Novel endoscopic hemostasis technique for use during endoscopic submucosal dissection

Massively bleeding Dieulafoy lesion and unique rescue: a video based case report from National Liver Institute, Menoufia University

Background

Dieulafoy arteriole is a lamina propria vessel that unlike the other arterioles is getting bigger and bending into the mucosa of the gastrointestinal tract. Such anatomic aberration is unusual cause for life threatening gastrointestinal bleeds.

Case presentation

Herein, we report a case of an elderly gentleman, who had massively bleeding Dieulafoy lesion and endoscopic hemostasis of the spurting Dieulafoy by the use of the over-the-scope clip (OVESCO, Tübingen, Germany) has been successfully undertaken.

Conclusion

The endoscopic management of Dieulafoy related bleeds can be enriched by the use of over-the-scope clip, OVESCO, technique.

A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial

BACKGROUND

 Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups.

METHODS

 This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing.

RESULTS

 There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P < 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02).

CONCLUSIONS

 This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing.

Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding

Monopolar hemostatic forceps with soft coagulation (MHFSC) have been compared with hemoclips, heater probe, and argon plasma coagulation (APC) for the treatment of peptic ulcer bleeding. In this systematic review and meta-analysis, we compared MHFSC with other modalities in the treatment of peptic ulcer bleeding. We reviewed MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Scopus from inception to 7 January 2019 to identify studies comparing MHFSC with other modalities for peptic ulcer bleeding. The primary outcome of interest was achievement of initial hemostasis. Secondary outcomes were rebleeding, adverse events, procedure time, and length of hospital stay. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed by I statistic. We included five randomized controlled trials and one observational study comprising 693 patients with endoscopically confirmed actively bleeding ulcers (spurting or oozing) or nonbleeding visible vessel. MHFSC was superior to other modalities in achieving initial hemostasis (OR 0.25; 95% CI 0.08-0.81; I = 67%) and prevention of rebleeding (OR 0.28; 95% CI 0.09-0.86; I = 46%). Rates of adverse events were similar between MHFSC and other modalities. Procedure times were shorter with MHFSC (mean difference -4.15 min; 95% CI -4.83 to -3.47; I= 59%). Length of hospital stay was also shorter with MHFSC. MHFSC appears to be more effective than other modalities for achievement of initial hemostasis and reduction of rebleeding among patients with peptic ulcer bleeding.

CO2 insufflation versus air insufflation for endoscopic submucosal dissection: A meta-analysis of randomized controlled trials

Background

Carbon dioxide (CO₂) insufflation is increasingly used for endoscopic submucosal dissection (ESD) owing to the faster absorption of CO₂ as compared to that of air. Studies comparing CO₂ insufflation and air insufflation have reported conflicting results.

Objectives

This meta-analysis is aimed to assess the efficacy and safety of use of CO₂ insufflation for ESD.

Methods

Clinical trials of CO₂ insufflation versus air insufflation for ESD were searched in PubMed, Embase, the Cochrane Library and Chinese Biomedical Literature Database. We performed a meta-analysis of all randomized controlled trials (RCTs).

Results

Eleven studies which compared the use of CO₂ insufflation and air insufflation, with a combined study population of 1026 patients, were included in the meta-analysis (n = 506 for CO₂ insufflation; n = 522 for air insufflation). Abdominal pain and VAS scores at 6h and 24h post-procedure in the CO₂ insufflation group were significantly lower than those in the air insufflation group, but not at 1h and 3h after ESD. The percentage of patients who experienced pain 1h and 24h post-procedure was obviously decreased. Use of CO₂ insufflation was associated with lower VAS scores for abdominal distention at 1h after ESD, but not at 24h after ESD. However, no significant differences were observed with respect to postoperative transcutaneous partial pressure carbon dioxide (PtcCO₂), arterial blood carbon dioxide partial pressure (PaCO₂), oxygen saturation (SpO₂%), abdominal circumference, hospital stay, white blood cell (WBC) counts, C-Reactive protein (CRP) level, dosage of sedatives used, incidence of dysphagia and other complications.

Conclusion

Use of CO₂ insufflation for ESD was safe and effective with regard to abdominal discomfort, procedure time, and the residual gas volume. However, there appeared no significant differences with respect to other parameters namely, PtcCO₂, PaCO₂, SpO₂%, abdominal circumference, hospital stay, sedation dosage, complications, WBC, CRP, and dysphagia.

