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Karna R, Hans B, Nasereddin T, Chaudhary D, Dhawan M. Comparison of mechanical and thermal therapy in upper gastrointestinal bleeding: an analysis of efficacy outcomes. Proc AMIA Symp 2024; 37:734-741. [PMID: 39165805 PMCID: PMC11332638 DOI: 10.1080/08998280.2024.2381180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 08/22/2024] Open
Abstract
Background Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a complication of dual antiplatelet therapy (DAPT) and direct oral anticoagulant therapy (DOAC). There is a lack of data comparing mechanical therapy (clips) with thermal therapy in this population. Methods We conducted a retrospective chart review of patients undergoing urgent/emergent endoscopy for NVUGIB while being on DAPT or DOAC. Patients who had DAPT/DOAC held as per American Society of Gastrointestinal Endoscopy guidelines were excluded from the study. Results A total of 122 patients were included in the study. There was no difference in primary hemostasis, rebleeding rate, rescue hemostatic procedure, and 30-day mortality between the mechanical and thermal therapy groups. The mechanical therapy group had a significantly higher rate of prolonged length of stay (61.2% vs 38.9%, P = 0.02), serious clinical outcomes (56% vs 37.5%, P = 0.04), and intensive care unit admissions (50% vs 20.8%, P = 0.001) than the thermal therapy group. Conclusion Patients on DAPT/DOAC presenting with NVUGIB can undergo mechanical or thermal endoscopic intervention without a significant difference in achieving primary hemostasis, rebleeding, requiring a secondary procedure, or mortality outcomes.
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Affiliation(s)
- Rahul Karna
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Bandhul Hans
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Thayer Nasereddin
- Indianapolis Gastroenterology and Hepatology, Indianapolis, Indiana, USA
| | - Dhruv Chaudhary
- Division of Gastroenterology and Hepatology, Columbus, Georgia, USA
| | - Manish Dhawan
- Division of Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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2
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AbiMansour J, Kamba S, Wong Kee Song LM, Rajan E. Through-the-scope clip retention rates and performance in a porcine model. Endosc Int Open 2024; 12:E52-E56. [PMID: 38193006 PMCID: PMC10774014 DOI: 10.1055/a-2221-7908] [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: 09/16/2023] [Accepted: 11/17/2023] [Indexed: 01/10/2024] Open
Abstract
Background and study aims Limited comparative data exist to guide optimal through-the-scope (TTS) clip selection. The aim of this study was to compare the efficacy, retention, and safety of three industry-leading TTS clips on tissue that mimics common clinical scenarios. Methods A survival study involving six domestic pigs was undertaken. Three commonly used clip models were selected: Assurance (STERIS, Mentor, Ohio, United States), Resolution (Boston Scientific, Boston, Massachusetts, United States), and SureClip (Micro-Tech, Ann Arbor, Michigan, United States). To mimic clinical practice, the following scenarios were assessed: (1) normal mucosa; (2) cold snare resection; and (3) hot mucosal resection simulating fibrotic ulcers. Deployment of clips was randomized to target sites. Repeat endoscopy was performed 2 weeks following placement. Endoscopists rated the ease of use of clip placement on a Likert scale of 1 to 5. Results Fifty-four clips (18 Assurance, 18 Resolution, and 18 SureClip) were placed in six pigs. Mucosal healing was noted at all sites on follow up. Overall retention was nine of 18 (50.0%) SureClip, 10 of 18 (55.6%) Assurance, and 13 of 18 (72.2%) Resolution ( P =0.369). There was no difference in clip retention on normal and cold snare resection sites; however, clip retention was significantly higher for Resolution clips on fibrotic ulcers (50.0% versus 0% for Assurance and 0% SureClip, P =0.03). No adverse events were reported. Ease of use was equivalent across all models. Conclusions All clips were equivalent in efficacy and safety with successful clip deployment and mucosal healing. Overall retention rate was low for fibrotic tissue, with an improved retention rate observed with Resolution clips.
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Affiliation(s)
- Jad AbiMansour
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | - Shunsuke Kamba
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | | | - Elizabeth Rajan
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
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Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
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Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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4
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Kim SH, Lee JK, Lim YJ, Kim JH. The risk factors for prolonged hemostatic clip retention after endoscopic submucosal dissection for gastric neoplasm. Surg Endosc 2021; 36:1123-1130. [PMID: 33629182 DOI: 10.1007/s00464-021-08379-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic hemostatic clipping is a safe and efficient treatment used to manage bleeding or perforation during endoscopic submucosal dissection (ESD) for gastric neoplasm. However, the natural history of applied hemoclips during ESD has not been elucidated. As prolonged clip retention limits the use of magnetic resonance imaging and may impede the ulcer healing process, we investigated the factors associated with prolonged hemoclip retention during gastric ESD. METHODS We retrospectively reviewed 199 patients who underwent gastric ESD with hemoclip application from January 2006 to January 2019. The primary outcome was the prolonged hemoclip retention rate 3 months after ESD. We examined the records of subjects followed at 3, 6, and 12 months and then annually after ESD to monitor clip retention. RESULTS The prolonged hemoclip retention rate at 3 months was 27.1% (54/199). The risk of hemoclip retention was significantly lower at the antrum (19.6%, P = 0.03). Hemoclips at the angle tended to remain longer than other locations in the stomach (40.6%, P = 0.081) while there was no difference in the number of applied clips depending upon the location of the lesion. By Kaplan-Meier survival analysis, clips at the antrum detached significantly earlier than those at other locations (P = 0.011). CONCLUSIONS Most of the hemostatic clips attached during ESD were spontaneously removed by 3 months after gastric ESD. However, clips positioned at angle are suspected to have a high probability of prolonged retention. With this in mind, more attention is needed when using hemoclips on angle.
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Affiliation(s)
- Sang Hoon Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Dongguk-ro 27 Ilsandong-gu, Goyang, 10326, Republic of Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Dongguk-ro 27 Ilsandong-gu, Goyang, 10326, Republic of Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Dongguk-ro 27 Ilsandong-gu, Goyang, 10326, Republic of Korea
| | - Jae Hak Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Dongguk-ro 27 Ilsandong-gu, Goyang, 10326, Republic of Korea.
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5
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Xavier AT, Campos JF, Robinson L, Lima EJM, da Rocha LCM, Arantes VN. Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications. Ann Gastroenterol 2020; 33:563-570. [PMID: 33162733 PMCID: PMC7599350 DOI: 10.20524/aog.2020.0526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/26/2020] [Indexed: 12/26/2022] Open
Abstract
Endoscopic clipping has become a common practice among endoscopists. Several models are available, most frequently being introduced via the working channel of the endoscope (through-the-scope); however, larger clips can also be mounted onto the distal tip of the endoscope (over-the-scope). The main indications for endoclip placement include providing effective mechanical hemostasis for bleeding lesions and allowing endoscopic closure of gastrointestinal perforations. Endoclips can also be used prophylactically after endoscopic resection; however, this practice is still controversial. This review discusses the main indications for endoscopic clipping in the esophagus, stomach, duodenum and colon to manage acute bleeding lesions, and the criteria to be used in the prevention of delayed post-polypectomy bleeding.
