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Judge C, Bandle J, Wang A, Gadbois K, Simsiman A, Wood R, Wisbach G. Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up. JSLS 2024; 28:e2023.00059. [PMID: 38562949 PMCID: PMC10984372 DOI: 10.4293/jsls.2023.00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Objectives We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution. Methods A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2. Results Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8. Conclusion TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.
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Affiliation(s)
- Carolyn Judge
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
| | - Jesse Bandle
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
| | - Andrew Wang
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
| | - Kyle Gadbois
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
| | - Amanda Simsiman
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
| | - Robin Wood
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
| | - Gordon Wisbach
- Department of General Surgery, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Judge, Bandle, Gadbois, and Wisbach)
- Department of Obstetrics and Gynecology, Naval Medical Readiness and Training Command, San Diego, California, USA. (Drs Wang, Simsiman, and Wood)
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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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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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Pohl H, Grimm IS, Moyer MT, Hasan MK, Pleskow D, Elmunzer BJ, Khashab MA, Sanaei O, Al-Kawas FH, Gordon SR, Mathew A, Levenick JM, Aslanian HR, Antaki F, von Renteln D, Crockett SD, Rastogi A, Gill JA, Law RJ, Elias PA, Pellise M, Wallace MB, Mackenzie TA, Rex DK. Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial. Gastroenterology 2019; 157:977-984.e3. [PMID: 30885778 PMCID: PMC8224988 DOI: 10.1053/j.gastro.2019.03.019] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding. METHODS We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (≥20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse event. RESULTS A total of 919 patients were randomly assigned to groups and completed follow-up. Postprocedure bleeding occurred in 3.5% of patients in the clip group and 7.1% in the control group (absolute risk difference [ARD] 3.6%; 95% confidence interval [CI] 0.7%-6.5%). Among 615 patients (66.9%) with a proximal large polyp, the risk of bleeding in the clip group was 3.3% and in the control group was 9.6% (ARD 6.3%; 95% CI 2.5%-10.1%); among patients with a distal large polyp, the risks were 4.0% in the clip group and 1.4% in the control group (ARD -2.6%; 95% CI -6.3% to -1.1%). The effect of clip closure was independent of antithrombotic medications or polyp size. Serious adverse events occurred in 4.8% of patients in the clip group and 9.5% of patients in the control group (ARD 4.6%; 95% CI 1.3%-8.0%). CONCLUSIONS In a randomized trial, we found that endoscopic clip closure of the mucosal defect following resection of large colon polyps reduces risk of postprocedure bleeding. The protective effect appeared to be restricted to large polyps located in the proximal colon. ClinicalTrials.gov no: NCT01936948.
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Affiliation(s)
- Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire; Section of Gastroenterology and Hepatology, VA White River Junction, White River Junction, Vermont.
| | - Ian S. Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew T. Moyer
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Muhammad K. Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Douglas Pleskow
- Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Firas H. Al-Kawas
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Sibley Memorial Hospital, Washington, DC
| | - Stuart R. Gordon
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire,Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John M. Levenick
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Harry R. Aslanian
- Section of Digestive Diseases, Yale-New Haven Hospital, New Haven, Connecticut
| | - Fadi Antaki
- Division of Gastroenterology, John D. Dingell Veterans Affairs Medical Center and Wayne State University, Detroit, Michigan
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Medical Center (CHUM) and Research Center (CRCHUM), Montreal, QC, Canada
| | - Seth D. Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas City, Kansas
| | - Jeffrey A. Gill
- Division of Gastroenterology James A. Haley VA, University of South Florida, Tampa, Florida
| | - Ryan J. Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Pooja A. Elias
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Maria Pellise
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Michael B. Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Todd A. Mackenzie
- The Dartmouth Institute, Department for Biomedical Data Science, Lebanon, New Hampshire
| | - Douglas K. Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Chiu PW. Endoscopic Management of Peptic Ulcer Bleeding: Recent Advances. Clin Endosc 2019; 52:416-418. [PMID: 31405266 PMCID: PMC6785411 DOI: 10.5946/ce.2018.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 05/30/2019] [Indexed: 12/16/2022] Open
Abstract
Bleeding peptic ulcers remained as one of the commonest causes of hospitalization worldwide. While endoscopic hemostasis serves as primary treatment for bleeding ulcers, rebleeding after endoscopic hemostasis becomes more and more difficult to manage as patients are usually poor surgical candidates with multiple comorbidities. Recent advances in management of bleeding peptic ulcers aimed to further reduce the rate of rebleeding through-(1) identification of high risk patients for rebleeding and mortality; (2) improvement in primary endoscopic hemostasis and; (3) prophylactic angiographic embolization of major arteries. The technique and clinical evidences for these approaches will be reviewed in the current article.
