONS Hemostatic powder may be a promising new simple and effective method to prevent early post-ESD bleeding in high-risk patients, especially for those with larger resection. (Clinical trial registration number: NCT02625792).
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Affiliation(s)
- Kyu Yeon Hahn
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Kang Lee
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Cahyadi O, Bauder M, Meier B, Caca K, Schmidt A. Effectiveness of TC-325 (Hemospray) for treatment of diffuse or refractory upper gastrointestinal bleeding - a single center experience. Endosc Int Open 2017; 5:E1159-E1164. [PMID: 29124127 PMCID: PMC5677459 DOI: 10.1055/s-0043-118794] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS TC-325 (Hemospray, Cook Medical) is a powder agent for endoscopic hemostasis in patients with upper gastrointestinal bleeding (UGIB). Although most publications are based on case-reports and retrospective studies, data on efficacy are promising. Here we report our experience with TC-325 for diffuse or refractory UGIB. PATIENTS AND METHODS Data on patients receiving TC-325 for endoscopic hemostasis from November 2013 to February 2017 at our center were analyzed retrospectively. Primary endpoints were technical success (successful immediate hemostasis) and clinical success (effective hemostasis and no recurrent bleeding). Secondary endpoints were recurrent bleeding within 3 and 7 days, hospital mortality and TC-325 associated complications. TC-325 was used for bleeding not amenable to standard endoscopic treatment (e. g. diffuse bleeding) or as salvage therapy after failure of conventional methods. RESULTS Fifty-two patients received TC-325 treatment. Most of the patients were treated for peptic ulcer bleeding (18/52 patients, 34.6 %) and post-interventional bleeding (13/52 patients, 25 %). Hemospray was used in 23/52 (44.2 %) patients as monotherapy and in 29/52 (55.8 %) patients as a salvage therapy. Application of the powder on the bleeding source was successful in all patients with no therapy-related adverse events (AEs). Immediate hemostasis was achieved in 51/52 (98.1 %) patients. Recurrent bleeding within 3 and 7 days was observed in 22/51 and 25/51 patients respectively (43.1 % and 49 %). The overall clinical success was 56.9 % on day 3 and 51 % on day 7. Total mortality was 15.4 % (8 patients), bleeding associated mortality was 3.8 % (2 patients). There were no therapy-related AEs. CONCLUSIONS TC-325 showed a high technical success rate as monotherapy for bleeding sources not amenable to standard methods or as an "add-on" therapy after unsuccessful hemostasis. However, rebleeding was frequent in this cohort and further studies are warranted to exactly define a treatment algorithm for TC-325 use.
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Affiliation(s)
- Oscar Cahyadi
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Markus Bauder
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Benjamin Meier
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Arthur Schmidt
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
- Department of Medicine II, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Kwek BEA, Ang TL, Ong PLJ, Tan YLJ, Ang SWD, Law NM, Thurairajah PH, Fock KM. TC-325 versus the conventional combined technique for endoscopic treatment of peptic ulcers with high-risk bleeding stigmata: A randomized pilot study. J Dig Dis 2017; 18:323-329. [PMID: 28485544 DOI: 10.1111/1751-2980.12481] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/03/2017] [Accepted: 05/05/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Preliminary studies on a new topical hemostatic agent, TC-325, have shown its safety and effectiveness in treating active upper gastrointestinal (GI) bleeding. However, to date there have been no randomized trials comparing TC-325 with the conventional combined technique (CCT). Our pilot study aimed to compare the efficacy and safety of TC-325 with those of CCT in treating peptic ulcers with active bleeding or high-risk stigmata. METHODS This was a comparative randomized study of patients with upper GI bleeding who had Forrest class I, IIA or IIB ulcers. RESULTS Altogether 20 patients with a mean age of 70 years (range 23-87 years) were recruited, including 16 men, with a mean hemoglobin of 97 g/L. Initial hemostasis was successful in 19 (95.0%) patients, including 90.0% (9/10) in the TC-325 group and 100% (10/10) in the CCT group. TC-325 monotherapy failed to stop bleeding in a patient with Forrest IB posterior duodenal wall ulcer. Rebleeding was seen in 33.3% (3/9) of the patients in the TC-325 group and 10.0% (1/10) in the CCT group. One patient required angio-embolization therapy while three had successful conventional endotherapy. Two patients from the TC-325 group had serious adverse events that were not procedure- or therapy-related. In patients with Forrest IIA or IIB ulcers, five received TC-325 monotherapy; none had rebleeding. CONCLUSIONS Our pilot study showed that TC-325 has a tendency towards a higher rebleeding rate than CCT, when treating actively bleeding ulcers. Larger trials are necessary for definitive results.
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Affiliation(s)
- Boon Eu Andrew Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Peng Lan Jeannie Ong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Yi Lyn Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Shih Wen Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Ngai Moh Law
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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New and emerging technologies to endoscopically manage nonvariceal upper gastrointestinal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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New Endoscopic Technologies and Procedural Advances for Endoscopic Hemostasis. Clin Gastroenterol Hepatol 2016; 14:1234-44. [PMID: 27215365 DOI: 10.1016/j.cgh.2016.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023]
Abstract
Endoscopic interventions are first-line therapy for upper and lower gastrointestinal bleeding. Injection therapy in combination with a second endoscopic modality has reduced re-bleeding, need for surgery and mortality in non-variceal bleeding. For variceal bleeding endoscopic banding or cyanoacrylate injection techniques are recommended interventions. However, despite ease of application and general acceptance of these techniques, there is an ongoing re-bleeding rate associated with significant in-hospital mortality. We discuss current literature on new advances in endoscopic technologies and procedural techniques that have emerged to improve patient outcomes.
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