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Affiliation(s)
- Amaury Teixeira Xavier
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes).,Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | - Júlia Faria Campos
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes).,Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | - Lucinda Robinson
- Department of Medicine, Flinders Medical Centre, Adelaide, Australia (Lucinda Robinson)
| | - Elmar José Moreira Lima
- Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | | | - Vitor Nunes Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes)
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Xu Y, Zhong S, Liang W, Lin XL. The risk factors for delayed bleeding after endoscopic resection of colorectal tumors: a meta-analysis. Expert Rev Gastroenterol Hepatol 2020; 14:1083-1092. [PMID: 32721191 DOI: 10.1080/17474124.2020.1801416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The most common complication of post-colorectal endoscopic resection is delayed bleeding. The assessment of risk factors for delayed bleeding provides important and useful information in standard clinical operations. The risk factors have been previously reported; however, they remain inconsistent across different studies. AREAS COVERED In this meta-analysis, the patient conditions, lesion-related factors, and operation-related factors were compared between delayed bleeding and no bleeding. PubMed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched to identify eligible studies. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated along with heterogeneity. EXPERT OPINION This study is the first meta-analysis to investigate risk factors for colorectal delayed bleeding. We found several risk factors contributing to this condition: colorectal tumors located in the proximal colon, a history of antithrombotic drug use, high-grade intraepithelial neoplasia or early cancer, piecemeal resection, intraoperative hemorrhage, no clip placement, and severe submucosal fibrosis. Despite our findings, we also conclude that more high-quality, large-scale clinical randomized controlled studies are needed due to limited retrospective studies at present. Future therapeutic colonoscopies should focus on precise diagnosis, treatment safety, and management during the perioperative period.
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Affiliation(s)
- Yanqin Xu
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Shishun Zhong
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Wei Liang
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Xiao Lu Lin
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
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7
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Shin DY, Park S, Kim A, Kim ES, Jeon HH. Compatibility of endoclips in the gastrointestinal tract with magnetic resonance imaging. Sci Rep 2020; 10:16537. [PMID: 33024206 PMCID: PMC7539000 DOI: 10.1038/s41598-020-73726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/21/2020] [Indexed: 11/09/2022] Open
Abstract
There are no clear guidelines on the compatibility between endoclips that remain in the gastrointestinal (GI) tract and magnetic resonance imaging (MRI). The purpose of this study was to investigate the effect of 3T (T) MRI on endoclips placed in excised pig tissues. Two types of endoclips were assessed: Olympus EZ (HX-610-135L) and QuickClip Pro (HZ-202LR). We assessed tissue damage or perforation and detachment of endoclips under 3T MRI magnetic field. We also evaluated the magnitude of force required to detach the endoclips from the porcine tissue. We measured the magnetic force acting on the Olympus EZ clips. QuickClip Pro clips were used as a control in this study. There was no tissue damage and no detachment of the endoclips (Olympus EZ and QuickClip Pro) during 3T MRI. The force required to detach the Olympus EZ clips ranged from 0.9 to 3.0 N. The translational magnetic force acting on the endoclips was 3.18 × 10-3 N. Ex vivo experiments showed that the magnetic field generated by 3 MRI did not cause tissue damage or perforation and did not detach the endoclips. Olympus EZ clips and QuickClip Pro clips in the GI tract appear to be safe during 3T MRI.
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Affiliation(s)
- Dong Yeol Shin
- Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro Ilsan-donggu, Goyang-si, Goyang, 10444, Korea
| | - Sumi Park
- Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ain Kim
- Department of Human Biology, University of Toronto, Toronto, ON, Canada
| | - Eung-Sam Kim
- Department of Biological Sciences and Research Center of Ecomimetics, Chonnam National University, Gwangju, Korea.
| | - Han Ho Jeon
- Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro Ilsan-donggu, Goyang-si, Goyang, 10444, Korea.
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8
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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9
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Abdulfattah Bukhari M, Khashab MA. Optimized Training in the Use of Endoscopic Closure Devices. Gastrointest Endosc Clin N Am 2020; 30:197-208. [PMID: 31739965 DOI: 10.1016/j.giec.2019.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Successful closure of gastrointestinal defects is one of the most important goals for therapeutic endoscopy. Historically, surgical repair was the mainstay of treatment for any gastrointestinal defect; however, surgery is associated with high morbidity and mortality. Endoscopic management of gastrointestinal defects has developed rapidly in recent years and has become more effective, reducing the morbidity and mortality rates, and avoiding surgical interventions. Appropriate use of endoscopic techniques requires extensive knowledge of the devices and their advantages and limitations during practical applications.
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Affiliation(s)
- Majidah Abdulfattah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Medicine and Gastroenterology and Hepatology, International Medical Center, Jeddah 23214, Saudi Arabia
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1800 Orleans Street, Zayed Building, Suite 7125B, Baltimore, MD 21287, USA.
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10
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Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
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Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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12
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Abstract
Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.
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Affiliation(s)
- Jeffrey R Watkins
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA 98104, USA.
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13
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Nishizawa T, Akimoto T, Uraoka T, Mitsunaga Y, Maehata T, Ochiai Y, Fujimoto A, Goto O, Kanai T, Yahagi N. Endoscopic string clip suturing method: a prospective pilot study (with video). Gastrointest Endosc 2018; 87:1074-1078. [PMID: 29154910 DOI: 10.1016/j.gie.2017.11.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 11/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We developed a suturing method with string and clips for a single-channel endoscope. The feasibility of the string clip suturing method is evaluated in this prospective pilot study. METHODS This study involved 10 consecutive patients who underwent endoscopic submucosal dissection (ESD) for a duodenal tumor. Polyester string was tied to the arm of a partially out thrust clip. The clip and string can be passed through the instrument channel (3.2 mm) of a single-channel endoscope. The clip with string was placed at the distal edge of the large mucosal defect. A second clip was hooked on the string and placed on the opposite side. Both clips were gathered by pulling the free end of the string, and additional clips were placed to achieve complete closure. This method was compared with that for the previous 10 patients without mucosal closure after duodenal ESD. RESULTS Mean size of resected specimens was 39.1 ± 12.4 mm. The success rate of the string clip suturing method was 100% (10/10). The mean procedure time was 23.4 ± 13.8 minutes. Perforation during ESD occurred in 1 patient and was successfully closed by this method. None of the treated patients developed serious adverse events after the procedure. Compared with the no-suture group, the length of stay was significantly shorter (P = .038). CONCLUSION The string clip suturing method appears to be a safe and effective method for closure of large mucosal defects. (Clinical trial registration number: UMIN000023698.).