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Affiliation(s)
- Philip Wy Chiu
- Department of Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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Abdelaziz M. Hemostatic forceps in various gastrointestinal bleeding scenarios: A single center comparative study with endoclip. COGENT MEDICINE 2019. [DOI: 10.1080/2331205x.2019.1623000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Mohamad Abdelaziz
- Department of Tropical medicine and gastroenterology, University of Sohag, Akhmim, Egypt
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Nagata N, Ishii N, Kaise M, Shimbo T, Sakurai T, Akiyama J, Uemura N. Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping. Gastrointest Endosc 2018; 88:841-853.e4. [PMID: 30036505 DOI: 10.1016/j.gie.2018.07.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 07/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Very few prospective studies with over 100 samples have evaluated the long-term outcomes of endoscopic therapy for colonic diverticular bleeding (CDB). This study sought to elucidate the recurrent bleeding risk of endoscopic band ligation versus clipping for definitive CDB based on stigmata of recent hemorrhage (SRH). METHODS Patients emergently hospitalized for acute lower GI bleeding and examined by high-resolution colonoscopy were enrolled. Better visualization of SRH from a diverticulum was obtained using a water-jet device. Endoscopic band ligation or clipping was performed as first-line treatment, and patients were prospectively followed after discharge. RESULTS No statistical difference was found between the ligation (n = 61) and clipping (n = 47) groups in baseline characteristics or follow-up period. The probability of 1-year recurrent bleeding was 11.5% in the ligation group versus 37.0% in the clipping group (P = .018). No patients required surgery or experienced perforation. One patient in the ligation group experienced diverticulitis the next day. In patients with recurrent bleeding within 7 days, the recurrent bleeding site was the same diverticulum, and ulceration was found in the ligation group on repeat colonoscopy. In patients with recurrent bleeding after 2 months, repeat colonoscopy identified that the recurrent bleeding site was different, and scar formation was seen in the ligation group. The left side of the colon was an independent predictor for recurrent bleeding in the ligation group but not in the clipping group. CONCLUSIONS Band ligation for definitive CDB has better outcomes than clipping during long-term follow-up after endoscopic therapy, probably because of complete elimination of the diverticulum. CDB can recur at the same diverticulum in the short term but at a different diverticulum in the long term.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naoki Ishii
- Gastroenterology Division, Koga Hospital, Koga, Japan; Gastroenterology Division, St. Luke's International Hospital, Tokyo, Japan
| | - Mitsuru Kaise
- Gastroenterology Division, Nippon Medical School, Tokyo, Japan
| | - Takuro Shimbo
- Department of Internal Medicine, Ohta Nishinouchi Hospital, Fukushima, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan; Department of Gastroentegology, The Jikei University School of Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
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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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Goelder SK, Brueckner J, Messmann H. Endoscopic hemostasis state of the art - Nonvariceal bleeding. World J Gastrointest Endosc 2016; 8:205-211. [PMID: 26962402 PMCID: PMC4766253 DOI: 10.4253/wjge.v8.i4.205] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/04/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
New endoscopic techniques for hemostasis in nonvariceal bleeding were introduced and known methods further improved. Hemospray and Endoclot are two new compounds for topical treatment of bleeding. Initial studies in this area have shown a good hemostatic effect, especially in active large scale oozing bleeding, e.g., tumor bleedings. For further evaluation larger prospective studies comparing the substanced with other methods of endoscopic hemostasis are needed. For localized active arterial bleeding primary injection therapy in the area of bleeding as well as in the four adjacent quadrants offers a good method to reduce bleeding activity. The injection is technically easy to learn and practicable. After bleeding activity is reduced the bleeding source can be localized more clearly for clip application. Today many different through-the-scope (TTS) clips are available. The ability to close and reopen a clip can aid towards good positioning at the bleeding site. Even more important is the rotatability of a clip before application. Often multiple TTS clips are required for secure closure of a bleeding vessel. One model has the ability to use three clips in series without changing the applicator. Severe arterial bleeding from vessels larger than 2 mm is often unmanageable with these conventional methods. Here is the over-the-scope-clip system another newly available method. It is similar to the ligation of esophageal varices and involves aspiration of tissue into a transparent cap before closure of the clip. Thus a greater vascular occlusion pressure can be achieved and larger vessels can be treated endoscopically. Patients with severe arterial bleeding from the upper gastrointestinal tract have a very high rate of recurrence after initial endoscopic treatment. These patients should always be managed in an interdisciplinary team of interventional radiologist and surgeons.