Endoscopic haemostasis: an overview of procedures and clinical scenarios

Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.

Preventing and controlling bleeding in gastric endoscopic submucosal dissection

Although techniques and instruments for endoscopic submucosal dissection (ESD) have improved, bleeding is still the most common complication. Minimizing the occurrence of bleeding is important because blood can interfere with subsequent procedures. Generally, ESD-related bleeding can be divided into intraprocedural and postprocedural bleedings. Postprocedural bleeding can be further classified into early post-ESD bleeding which occurs within 48 hours after ESD and late post-ESD bleeding which occurs later than 48 hours after ESD. A basic principle for avoiding intraprocedural bleeding is to watch for vessels and coagulate them before cutting. Several countertraction devices have been designed to minimize intraprocedural bleeding. Methods for reducing postprocedural bleeding include administration of proton-pump inhibitors or prophylactic coagulation after ESD. Medical adhesive spray such as n-butyl-2-cyanoacrylate is also an option for preventing postprocedural bleeding. Various endoscopic treatment modalities are used for both intraprocedural and postprocedural bleeding. However, hemoclipping is infrequently used during ESD because the clips interfere with subsequent resection. Bleeding that occurs as a result of ESD can usually be managed easily. Nonetheless, more effective ways to prevent bleeding, including reliable ESD techniques, must be developed.

Endoscopic submucosal dissection--current success and future directions

More than 10 years have passed since endoscopic submucosal dissection (ESD) was first developed in Japan. ESD enables en bloc complete resection of superficial gastrointestinal neoplasms regardless of the size and location of the lesions. With improvements in techniques and devices, excellent therapeutic results have been achieved despite the inherent technical difficulties of this procedure. ESD aiming for curative treatment can be performed for gastrointestinal neoplasms without risk of lymph node metastasis. Accurate histopathologic examination of the resected specimen is required to determine the risk of lymph node metastasis, for which en bloc resection is beneficial. Owing to the high success rate of en bloc complete resection and accurate histopathologic examination, tumour recurrence rates after ESD are reported to be very low in Japan. Excellent results of ESD in a large number of cases have also been reported from other Asian countries such as South Korea, Taiwan and China. Although scepticism exists among Western clinicians regarding the application of ESD, it is developing slowly and reports indicate promising results in some European countries. With further development of technologies, such as endoscopic robotics, ESD could become the worldwide treatment of choice for early gastrointestinal neoplasms.

A water-jet videoendoscope may reduce operation time of endoscopic submucosal dissection for early gastric cancer

BACKGROUND

One of the problems with endoscopic submucosal dissection (ESD) for early gastric cancer is that it prolongs procedure time considerably.

AIM

The purpose of this study was to investigate whether a videoendoscope with water-jet function shortened the time of ESD for early gastric cancer.

METHODS

A total of 82 early gastric cancers that were intramucosal, differentiated-type adenocarcinoma ≤2 cm, without ulcer or scar, in 75 consecutive patients were investigated. Three supervised resident endoscopists participated as operators. After stratification by the operator and tumor location, the lesions were randomly assigned to the water-jet videoendoscope or a conventional videoendoscope groups. An insulated tipped knife was used for the ESD procedure. Total operation time was evaluated as a primary endpoint.

RESULTS

The median (25-75th percentile) total operation time for the water-jet videoendoscope group was 51 (33-87) minutes, which was shorter than the 62 (43-88) minutes for the conventional videoendoscope, but it did not reach significance (P = 0.201). Multivariate analysis revealed that the water-jet videoendoscope (OR 3.0, P = 0.046), tumor size ≤14 mm (OR 3.2, P = 0.040) and antral tumor (OR 4.5, P = 0.046) were significantly associated with short (≤60 min) operation time.

CONCLUSIONS

The water-jet videoendoscope may reduce operation time of ESD for early gastric cancer, compared with conventional videoendoscope. A large-scale multicenter trial is warranted to clarify the efficacy of the water-jet videoendoscope for gastric ESD.

Diazepam during endoscopic submucosal dissection of gastric epithelial neoplasias

AIM: To investigate risk factors and adverse events related to high-dose diazepam administration during endoscopic submucosal dissection for gastric neoplasias.