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology, National Hospital Organization Tokyo Medical Center, Toky, Japan
| | - Yutaka Mitsunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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14
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Endoscopic mucosal resection and endoscopic submucosal dissection: technique and new directions. Curr Opin Gastroenterol 2017; 33:315-319. [PMID: 28704212 DOI: 10.1097/mog.0000000000000388] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Most of small tumours in gastrointestinal tract are easily removed by endoscopic mucosal resection (EMR). However, EMR are sometimes not reliable to ensure the complete resection for large tumours. Although endoscopic submucosal dissection (ESD) was developed, it had a higher risk for complications such as perforation and bleeding. The techniques and clinical outcomes of EMR and ESD are reviewed. RECENT FINDINGS ESD is more effective for early gastric and oesophageal cancer with higher en-bloc resection rate and lower local recurrence in comparison to EMR. Several studies report favourable long-term outcomes of ESD. ESD has become a standard technique in Japan and other East Asian countries. Piecemeal resection using EMR technique is widely accepted for colorectal large adenomas and results in good clinical outcomes in most patients. However, apparent cancerous lesions need endoscopic en-bloc resection by ESD. SUMMARY Further development of the technique, devices and training systems will promote worldwide standardization of ESD.
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Daure E, Ross L, Webster CRL. Gastroduodenal Ulceration in Small Animals: Part 2. Proton Pump Inhibitors and Histamine-2 Receptor Antagonists. J Am Anim Hosp Assoc 2016; 53:11-23. [PMID: 27841679 DOI: 10.5326/jaaha-ms-6634] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In the first part of this review, we discussed the pathophysiology and epidemiology of gastric acid secretion and the epidemiology of gastroduodenal ulceration in dogs and cats. In this section, we discuss the pharmacology and evidence-based clinical use of histamine-2 receptor antagonists and proton pump inhibitors.
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Affiliation(s)
- Evence Daure
- From the Centre Vétérinaire Daubigny, Quebec, Canada (E.D.); and the Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts (L.R., C.R.L.W.)
| | - Linda Ross
- From the Centre Vétérinaire Daubigny, Quebec, Canada (E.D.); and the Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts (L.R., C.R.L.W.)
| | - Cynthia R L Webster
- From the Centre Vétérinaire Daubigny, Quebec, Canada (E.D.); and the Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts (L.R., C.R.L.W.)
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Boules M, Chang J, Haskins IN, Sharma G, Froylich D, El-Hayek K, Rodriguez J, Kroh M. Endoscopic management of post-bariatric surgery complications. World J Gastrointest Endosc 2016; 8:591-599. [PMID: 27668069 PMCID: PMC5027029 DOI: 10.4253/wjge.v8.i17.591] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/02/2016] [Accepted: 07/22/2016] [Indexed: 02/05/2023] Open
Abstract
Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.
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Ghassemi KA, Jensen DM. Evolving techniques for gastrointestinal endoscopic hemostasis treatment. Expert Rev Gastroenterol Hepatol 2016; 10:615-23. [PMID: 26651414 PMCID: PMC6063521 DOI: 10.1586/17474124.2016.1130623] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.
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Affiliation(s)
- Kevin A. Ghassemi
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group
| | - Dennis M. Jensen
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group,Division of Gastroenterology, VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
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19
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Wee E, Sachin MP, Chinnappa U, Chang S, Yip CHB. Deployment of a Short, Single-Opening Endoscopic Clip Versus a Long, Reopening Endoscopic Clip in Clinical Practice. Dig Dis Sci 2015; 60:2287-93. [PMID: 25822036 DOI: 10.1007/s10620-015-3636-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/17/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND Endoscopic clips vary in their designs and costs. Clip wastage is a common problem, and this is dependent on the success of its deployment. AIMS The aim of this study is to compare the rates of successful deployment between two different commonly used endoscopic clips. METHODS A single-center, retrospective study was conducted. Endoscopy reports of patients with clips deployed over 24 months were reviewed. We compared a long-pronged, reopening endoscopic clip (type A: Resolution clip; Boston Scientific, Natick, MA, USA) versus a short-pronged, single-opening clip (type B: QuickClip2; Olympus Medical Systems Corp, Japan). The main outcome was clip deployment success rate. Secondary outcomes were predictors of successful deployment, cost, and wastage. RESULTS Of 14,690 endoscopic cases, 472 clips (171 type A and 301 type B) were deployed in 262 procedures. Type A clips had a significantly higher successful deployment rate (147/171, 86.0 %) than type B clips (221/301, 73.4 %) (p = 0.002). On multivariate analysis, variables independently associated with successful deployment included using type A clips (OR 2.07, 95 % CI 1.20-3.55; p = 0.009) and clips placed in the lower gastrointestinal tract (OR 3.48, 95 % CI 1.64-7.40; p = 0.001). The cost of using type A clips was higher than type B clips (p < 0.001). Type B clips were associated with more wastage (p = 0.049). CONCLUSIONS Long-pronged, reopening clips (type A) have a better deployment rate than short-pronged, single-opening clips (type B). Although type A clips had less wastage, the cost per procedure was higher.
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Affiliation(s)
- Eric Wee
- Division of Gastroenterology, Department of General Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore,
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20
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Brock AS, Rockey DC. Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:523-33. [PMID: 26142036 DOI: 10.1016/j.giec.2015.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.
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Affiliation(s)
- Andrew S Brock
- Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.
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21
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Evaluating long-term attachment of a novel endoclip in porcine stomachs: a prospective study of initial deployment success and clip retention rates at different regions of the stomachs. Surg Endosc 2015; 30:1100-6. [DOI: 10.1007/s00464-015-4305-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/26/2015] [Indexed: 12/11/2022]
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Palmer R, Braden B. New and emerging endoscopic haemostasis techniques. Frontline Gastroenterol 2015; 6:147-152. [PMID: 28839802 PMCID: PMC5369562 DOI: 10.1136/flgastro-2014-100540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/02/2015] [Accepted: 01/05/2015] [Indexed: 02/04/2023] Open
Abstract
Endoscopic treatment has been accepted as first-line treatment of upper gastrointestinal bleeding, both for variceal as well as for non-variceal haemorrhage. Dual modality treatment including injection therapy with mechanical or thermal haemostatic techniques has shown superior outcome compared with injection monotherapy in non-variceal bleeding. During recent years, new endoscopic devices have been developed and existing endoscopic techniques have been adapted to facilitate primary control of bleeding or achieve haemostasis in refractory haemorrhage. For mechanical haemostasis, larger, rotatable and repositionable clips have been developed; multiple-preloaded clips are also available now. Over the scope clips allow to ligate larger vessels and can close ulcer defects up to 20 mm. Topical, easily applied substances withdraw fluid from the blood and thereby initiate blood clotting. This can be helpful in diffuse oozing bleeding, for example, from tumour or hypertensive gastropathy and has also shown promising results in variceal and arterial bleeding as bridging before definitive treatment is available. Radiofrequency ablation and multiband ligation have emerged as new tools in the endoscopic management of gastric antral vascular ectasia. In acute refractory variceal bleeding, a covered and removable oesophagus stent can provide tamponade and gain time for transport to an interventional endoscopic centre or for radiological intervention such as TIPS.