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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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11
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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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12
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Shen C, Chen H, Yin Y, Chen J, Han L, Zhang B, Chen Z, Chen J. Endoscopic versus open resection for small gastric gastrointestinal stromal tumors: safety and outcomes. Medicine (Baltimore) 2015; 94:e376. [PMID: 25569663 PMCID: PMC4602836 DOI: 10.1097/md.0000000000000376] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic resection has been performed to treat small gastric neoplasms. However, this technique for small gastric gastrointestinal stromal tumors (GISTs) remains controversial. This study aims to compare the safety and surgical outcomes of endoscopic versus open resection of small gastric GISTs.The medical records of 54 consecutive gastric GISTs patients with tumor size of ≤2 cm, who were surgically treated with endoscopic resection (endoscopic group) or open surgery (laparotomy group) in a single institution from March 2010 to June 2014, were retrospectively analyzed. The clinical and tumor characteristics, surgical safety, and tumor-related outcomes were evaluated.Of 54 patients, 32 and 22 patients underwent endoscopic resection and laparotomy, respectively. Patients who underwent endoscopic resection yielded a significantly shorter hospital stay compared with patients who underwent laparotomy (P < 0.001). Compared with patients in the endoscopic group, patients in the laparotomy group had more intraoperative blood loss (P < 0.001), had longer nasogastric tube retention (P < 0.001), and required longer operative time (P < 0.001). More laparotomy patients required postoperative analgesic drugs than those in the endoscopic group (n = 9 vs 4; P = 0.016). Gastric perforation occurred in 1 case during operation in the endoscopic group. Patients who underwent these 2 procedures did not differ with respect to tumor size (P = 0.168), perioperative transfusion (P = 1.000), reoperation (P = 1.000), early satiety (P = 0.560), and postoperative bleeding (P = 1.000). With a median follow-up time of 34.5 months, 1 high-risk patient in each group experienced tumor recurrence/metastasis postoperatively.The endoscopic procedure allows safe resection with good surgical outcomes for small gastric GISTs compared with laparotomy. Moreover, larger randomized controlled trials are warranted to confirm endoscopic application for small gastric GISTs.
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Affiliation(s)
- Chaoyong Shen
- From the Department of Gastrointestinal Surgery (CS, HC, YY, JC, BZ, ZC, JC); and Intensive Care Unit (LH), West China Hospital, Sichuan University, Chengdu, Sichuan, China
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13
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Law R, Deters JL, Miller CA, Marler RJ, Baron TH. Endoscopic band ligation for closure of GI perforations in a porcine animal model (with video). Gastrointest Endosc 2014; 80:717-722. [PMID: 25085337 DOI: 10.1016/j.gie.2014.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 06/03/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND GI perforations occur rarely during endoscopy but have life-threatening implications. OBJECTIVE To evaluate endoscopic band ligation (EBL) for closure of acute GI perforations by using a porcine model. DESIGN Investigator-initiated interventional pilot study by using an in vivo porcine model. SETTING Tertiary-care institution. SUBJECTS Ten domestic pigs. INTERVENTION Each animal underwent a single endoscopic procedure, with creation of a single GI lumen perforation. Perforations of 10 to 20 mm were created in the esophagus, stomach, duodenum, and colon. EBL was used for closure. Fourteen days later, the pigs were killed, microbial cultures were obtained, and histologic review was done. MAIN OUTCOME MEASUREMENTS Immediate and delayed endoscopic closure of the perforation site, evidence of clinical peritonitis during the 14-day follow-up. RESULTS Ten pigs completed the protocol and survived without clinical peritonitis during the 14-day follow-up. Endoscopic closure of a 15-mm esophageal perforation failed, thus, no attempt was made to close a 20-mm esophageal perforation. Closure of all other perforations was successful. At necropsy, fibrinous peritonitis was suspected in one animal with a 10-mm duodenal perforation. Chronic inflammation and fibroplasia at the perforation sites were the most common histologic findings. LIMITATIONS The applicability of widespread use in humans remains unknown despite successful case reports in the medical literature. CONCLUSION EBL can be used successfully to close 10 to 20 mm perforations within normal stomach, duodenum, and colon and can prevent clinically relevant intra-abdominal infections. However, for esophageal perforations, closure may be limited to small (≤10 mm), iatrogenic perforations.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jodie L Deters
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles A Miller
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald J Marler
- Department of Comparative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Todd H Baron