METHODS: Between February 2002 and December 2009, a total of 286 patients with gastric epithelial neoplasia underwent endoscopic submucosal dissection in our hospital. To achieve moderate sedation, 5-7.5 mg of diazepam was administered intravenously by non-anesthesiologists. Intermittent additional administration of 2.5-5 mg diazepam was performed if uncontrollable body movement of the patient was observed. All patients were classified into groups based on the required diazepam dose: low-dose (≤ 17.5 mg, n = 252) and high-dose (> 17.5 mg, n = 79).

RESULTS: Differences between the low- and high-dose diazepam groups were observed in lifetime alcohol consumption (0.30 ± 0.48 vs 0.44 ± 0.52 tons, P = 0.032), body weight (58.4 ± 10.3 vs 62.0 ± 9.9 kg, P = 0.006), tumor size (15 ± 10 vs 23 ± 18 mm, P < 0.001), lesion location (P < 0.001) and the presence of ulcerative findings (14/238 vs 18/61, P < 0.001). Multivariate analysis identified all five variables as independently related to required diazepam dosage. In terms of adverse reactions to diazepam administration, paradoxical excitement was significantly more frequent in the high-dose diazepam group (P < 0.001).

CONCLUSION: Intermittent administration of diazepam enabled safe completion of gastric endoscopic submucosal dissection except in patients who were alcohol abusers or obese, or who showed complicated lesions.

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.

Proton Pump Inhibitor Therapy before and after Endoscopic Submucosal Dissection: A Review

Endoscopic submucosal dissection (ESD) is a novel endoscopic procedure first developed in the 1990s which enables en bloc resection of gastric neoplastic lesions that are difficult to resect via conventional endoscopic mucosal resection. However, given that ESD increases the risk of intra- and post-ESD delayed bleeding and that platelet aggregation and coagulation in artificial ulcers after ESD strongly depend on intragastric pH, faster and stronger acid inhibition via proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H(2)RAs) as well as endoscopic hemostasis by thermocoagulation during ESD have been used to prevent ESD-related bleeding. Because PPIs more potently inhibit acid secretion than H(2)RAs, they are often the first-line drugs employed in ESD treatment. However, acid inhibition after the initial infusion of a PPI is weaker in the early phase than that achievable with H(2)RAs; further, PPI effectiveness can vary depending on genetic differences in CYP2C19. Therefore, optimal acid inhibition may require tailored treatment based on CYP2C19 genotype when ESD is performed, with a concomitant infusion of PPI and H(2)RA possibly most effective for patients with the rapid metabolizer CYP2C19 genotype, while PPI alone may be sufficient for those with the intermediate or poor metabolizer genotypes.

Active gastrointestinal bleeding: Use of hemostatic forceps beyond endoscopic submucosal dissection

To the best of our knowledge, this is the first report of the application of hemostatic forceps in active gastrointestinal (GI) bleeding that is not related to endoscopic submucosal dissection. An 86-year-old woman with chronic intake of low-dose aspirin had a Dieulafoy’s lesion of the third duodenal portion. Bleeding control with epinephrine injection was unsuccessful. A 60-year-old man presented with a bleeding ulcer in the duodenal bulb. Ten days after combined endotherapy, he had recurrent bleeding from two minimal lesions in the same location. A 66-year-old woman under combined antithrombotic treatment was referred to us for chronic GI bleeding of unexplained origin. Endoscopy revealed active diverticular bleeding in the second duodenal portion. A 61-year-old woman underwent endoscopic mucosal resection of superficial gastric adenocarcinoma, which was complicated with immediate bleeding. In all cases, the blood was washed out using a water-jet-equipped, single-channel gastroscope with a large working channel. The bleeding points were pinched and retracted with hemostatic forceps. Monopolar electrocoagulation was performed using an electrosurgical current generator. Hemostasis was achieved. No complications occurred. In conclusion, hemostatic forceps may be an effective as well as safe alternative approach for active GI bleeding of various origins.

A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding

BACKGROUND

Endoscopic submucosal dissection (ESD) is one of the curative endoluminal surgical procedures for gastric epithelial neoplasms. There has been little research on bleeding after gastric ESD.

OBJECTIVE

To investigate cases of post-ESD bleeding and to verify whether a second-look endoscopy after ESD is effective in the prevention of delayed bleeding.

DESIGN

A retrospective study with consecutive data.

SETTING

A single tertiary referral center.

SUBJECTS

A total of 454 gastric epithelial neoplasms (386 early gastric cancers and 68 gastric adenomas).