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Affiliation(s)
- Rebecca Palmer
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
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23
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García-García ML, Martín-Lorenzo JG, Torralba-Martínez JA, Lirón-Ruiz R, Miguel Perelló J, Flores Pastor B, Pérez Cuadrado E, Aguayo Albasini JL. Emergency endoscopy for gastrointestinal bleeding after bariatric surgery. Therapeutic algorithm. Cir Esp 2014; 93:97-104. [PMID: 25438773 DOI: 10.1016/j.ciresp.2014.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/07/2014] [Accepted: 05/07/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.
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Affiliation(s)
- María Luisa García-García
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España.
| | - Juan Gervasio Martín-Lorenzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | | | - Ramón Lirón-Ruiz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Joana Miguel Perelló
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Benito Flores Pastor
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Enrique Pérez Cuadrado
- Sección de Gastroenterología y Endoscopia, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - José Luis Aguayo Albasini
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España; Departamento de Cirugía, Campus de Excelencia Internacional «Campus Mare Nostrum», Universidad de Murcia, Murcia, España
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24
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The role of hemoclips reinforcement in the ligation-assisted endoscopic enucleation for small GISTs in gastric fundus. BIOMED RESEARCH INTERNATIONAL 2014; 2014:247602. [PMID: 24895557 PMCID: PMC4033522 DOI: 10.1155/2014/247602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 04/14/2014] [Accepted: 04/20/2014] [Indexed: 02/06/2023]
Abstract
Background. Endoscopic ultrasonography- (EUS-) assisted band ligation has been proven to be a safe and effective procedure for the treatment of small gastrointestinal stromal tumors (GISTs) apart from the relatively high risk of the postligation perforation of the gastric fundus. The aim of this study is to investigate the efficacy of hemoclip reinforcement in treating small GISTs in the gastric fundus. Method. During a standard endoscopy, a transparent cap attached to the endoscopic tip was placed over the lesion to exert sustained maximal aspiration before a rubber band was released. Once a definite ligation was confirmed by EUS, the tumor was enucleated. Four to 6 hemoclips were placed on the folds around the ligation band to reduce the tension of the ligation site. Results. The small GISTs were resected completely in 192 patients. Two cases of delayed perforation were found 72 hours after the procedure and successfully treated with an ordinary conservative method. Conclusion. Hemoclip-reinforced endoscopic band ligation with systematic follow-up using EUS appears to be a simple and effective technique for the resection of small GISTs in the gastric fundus.
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Saxena P, Ji-Shin E, Haito-Chavez Y, Valeshabad AK, Akshintala V, Aguila G, Kumbhari V, Ruben DS, Lennon AM, Singh V, Canto M, Kalloo A, Khashab MA. Which clip? A prospective comparative study of retention rates of endoscopic clips on normal mucosa and ulcers in a porcine model. Saudi J Gastroenterol 2014; 20:360-5. [PMID: 25434317 PMCID: PMC4271011 DOI: 10.4103/1319-3767.145328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIM There are currently no data on the relative retention rates of the Instinct clip, Resolution clip, and QuickClip2Long. Also, it is unknown whether retention rate differs when clips are applied to ulcerated rather than normal mucosa. The aim of this study is to compare the retention rates of three commonly used endoscopic clips. MATERIALS AND METHODS Six pigs underwent upper endoscopy with placement of one of each of the three types of clips on normal mucosa in the gastric body. Three mucosal resections were also performed to create "ulcers." Each ulcer was closed with placement of one of the three different clips. Repeat endoscopy was performed weekly for up to 4 weeks. RESULTS Only the Instinct and Resolution clips remained attached for the duration of the study (4 weeks). At each time point, a greater proportion of Instinct clips were retained on normal mucosa, followed by Resolution clips. QuickClip2Long had the lowest retention rate on normal mucosa. Similar retention rates of Instinct clips and Resolution clips were seen on simulated ulcers, although both were superior to QuickClip2Long. However, the difference did not reach statistical significance. All QuickClip2Long clips were dislodged at 4 weeks in both the groups. CONCLUSIONS The Resolution and Instinct clips have comparable retention rates and both appeared to be better than the QuickClip2Long on normal mucosa-simulated ulcers; however this did not reach statistical significance. Both the Resolution clip and the Instinct clip may be preferred in clinical situations when long-term clip attachment is required, including marking of tumors for radiotherapy and anchoring feeding tubes or stents. Either of the currently available clips may be suitable for closure of iatrogenic mucosal defects without features of chronicity.
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Affiliation(s)
- Payal Saxena
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Eun Ji-Shin
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Yamile Haito-Chavez
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ali K. Valeshabad
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Venkata Akshintala
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Gerard Aguila
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vivek Kumbhari
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dawn S. Ruben
- Department of Molecular and Comparative Pathobiology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anne-Marie Lennon
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vikesh Singh
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Marcia Canto
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anthony Kalloo
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A. Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA,Address for correspondence: Asst. Prof. Mouen A. Khashab, Director of Therapeutic Endoscopy, Johns Hopkins Hospital, 1800 Orleans St, Suite 7125B, Baltimore, MD 21287, USA. E-mail:
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26
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Daram SR, Tang SJ, Wu R, To SDF. Benchtop testing and comparisons among three types of through-the-scope endoscopic clipping devices. Surg Endosc 2013; 27:1521-9. [PMID: 23292554 DOI: 10.1007/s00464-012-2679-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/22/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Through-the-scope (TTS) endoscopic clipping devices are widely used. No benchtop testing or direct comparisons of these endoclips have been performed to show their rotational ability and inherent mechanical strengths during closure and after deployment. This study aimed to provide benchtop data that can be used to guide clinical applications and to promote future device research and development. METHODS Benchtop testing and comparisons were performed for three groups of TTS clips: QuickClip2 long, resolution, and instinct clips. The main outcome measurements were device-in-endoscope retroflection angles (DIERA), opening strength, "snapping" force of acute clip closure, and neoprene pulling strength. RESULTS The achievable gastroscope DIERA was 10° for QuickClip2, 3° for the resolution clip, and 10° for the instinct clip. The QuickClip and the Instinct clip rotated almost equally well under all endoscope configurations, including endoscopic retrograde cholangiopancreatography (ERCP). With or without a sheath, the resolution clip lacked the ability to rotate. During clip opening force testing (the amount of force required to force open the jaws of a deployed clip by 3.2 mm; 3.2 mm was chosen due to the standard dimension of the gauge used for the measurement), the Instinct clips were the strongest. For the Instinct clips, an opening force of 404 ± 124 g was needed to open the closed clip, and an additional 386 ± 133 g was required to open the clip jaws to 3.2 mm. In terms of snapping force during acute closure and neoprene pulling strength, the instinct and resolution clips performed almost equally. The limitations of the study were the benchtop testing and the finite sample size for closing and pulling strength comparisons. CONCLUSIONS The QuickClip2 and the Instinct clip rotate equally well under different endoscope configurations. The resolution clips lack rotational ability. The instinct clips are stronger mechanically than the other two TTS clips. Stronger clips are perhaps associated with higher therapeutic efficacy and retention rates.