- Division of Gastroenterology & Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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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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Kojima F, Sato T, Tsunoda S, Takahata H, Hamaji M, Komatsu T, Okada M, Sugiura T, Oshiro O, Sakai Y, Date H, Nakamura T. Development of a novel marking system for laparoscopic gastrectomy using endoclips with radio frequency identification tags: feasibility study in a canine model. Surg Endosc 2014; 28:2752-9. [PMID: 24651896 DOI: 10.1007/s00464-014-3501-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intraoperative identification of early gastric cancer is difficult to conduct during laparoscopic procedures. In this study, we investigated the feasibility and accuracy of a newly developed marking system using endoclips with radio frequency identification (RFID) tags in a canine model. METHODS RFID is a wireless near field communication technology. Among the open frequency bands available for medical use, 13.56 MHz is suitable for a surgical marking system because of the similar and linear signal decay both in air and in biological tissues. The proposed system consists of four parts: (a) endoclips with RFID tags, (b) endo-clip applier equipment, (c) laparoscopic locating probe, and (d) signal processing units with audio interface. In the experimental setting using canine models, RFID-tagged endoclips were applied to the mucosa of each dog's stomach. During the subsequent operation, the clips with RFID tags placed in five dogs were located by the detection of the RFID signal from the tag (RFID group), and the conventional clips in the other six dogs were located by finger palpation (FP group). The detected sites were marked by ablation on the serosal surface. Distance between the clips and the metal pin needles indicating ablated sites were measured with X-ray radiographs of the resected specimen. RESULTS All clips were successfully detected by the marking system in the RFID group (10/10) and by finger palpation in the FP group (17/17). The medians of detection times were 31.5 and 25.0 s, respectively; the distances were 5.63 and 7.62 mm, respectively. The differences were not statistically significant. No adverse event related to the procedures was observed. CONCLUSIONS Endoclips with RFID tags were located by our novel marking system in an experimental laparoscopic setting using canine stomachs with substantial accuracy comparable to conventional endoclips located by finger palpation through an open approach.
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Affiliation(s)
- Fumitsugu Kojima
- Department of Bioartificial Organs, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
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Nam KW, Lee SB, Kim IY, Kim KG, Park SJ. A new hemostatic clip for endoscopic surgery that can maintain blood flow after clipping. World J Gastroenterol 2014; 20:1325-1331. [PMID: 24574807 PMCID: PMC3921515 DOI: 10.3748/wjg.v20.i5.1325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To develop a new hemostatic device for endoscopic surgery that can control the bleeding without completely occluding the bleeding vessel.
METHODS: A hemostatic clip and its applier that can stanch bleeding while maintaining blood flow through the clipped vessel was introduced, and the performance of the proposed clip was evaluated using in vitro and in vivo experiments.
RESULTS: During in vitro experiments, no leakage was found after clipping at cuts made in artificial vessels, and flow was maintained through the clipped artificial vessels. In experiments on rats, all the implanted clips occluded the target vessels successfully, and no bleeding or tissue damage was observed at the operative site after the rats were euthanized on postoperative day 7. In experiments on pigs, bleeding stopped immediately after partial clipping of a damaged vessel, and some amount of blood flow was consistently maintained through the clipped vessel after hemostasis.
CONCLUSION: We believe that the proposed hemostatic clip and clip applier can enhance patient safety during laparoscopic surgery.
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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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Camus M, Jensen DM, Ohning GV, Kovacs TO, Ghassemi KA, Jutabha R, Machicado GA, Dulai GS, Hines JO. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers. Endoscopy 2013; 45:397-400. [PMID: 23616128 PMCID: PMC3804305 DOI: 10.1055/s-0032-1326294] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We report a case series of all consecutive patients hospitalized in our two tertiary referral medical centers over the past 17 years for Cameron ulcers causing severe upper gastrointestinal hemorrhage (GIH) or severe obscure GIH. Cameron ulcers were diagnosed in 25 of the 3960 screened patients with severe upper GIH or severe obscure GIH (0.6 %). Of these, 21 patients had a prospective follow-up (median time 20.4 months [interquartile range: 8.5 - 31.8]). Patients were more often elderly women with chronic anemia, always had large hiatal hernias, and were usually referred for obscure GIH. Twelve of the 21 patients (57 %) were referred for surgery while being treated with high-dose proton pump inhibitors (PPIs). The other 9 patients (43 %) continued PPIs without any rebleeding during the follow-up. Cameron ulcers in large hiatal hernias are an uncommon cause of severe upper GIH. The choice of medical vs. surgical therapy should be individualized.