INTERVENTIONS

ESD and second-look endoscopy.

MAIN OUTCOME MEASUREMENTS

Predictors on post-ESD bleeding by univariate analysis, incidence of post-ESD bleedings, and the timing of those before and after second-look endoscopy.

RESULTS

Post-ESD bleeding occurred in 26 (5.7%) lesions. Gross type (flat or depressed type) was the only factor influencing post-ESD bleeding. All cases of post-ESD bleeding occurred within 14 days after ESD (median 2; range 0-14), and bleeding tended to occur from the lower and upper stomach earlier and later, respectively. In 19 lesions with delayed bleeding more than 24 hours after ESD, the maximum delayed bleeding rates before and after the second-look endoscopy were 2.8% and 2.5%, respectively.

LIMITATIONS

A retrospective, single-center analysis.

CONCLUSIONS

A second-look endoscopy after gastric ESD may contribute little to the prevention of delayed bleeding.

Feasibility of endoscopic submucosal dissection for patients with chronic renal failure on hemodialysis

BACKGROUND

Endoscopic submucosal dissection (ESD) is expected as a curative method for node-negative gastrointestinal cancers. Little is known about ESD for patients with end-stage chronic renal failure (CRF) on hemodialysis. We aimed to evaluate the efficacy and safety of ESD for patients with CRF on hemodialysis.

METHODS

Ten consecutive patients with 12 lesions who underwent ESD (stomach, seven; colorectum, three) between March 2002 and August 2007 were retrospectively investigated in terms of the technical feasibility and complications.

RESULTS

All the lesions were resected in a single piece and en-bloc and R0 resection rate was 100%. Histology revealed that all the lesions fulfilled the criteria of node-negative cancers. Delayed bleeding requiring blood transfusion on the day after ESD, and shunt occlusion, which necessitated a radiological intervention 7 days after ESD, occurred in one stomach case. Delayed perforation followed by emergency surgery 2 days after ESD occurred in one colorectal case.

CONCLUSIONS

ESD for CRF patients may be technically feasible, but substantial risks should be considered. Early detection of late-onset complications is essential with intensive medical check-up for at least 1 week in order to prevent complications from becoming severe.

Endoscopic submucosal dissection for esophageal squamous cell neoplasms

Endoscopic submucosal dissection (ESD) has gradually gained acceptance as one of the standard treatments for early esophageal cancer, as well as for early gastric cancer in Japan, but standardization of the knowledge is still incomplete. The final goal to perform ESD is not to resect the lesion in an en bloc fashion, but to save the patient from esophageal cancer-related death. Thus, the indications should be considered based on the entire patient, not just the target lesion itself, and pre-, peri- and postoperative management of the patient is also very important, as well as technical aspects of ESD. In terms of the techniques of ESD, owing to refinement of the procedural strategy, invention of the devices, and the learning curve, acceptable safety and favorable middle-term efficacy have been obtained. We believe that ESD will become a standard treatment for early esophageal cancer not only in Japan but also worldwide in the near future.

Is it possible to predict the procedural time of endoscopic submucosal dissection for early gastric cancer?

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has been expected to be a possible curative treatment, especially for node-negative early gastric cancer (EGC). We investigated the influential factors on the procedural time of gastric ESD with a Flex knife for the estimation.

METHODS

In 222 intestinal-type EGC resected by ESD experts with established techniques, age, sex, location, circumference, gross type, tumor size, tumor depth, ulcerative findings, the period of ESD, the operator, and the experience of the operator were retrospectively analyzed. Predictors with a significant difference, as determined by multivariate analysis, were used to compose a predictive formula of procedural time.

RESULTS

Location, gross type, tumor depth, ulcerative findings, and tumor size were considered influential factors on the procedural time by univariate analysis. Location in the upper-third of the stomach, presence of ulcerative findings, and > 20 mm in size were independent factors, as determined by multivariate analysis. Procedural time (min) was nearly equal to the maximal tumor size (mm) multiplied by 2.5, and an additional 40 min was required if the tumor was located in the upper-third of the stomach or had ulcerative findings (in both situations, an additional 80 min was needed).

CONCLUSION

The procedural time of ESD with a Flex knife for EGC can be predicted by tumor size, location, and existence of ulcerative findings. The estimation of procedural time may be very useful to determine the operation schedule.