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Affiliation(s)
- Sumanth R Daram
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
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27
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Abstract
This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy.
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Affiliation(s)
- Loren Laine
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut 06520-8019, USA.
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Satgunam S, Miedema B, Whang S, Thaler K. Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model. Surg Endosc 2012; 26:2331-8. [PMID: 22361735 DOI: 10.1007/s00464-012-2185-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 07/04/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model. METHODS Cholecystectomies were attempted in five 88-130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route. RESULTS Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present. CONCLUSIONS NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.
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Affiliation(s)
- Shean Satgunam
- Department of Surgery, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
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29
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Naegel A, Bolz J, Zopf Y, Matthes K, Mueller B, Kraus F, Neurath MF, Maiss J. Hemodynamic efficacy of the over-the-scope clip in an established porcine cadaveric model for spurting bleeding. Gastrointest Endosc 2012; 75:152-9. [PMID: 22100298 DOI: 10.1016/j.gie.2011.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 08/04/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Clip application has been proven to be effective for endoscopic hemostasis. There are limited bench data on the efficacy of the over-the-scope clip (OTSC) for the treatment of spurting GI hemorrhage. We evaluated the hemodynamic efficacy of the OTSC in an established bleeding model. OBJECTIVE To evaluate the hemodynamic efficacy of the OTSC in an established bleeding model. DESIGN Prospective experimental trial with historical comparison. SETTING We tested the OTSC prospectively in a validated bleeding model by using the compact Erlangen Active Simulator for Interventional Endoscopy equipped with an upper GI organ package. The artificial blood circulation system of the simulator was connected to an arterial pressure transducer. Two investigators with different endoscopic experience (4000 and 10,000 endoscopies performed) participated. Each investigator treated 16 bleeding sites in the simulator with the OTSC by using only suction (n = 8) and a novel retraction device to grasp tissue (n = 8). Systemic pressures were recorded 1 minute before, during, and 1 minute after clip application to objectify the effects of clipping on the vessel diameter. MAIN OUTCOME MEASUREMENTS Mean and maximum reduction in vessel diameter. RESULTS The application of the OTSC on the bleeding vessel led to a significant increase in systemic pressure (P < .001) and decreased vessel diameter (P < .001) independent of the endoscopic experience of the investigator. There was no difference in the decrease in vessel diameter based on the application technique (suction vs suction plus grasping). A historical comparison with our former trials demonstrated that the OTSC decreased the vessel diameter significantly more than other traditional endoclips. LIMITATIONS Small sample size. CONCLUSIONS We could demonstrate the efficacy of the OTSC with increased hemodynamic efficiency compared with other endoscopic clip devices tested previously.
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Affiliation(s)
- Andreas Naegel
- Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany
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30
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Abstract
Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Large-channel therapeutic endoscopes are recommended. Endoscopists should be very experienced in management of patients with UGI hemorrhage, including the use of various hemostatic devices. For patients with major stigmata of ulcer hemorrhage--active arterial bleeding, nonbleeding visible vessel, and adherent clot--combination therapy with epinephrine injection and either thermal coaptive coagulation (with multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton-pump inhibitors are recommended as concomitant therapy with endoscopic hemostasis of major stigmata. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic therapy and should be triaged to less intensive care and be considered for early discharge. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce cost of medical care.
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Affiliation(s)
- Thomas O G Kovacs
- CURE Digestive Diseases Research Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073-1003, USA.
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31
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Abstract
Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce the cost of medical care. This article discusses the important aspects of the diagnosis and treatment of bleeding from ulcers, with a focus on endoscopic therapy.
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Affiliation(s)
- Thomas O G Kovacs
- CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, VA Greater Los Angeles Healthcare System, CA 90073-1003, USA.
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32
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Schrijver AM, Siersema PD, Vleggaar FP, Hirdes MMC, Monkelbaan JF. Endoclips for fixation of nasoenteral feeding tubes: a review. Dig Liver Dis 2011; 43:757-61. [PMID: 21482207 DOI: 10.1016/j.dld.2011.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 02/22/2011] [Accepted: 02/24/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Maintaining the position of an endoscopically placed nasoenteral feeding tube beyond the pylorus is often problematic because of retrograde migration. Fixation of a feeding tube to the small intestinal wall with an endoclip may prevent this. This article reviews available literature on the feasibility, efficacy and safety of endoclips for fixation of nasoenteral feeding tubes. METHODS A systematic search of the English literature was performed using MEDLINE, EMBASE and Cochrane databases to identify articles assessing the use of endoclips for fixation of feeding tubes, as well as articles assessing duration of attachment of endoclips. RESULTS Five cohort series were identified that evaluated the applicability of endoclips for fixation of feeding tubes to the small intestinal wall. In all patients, except one, a nasoenteral feeding tube could be successfully fixated to the small intestinal wall. During follow-up, no spontaneous migrations of feeding tubes were observed. No complications related to placement or removal of endoclips were observed. Three comparative studies evaluated duration of attachment of different types of endoclips to the gastrointestinal wall. Duration of attachment ranged from less than 1 week to more than 18 weeks, depending on the type of endoclip. CONCLUSIONS Based on available literature the use of endoclips for fixation of nasoenteral feeding tubes is feasible, effective and safe. Data from randomized controlled trials are needed.
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Affiliation(s)
- A M Schrijver
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
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Abstract
Lower gastrointestinal bleeding is common and can result from several colonic causes including diverticulosis, arteriovenous malformations, ischemia, inflammatory bowel disease, infectious colitis, neoplasm, postpolypectomy, and anastomotic and radiation proctitis. Following resuscitation and evaluation, colonoscopy can be used for diagnosis and treatment. Most physicians prescribe a bowel preparation for their patients. Therapeutic options include injection, coagulation (monopolar or bipolar cautery, argon plasma coagulator), and mechanical (clips, bands, detachable loops) devices.