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Affiliation(s)
- Marine Camus
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States.,Department of Gastroenterology, Lariboisiere Hospital, APHP, University Paris 7, France
| | - Dennis M. Jensen
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States.,Division of Digestive Diseases at VA GLAHC, Los Angeles, CA, United States
| | - Gordon V. Ohning
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States.,Division of Digestive Diseases at VA GLAHC, Los Angeles, CA, United States
| | - Thomas O. Kovacs
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States.,Division of Digestive Diseases at VA GLAHC, Los Angeles, CA, United States
| | - Kevin A. Ghassemi
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
| | - Rome Jutabha
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
| | - Gustavo A. Machicado
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States.,Division of Digestive Diseases at VA GLAHC, Los Angeles, CA, United States
| | - Gareth S. Dulai
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States.,Division of Digestive Diseases at VA GLAHC, Los Angeles, CA, United States
| | - Joel O. Hines
- Department of Gastrointestinal Surgery at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
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Ishii N, Hirata N, Omata F, Itoh T, Uemura M, Matsuda M, Suzuki S, Iizuka Y, Fukuda K, Fujita Y. Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping. Gastrointest Endosc 2012; 76:1175-81. [PMID: 23021162 DOI: 10.1016/j.gie.2012.07.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 07/30/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Predictors of refractory colonic diverticular hemorrhage after endoscopic clipping (EC) remain unclear. OBJECTIVE To elucidate the predictors of uncontrolled bleeding after EC. DESIGN Retrospective study. SETTING Two tertiary referral centers. PATIENTS Eighty-nine patients with colonic diverticular hemorrhage who underwent EC as a first-line treatment were included. INTERVENTIONS If bleeding remained uncontrolled after 1 or 2 EC sessions, other interventions (transcatheter arterial embolization, endoscopic band ligation, or surgery) were performed. Patients were divided into EC-controlled and EC-uncontrolled groups; the characteristics of each group were compared. MAIN OUTCOME MEASUREMENTS Comorbidities, location of bleeding diverticula, and EC technique (direct vs indirect placement). RESULTS Initial treatment with EC was successful in 87 patients. Early rebleeding (primary failure) occurred in 30 of 87 patients (34%). Secondary failure occurred in 6 of 22 patients treated with reclipping (27%). Cumulatively, 78 patients were successfully managed with EC. Non-EC treatments were required in 11 patients. Location in the right side of the colon, particularly in the ascending colon, was significantly more common in the EC-uncontrolled group than in the EC-controlled group (P = .017 and P = .0029, respectively). Although the difference was not significant, bleeding was successfully managed in all 13 patients treated with direct placement. Bleeding remained uncontrolled after EC in 11 of 52 ascending cases (21%) treated with indirect placement. Diverticular hemorrhage in other locations was managed regardless of EC technique. LIMITATIONS Retrospective study. CONCLUSIONS Location in the ascending colon is a significant predictor of refractory colonic diverticular hemorrhage after EC. Indirect placement of hemoclips in ascending lesions is ineffective.
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Affiliation(s)
- Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
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20
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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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22
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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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Kim HI, Hyung WJ, Lee CR, Lim JS, An JY, Cheong JH, Choi SH, Noh SH. Intraoperative portable abdominal radiograph for tumor localization: a simple and accurate method for laparoscopic gastrectomy. Surg Endosc 2010; 25:958-63. [PMID: 20725742 DOI: 10.1007/s00464-010-1288-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 07/26/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND During laparoscopic gastrectomy, it is impossible to identify early gastric cancer (EGC) lesions; therefore, a precise localization technique is required. In this study, we evaluated a novel method of intraoperative portable abdominal radiograph for localization of EGC lesions after preoperative endoscopic clipping. METHODS A retrospective study of 80 patients who had undergone laparoscopic gastrectomies with our intraoperative abdominal radiographic method of tumor localization was performed. During preoperative endoscopy, endoscopic metal clips were applied just proximal to the tumor. A plain abdominal radiograph taken immediately after oral administration of effervescent agents was employed to select candidates for intraoperative localization. Intraoperative vessel clips were laparoscopically applied along the greater and lesser curvatures, and a portable abdominal radiograph was taken to identify the location of endoscopic clips relative to laparoscopic vessel clips. RESULTS In all patients, endoscopic clips were applied proximal to the lesion without complications. Both intraluminally and extraluminally placed clips were successfully detected by intraoperative portable abdominal radiograph in all patients. Mean ± standard deviation (SD) proximal margin length was 34.2 ± 20.2 mm. All patients had tumor-free resection margin. CONCLUSIONS Preoperative endoscopic clipping and intraoperative portable abdominal radiograph is an accurate and simple tumor localization method in laparoscopic gastrectomy.
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Affiliation(s)
- Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, 120-752, Korea
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24
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Abstract
Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, MOB 233, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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