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Affiliation(s)
- Charles B Whitlow
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Ferreira LEVV, Song LMWK, Baron TH. Management of acute postoperative hemorrhage in the bariatric patient. Gastrointest Endosc Clin N Am 2011; 21:287-94. [PMID: 21569980 DOI: 10.1016/j.giec.2011.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is one of the treatment options for achieving and preserving weight loss and managing medical complications related to obesity. After bariatric surgery, early or late adverse events, such as intraluminal or extraluminal gastrointestinal hemorrhage, can occur. Early gastrointestinal bleeding is more often a complication associated with Roux-en-Y gastric bypass surgery than other bariatric procedures and usually arises from the gastrojejunal anastomosis. Early postoperative bleeding may be potentially life threatening, although death after postbariatric surgery as a consequence of acute bleeding is uncommon. Although early postoperative intraluminal bleeding can usually be managed conservatively, endoscopic therapy may be required.
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Affiliation(s)
- Lincoln E V V Ferreira
- Department of Medicine, Digestive Endoscopy Unit, Hospital Universitario da Universidade Federal de Juiz de Fora, Unidade de Endoscopia Digestiva-Avenida Eugenio do Nascimento s/no. Bairro: Dom Bosco - CEP:36038-330, Juiz de Fora, Minas Gerais, Brasil
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Swellengrebel HAM, Marijnen CAM, Vincent A, Cats A. Evaluating long-term attachment of two different endoclips in the human gastrointestinal tract. World J Gastrointest Endosc 2010; 2:344-8. [PMID: 21160584 PMCID: PMC2998819 DOI: 10.4253/wjge.v2.i10.344] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 08/31/2010] [Accepted: 09/07/2010] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the long-term attachment of two types of endoclips in the human gastrointestinal tract.
METHODS: In this prospective observational study, endoclips were placed and followed-up during endoscopies or using fluoroscopic images as part of a prospective feasibility study evaluating external beam radiotherapy (EBRT, wk 1-3) followed by high dose rate brachytherapy (HDRBT with an endoluminal applicator once a week for 3 wk, wk 9-11) in medically inoperablerectal cancer patients. Initially, the type and number of endoclips were chosenrandomly and later refined to 1 Resolution® clip (Microvasive) proximal and 2 Quickclips® (Olympus) distal to the tumor. Nine consecutive patients from between September 2007 and August 2008 were analyzed. Retention rates were evaluated over three different observational periods [period 1: pre-HDRBT (wk -2-8), period 2: during HDRBT (wk 9-11) and period 3: post-HDRBT (wk 12-16)].
RESULTS: In this study, a total of 44 clips were placed during endoscopy, either at the beginning or at the end of period 1. The Resolution clip had a higher overall retention rate than the Quickclip (P = 0.01). After a median period of 81 d after placement (in period 1), long-term retention rates for the Resolution clip and Quickclip clip were 67% and 35% respectively.
CONCLUSION: The Resolution clip has a high retention rate and is useful in situations where long-term attachment to the human gastrointestinal mucosa is warranted.
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Affiliation(s)
- Hendrik Albert Maurits Swellengrebel
- Hendrik Albert Maurits Swellengrebel, Annemieke Cats, Department of Gastroenterology and Hepatology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam 1066CX, The Netherlands
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Park PO, Long GL, Bergström M, Cunningham C, Vakharia OJ, Bakos GJ, Bally KR, Rothstein RI, Swain CP. A randomized comparison of a new flexible bipolar hemostasis forceps designed principally for NOTES versus a conventional surgical laparoscopic bipolar forceps for intra-abdominal vessel sealing in a porcine model. Gastrointest Endosc 2010; 71:835-41. [PMID: 19942215 DOI: 10.1016/j.gie.2009.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 08/08/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current devices for hemostasis in flexible endoscopy are inferior to methods used during open or laparoscopic surgery and might be ineffective for natural orifice transluminal endoscopic surgery. OBJECTIVE To compare new flexible bipolar forceps (FBF), designed principally for natural orifice transluminal endoscopic surgery, with laparoscopic bipolar forceps (LBF) for hemostasis of intra-abdominal porcine arteries. SETTING Surgical laboratories in Europe and the United States. DESIGN AND INTERVENTIONS New FBF for hemostasis (3.7-mm diameter), featuring electrode isolation, were compared with rigid 5-mm LBF (ERBE BiClamp LAP forceps) at recommended settings. A porcine model of acute hemostasis was prepared by suturing the uterine horns and cecum to the abdominal wall, exposing uterine arteries, ovarian pedicles, cecal mesenteric bundles, and the inferior mesenteric artery. This allowed access to 10 vessels in each pig by transabdominal laparoscopic devices or a transgastric double-channel gastroscope. Vessels were measured, coagulated at 4 and more points, and transected. Blood pressure was increased to more than 200 mm Hg for 10 minutes by administering phenylephrine. Delayed bleeding was identified. MAIN OUTCOME MEASUREMENTS In 7 pigs, a total of 65 vessels (1.5-6.0 mm) were randomly allocated to FBF (n = 32) or LBF (n = 33). Successful hemostasis both before and after blood pressure increase was equivalent between the 2 groups (before: 88% FBF vs 88% LBF, not significant [NS]; after: 97% FBF vs 94% LBF, NS). With FBF, the number of seals per vessel was 4.8 vs 4.4 with LBF (NS). The energy used to create FBF seals was 19.8 J vs 38.2 J for LBF (P < .05). LIMITATIONS Results from porcine studies may not reflect patient outcomes. CONCLUSIONS In a porcine model, transgastric FBF endoscopic hemostasis was as effective as conventional laparoscopic hemostasis using LBF across a wide range of vessels.
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Affiliation(s)
- Per-Ola Park
- Department of Surgery, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden
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Aplicaciones de los clips en la terapéutica endoscópica actual. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:171-8. [DOI: 10.1016/j.gastrohep.2009.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/13/2009] [Accepted: 04/17/2009] [Indexed: 12/17/2022]
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Jensen DM, Machicado GA, Hirabayashi K. Hemoclipping of chronic canine ulcers: a randomized, prospective study of initial deployment success, clip retention rates, and ulcer healing. Gastrointest Endosc 2009; 70:969-75. [PMID: 19640519 PMCID: PMC3789654 DOI: 10.1016/j.gie.2009.04.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 04/24/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Several different hemoclips are marketed for endoscopic hemostasis of nonvariceal upper GI (UGI) bleeding. No previous reports have compared success rates of clip deployment onto bases of chronic gastric ulcers (GUs), clip retention rates, or their influence on ulcer healing. OBJECTIVES For the treatment of chronic GUs, to compare 3 different hemoclips with multipolar electrocoagulation (MPEC) and control. DESIGN Randomized, controlled study. SUBJECTS Seven adult dogs with prehepatic portal hypertension had GUs created by rubber band ligation. Animals received oral proton pump inhibitors daily and underwent weekly endoscopies to quantitate clip retention and ulcer healing. INTERVENTIONS One week after banding, 10 chronic ulcers were randomized in pairs to control (no endoscopic treatment), MPEC, or different hemoclips (QuickClip2 [QC], TriClip [TC], or Resolution Clip [RC]). MAIN OUTCOME MEASUREMENTS Times and success of hemoclip deployment, clip retention rates, and ulcer healing rates on weekly endoscopies. RESULTS Success rates of clip deployment were 100% for the RC, 93.1% for the TC, and 83.3% for the QC. Clip retention rates were significantly higher with the RC than the QC or TC at 1 to 3 weeks. Retained clips did not delay GU healing compared with MPEC or control. CONCLUSIONS Hemoclipping time was similar with all 3 clips; the RC was retained significantly longer than the QC or TC, hemoclips did not delay ulcer healing compared with control or MPEC, and all 3 hemoclips were safe and no complications such as bleeding and weight loss were noted.
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The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding. Surg Laparosc Endosc Percutan Tech 2009; 19:2-10. [PMID: 19238058 DOI: 10.1097/sle.0b013e31818e9297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.
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Gill KRS, Pooley RA, Wallace MB. Magnetic resonance imaging compatibility of endoclips. Gastrointest Endosc 2009; 70:532-6. [PMID: 19555940 DOI: 10.1016/j.gie.2009.01.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 01/15/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic clipping devices are now available for treatment of GI hemorrhage and microperforations. All commercially available endoclips are labeled as magnetic resonance imaging (MRI) incompatible. No data are available about the actual magnetic field strength at which endoclips are first deflected nor the clinical relevance of the magnetic fields on endoclips used in GI endoscopy. OBJECTIVE To determine the compatibility of different endoclips with MRI. DESIGN Prospective observational study. SETTING Experiment on excised pig tissue in an MRI scanner. INTERVENTIONS The physical deflection and strength of attraction of endoclips: Resolution Clip, TriClip, QuickClip, and Ethicon Endo-surgery Clip were measured in different positions by using an MRI scanner at a field strength of 1.5 Tesla. Endoclips that demonstrated deflection were attached to a pig stomach and tested for detachment at a 1.5-Tesla MRI field strength. MAIN OUTCOME MEASUREMENTS Physical deflection and detachment from pig stomach mucosa in an MRI scanner. RESULTS All endoclips except the one made by Ethicon Endo-surgery demonstrated physical deflection under the tested conditions. The magnetic attraction was strongest for the Resolution Clip (0.7 gauss) compared with the TriClip (1.2 gauss) and the QuickClip (26.8 gauss). Only the Triclip demonstrated detachment from the pig gastric tissue under testing conditions. LIMITATIONS A pig model and a small number of clips. CONCLUSIONS The Ethicon Endo-surgery clip is compatible with MRI. All other clips showed deflection in a magnetic field, but only the TriClip demonstrated detachment from gastric tissue, and hence should be considered MRI incompatible.
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Affiliation(s)
- Kanwar Rupinder S Gill
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Jacksonville, Florida 32224, USA
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Chen Y, Zhang Q, Liao Y, Guo F, Zhang Y, Zeng Q, Jin W, Shi H, Zhou M. A modified canine model of portal hypertension with hypersplenism. Scand J Gastroenterol 2009; 44:478-85. [PMID: 19096979 DOI: 10.1080/00365520802624201] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to develop and describe an experimental canine model of portal hypertension with hypersplenism. MATERIAL AND METHODS Twenty-five dogs were used randomly divided into three groups: group I (control group, n = 5), group II (PVS, n = 10) and group III (PVS + SVS, n = 10). Portal vein stenosis (PVS) was performed in dogs of group II; in group III dogs the model was first prepared by PVS and additional splenic vein stenosis 3 weeks later (PVS + SVS). Portal vein pressure (PVP), length of spleen and fluctuation of hematocyte counts were measured and recorded at the appointed times. Surgery permitted visual verification of portosystemic collateral circulation. Histopathological variation of the spleen and condition of the bone marrow hyperplasia were examined to confirm the development of hypersplenism. RESULT Both group II and group III developed prehepatic portal hypertension; group III also presented satisfactory hypersplenism compared to the control group and group II, as documented at surgery and by hematologic and pathologic examination. CONCLUSIONS Based on this study, the modified model of portal hypertension (by PVS + SVS) appears appropriate when studying the relationship between hypersplenism and hemodynamics in portal hypertension. It is also likely to be useful in studying the influence of diseased spleen in the treatment of portal hypertension.
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Affiliation(s)
- Yunzhi Chen
- Department of General Surgery, First Affiliated Hospital, Wenzhou Medical College, Wenzhou, Zhejiang Province, China
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Endoscopic clips: past, present and future. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:158-60. [PMID: 19319378 DOI: 10.1155/2009/515937] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
Upper gastrointestinal bleeding secondary to ulcer disease is common and results in substantial patient morbidity and medical expense. After initial resuscitation to stabilize the patient, carefully performed endoscopy provides an accurate diagnosis and identifies high-risk ulcer patients who are likely to rebleed with medical therapy alone and will benefit most from endoscopic hemostasis. For patients with major stigmata of ulcer hemorrhage--active arterial bleeding, nonbleeding visible vessel, and adherent clot--combination therapy with epinephrine injection and either thermal coagulation (multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton pump inhibitors are recommended as concomitant therapy after successful endoscopic hemostasis. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic treatment and should receive high-dose oral proton pump inhibitor therapy. Effective medical and endoscopic management of ulcer hemorrhage can significantly improve outcomes and decrease the cost of medical care by reducing rebleeding, transfusion requirements, and the need for surgery.
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Affiliation(s)
- Thomas O G Kovacs
- CURE/Digestive Disease Research Center, VA Greater Los Angeles Healthcare System, Building 115, Room 212, 11301 Wilshire Boulevard, Los Angeles, CA 90073-1003, USA.
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Endoscopic clipping for the management of gastrointestinal bleeding. ACTA ACUST UNITED AC 2008; 5:559-68. [PMID: 18711412 DOI: 10.1038/ncpgasthep1233] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 07/04/2008] [Indexed: 02/06/2023]
Abstract
Endoscopic clipping is a safe and effective technique for the treatment of various bleeding gastrointestinal lesions. Randomized controlled trials and a meta-analysis have shown comparable efficacy between clipping and conventional contact thermal therapy for definitive hemostasis of nonvariceal upper gastrointestinal hemorrhage. Clipping also seems to be efficacious for selected lower gastrointestinal bleeding lesions, such as diverticular bleeding and postpolypectomy bleeding. Proficiency in clip application and endoscopic identification of lesions that are amenable to clipping are key determinants of a successful outcome.
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Yuan Y, Wang C, Hunt RH. Endoscopic clipping for acute nonvariceal upper-GI bleeding: a meta-analysis and critical appraisal of randomized controlled trials. Gastrointest Endosc 2008; 68:339-51. [PMID: 18656600 DOI: 10.1016/j.gie.2008.03.1122] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 03/31/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute nonvariceal upper-GI bleeding (NVUGIB) is common, with a high rate of recurrent bleeding and substantial mortality rate. Endoscopic clipping has the theoretical advantage of minimizing tissue injury and is increasingly used. OBJECTIVE We conducted a systematic review and meta-analysis to investigate any potential benefits of clipping over other endoscopic techniques for NVUGIB. DESIGN Randomized controlled trials (RCT) that compared clipping with other endoscopic hemostatic methods to treat NVUGIB were included. Summary effect size was estimated by odds ratio (OR) with a random-effects model. RESULTS Twelve RCTs met inclusion criteria. For peptic ulcer bleeding (PUB), the hemoclip (n = 351 patients) was compared with the heat probe alone, thermal therapy plus injection, and injection alone in 2, 2, and 5 studies, respectively (n = 348 patients). The rate of the initial hemostasis was nonsignificantly increased in the control group compared with the hemoclip group (92% vs 96%, OR 0.58 [95% CI, 0.19-1.75]). The rebleeding rate was nonsignificantly decreased with hemoclips compared with controls (8.5% vs 15.5%, OR 0.56 [95% CI, 0.30-1.05]). Emergency surgery and the mortality rate were not significantly different between the hemoclip and controls. Subgroup analysis conducted in studies that compared hemoclips with injection alone show similar results. Two studies and one study reported outcomes of interest for Dieulafoy's lesions and Mallory-Weiss syndrome, respectively. CONCLUSIONS RCTs that compared clipping alone with other endoscopic hemostatic techniques for NVUGIB were limited. Current evidence suggests that the hemoclip is not superior to other endoscopic modalities in terms of initial hemostasis, rebleeding rate, emergency surgery, and the mortality rate for treatment of PUB.
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Affiliation(s)
- Yuhong Yuan
- Division of Gastroenterology, McMaster University Health Science Centre, Hamilton, Ontario, Canada
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Affiliation(s)
- Louis M Wong Kee Song
- GI Bleeding Team, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
Endoscopic clips are relatively new devices that have been shown to be effective for the control of acute gastrointestinal hemorrhage. Various different models are available and offer simplicity of use with relatively few complications. Recently, endoscopic clips have been used for a variety of non-hemorrhagic conditions. In this article we review the literature and present current thinking about the indications, efficacy and safety of these devices.
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Affiliation(s)
- Michael J Grupka
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA.
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Cappell MS, Friedel D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med Clin North Am 2008; 92:511-50, vii-viii. [PMID: 18387375 DOI: 10.1016/j.mcna.2008.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Tang SJ, Rivas H, Tang L, Lara LF, Sreenarasimhaiah J, Rockey DC. Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery. Obes Surg 2008; 17:1261-7. [PMID: 18074504 DOI: 10.1007/s11695-007-9206-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. In the early postoperative stage, gastrointestinal (GI) bleeding is an infrequent but potentially serious complication that usually results from bleeding at the gastrojejunostomy staple-line. Observant management with transfusion for stable patients and surgical exploration for unstable patients is typically recommended for early GI bleeding. We hypothesized that use of endoclips, which do not cause thermal injury to the surrounding tissues (or anastomosis), may be preferable to thermal approaches which could cause tissue injury. We report 2 cases of early GI bleeding after RYGBP that were successfully managed with endoclip application to bleeding lesions. Emergent endoscopy was performed, and major stigmata such as active spurting vessel and adherent clot were noted at the gastrojejunostomy staple-lines. Endoscopic hemostasis using endoclips was readily applied to bleeding lesions at staple-lines. Primary hemostasis was achieved, and there was no recurrent bleeding or complication. We conclude that therapeutic endoscopy can be performed safely for early bleeding after RYGBP. In patients with early bleeding after RYGBP, use of endoclips is mechanistically preferable to other options.
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Affiliation(s)
- Shou-Jiang Tang
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8887, USA.
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Chan CYO, Yau KKK, Siu WT, Wong KHS, Luk YW, Tai TYP, Li KWM. Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study. Gastrointest Endosc 2008; 67:35-9. [PMID: 17945225 DOI: 10.1016/j.gie.2007.05.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 05/04/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The feasibility, efficacy, and safety of the TriClip in the management of peptic ulcer hemorrhage in human beings are scarcely reported in the literature. OBJECTIVE A pilot study was conducted to assess the feasibility, efficacy, and safety of the TriClip endoscopic clipping device in the control of peptic ulcer hemorrhage. DESIGN Prospective evaluation. SETTING Regional government hospital. PATIENTS From July 2004 to January 2005, patients older than 16 years and with Forrest type I and IIa peptic ulcer hemorrhages were included in the study. INTERVENTIONS TriClips were used for initial hemostasis. Salvage procedures, including adrenalin injection, heat probe application, argon plasma coagulation, or surgery will be carried out appropriately if TriClip failed to control bleeding alone. An endoscopy was repeated 24 hours later for the security of the TriClip and for any endoscopic evidence of recurrent bleeding. A follow-up endoscopy was performed 8 weeks later to assess ulcer healing. MAIN OUTCOME MEASUREMENTS Procedure time, successful hemostatic rate, number of clips used, ulcer recurrent bleeding rate, complications, and ulcer healing rate were measured. LIMITATIONS No comparative arm; pilot study only. RESULT A total of 27 cases (11 women, 16 men) were included in the study, with a median age of 70 years (range 18-88 years). There were 19 cases of duodenal ulcer and 8 cases of gastric ulcer, with median size of 8 mm (range 2-20 mm). The rate of successful hemostasis in the first endoscopy by TriClips alone was 81.5% (22/27), with a median procedure time of 10 minutes (range 3-30 minutes). In the second endoscopy, the endoscopic recurrent bleeding rate was 14.8% (4/27) and the TriClips were found dislodged in 11 patients (40.7%). The permanent hemostasis rate was 67% (18/27). The overall failure rate was 33% (9/27). Three patients required blood transfusion before the first endoscopy. There was no morbidity or mortality observed in all cases. All ulcers healed after 8 weeks. CONCLUSIONS The use of the TriClip is feasible in the initial control of peptic ulcer hemorrhage. However, we could not detect any obvious advantages in arresting bleeding vessels by using this new clipping device.
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