1
|
Abosheaishaa H, Abdallfatah A, Ahmed OT, Elfert K, Mohamed I, AlabdulRazzak I, Abdalla M, Sethi A, Abdelhalim O, Gayam VR, Eskaros S, Boulay B. The efficacy of Hemospray in managing bleeding related to gastrointestinal tumors: systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2024:00042737-990000000-00391. [PMID: 39012642 DOI: 10.1097/meg.0000000000002828] [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] [Indexed: 07/17/2024]
Abstract
INTRODUCTION Gastrointestinal (GI) bleeding stemming from malignant tumors is increasingly recognized, due to advancements in oncology and detection methods. Traditional endoscopic hemostatic techniques have shown variable success rates in managing hemorrhagic GI neoplasms. Hemospray, an emerging endoscopic hemostatic powder, offers promise in treating upper GI bleeding, potentially extending its utility to neoplastic bleeding sites. This meta-analysis aims to evaluate Hemospray's efficacy in managing bleeding related to GI tumors. METHODS We searched Embase, Scopus, Web of Science, Medline/PubMed, and Cochrane. Inclusion criteria encompassed studies focusing on malignancy-related GI bleeding and interventions utilizing Hemospray. Comparative studies contrasted Hemospray with standard endoscopic treatments (SET), while noncomparative studies assessed Hemospray's efficacy independently. The risk of bias was assessed using appropriate tools, and statistical analyses were performed using Review Manager and open Meta analyst software. RESULTS We included 19 studies in our meta-analysis. Hemospray demonstrated higher rates of immediate hemostasis compared to SET (odds ratio: 17.14, 95% confidence interval: 4.27-68.86), with consistent outcomes across studies. Rebleeding rates at 14 and 30 days were comparable between Hemospray and SET groups, suggesting similar efficacy in long-term hemostasis. Hemospray showed a significantly lower need for nonendoscopic hemostasis compared to SET (odds ratio: 0.51, 95% confidence interval: 0.30-0.87), indicating a potential reduction in supplementary interventions. Safety assessments revealed no confirmed adverse events directly linked to Hemospray. CONCLUSION This meta-analysis highlights Hemospray's efficacy in achieving immediate hemostasis in GI tumor-related bleeding, with potential benefits in reducing supplementary interventions and improving patient outcomes. Despite comparable rebleeding rates, Hemospray emerges as a valuable adjunctive therapy in managing malignant GI bleeding.
Collapse
Affiliation(s)
- Hazem Abosheaishaa
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai/NYC Health + Hospitals Queens, New York City, New York, USA
| | | | - Omar T Ahmed
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, Illinois
| | - Khaled Elfert
- Department of Internal Medicine, St. Barnabas Hospital Health System, New York City, New York
| | - Islam Mohamed
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Kansas
| | - Iyiad AlabdulRazzak
- Department of Internal Medicine, St. Elizabeth's Medical Center, Boston, Massachusetts
| | - Monzer Abdalla
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois
| | - Arashi Sethi
- Department of Internal Medicine, Icahn school of medicine at Mount Sinai NYC H&H/Queens
| | - Omar Abdelhalim
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai | Queens Hospital Center, New York City, New York
| | - Vijay Reddy Gayam
- Department of Internal Medicine, University of southwestern Medical Center, Dallas, Texas
| | - Saphwat Eskaros
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Brian Boulay
- Department of Gastroenterology and Hepatology, University of Illinois Hospital & Health Sciences System, Illinois, Chicago, USA
| |
Collapse
|
2
|
Kiattiweerasak A, Bongkotvirawan P, Aumpan N, Yamaoka Y, Miftahussurur M, Vilaichone RK. Predictive factors and prognosis of upper gastrointestinal bleeding in gastric cancer: A large population-based study (UGIB-GC trial). PLoS One 2023; 18:e0291926. [PMID: 37729185 PMCID: PMC10511075 DOI: 10.1371/journal.pone.0291926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 09/10/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Gastric cancer remains the fourth leading cause of cancer-related death worldwide. Significant number of gastric cancer patients presented with bleeding. OBJECTIVE This study aimed to identify risk factors and overall survival rates of bleeding gastric cancer patients. METHODS This retrospective cohort study was conducted between 2007-2022 at tertiary care center in Thailand. Clinical information, endoscopic findings and histological type were extensively reviewed and were compared between bleeders and non-bleeders. Patients were monitored for at least 5 years. RESULTS There were 20,981 patients who underwent upper gastrointestinal endoscopy during study period. Total of 201 gastric cancer patients were included in this study, 21 were excluded due to incomplete medical records. 180 gastric cancer patients were included with mean age of 60.5±14.3 years. There were 65 (36.1%) patients with gastrointestinal bleeding. Hypertension and chronic kidney disease were significantly more common in bleeders than non-bleeders (43.1% vs 23.5%, OR2.51, 95%CI 1.14.-5.52, p = 0.022; and 16.9% vs 5.2%, OR2.00, 95%CI 1.56-6.63, p = 0.025, respectively). current H. pylori infection was also significantly more common in bleeders than non-bleeders (84.6% vs. 55.7%, OR 4.39, 95%CI 1.90-10.12, p<0.001). Median overall survival of bleeders was significantly lower than non-bleeders (7±0.93 vs 10±2.10 months, p = 0.001). CONCLUSIONS Bleeding gastric cancer was not an uncommon condition. Majority of patients presented at advanced stage with grave prognosis. Male gender, hypertension, chronic kidney disease, and current H. pylori infection were reliable predictors for bleeding. Early diagnosis and prompt treatment are the key to improve clinical outcome.
Collapse
Affiliation(s)
- Anya Kiattiweerasak
- Gastroenterology and Hepatology Center, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Phubordee Bongkotvirawan
- Center of Excellence in Digestive Diseases and Gastroenterology Unit, Department of Medicine, Thammasat University, Pathumthani, Thailand
| | - Natsuda Aumpan
- Center of Excellence in Digestive Diseases and Gastroenterology Unit, Department of Medicine, Thammasat University, Pathumthani, Thailand
- Chulabhorn International College of Medicine (CICM) at Thammasat University, Pathumthani, Thailand
| | - Yoshio Yamaoka
- Department of Environmental and Preventive Medicine, Faculty of Medicine, Oita University, Yufu, Japan
- Research Center for Global and Local Infectious Diseases, Oita University, Yufu, Japan
- Department of Medicine, Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, United States of America
| | - Muhammad Miftahussurur
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ratha-korn Vilaichone
- Center of Excellence in Digestive Diseases and Gastroenterology Unit, Department of Medicine, Thammasat University, Pathumthani, Thailand
- Chulabhorn International College of Medicine (CICM) at Thammasat University, Pathumthani, Thailand
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| |
Collapse
|
3
|
Pittayanon R, Khongka W, Linlawan S, Thungsuk R, Aumkaew S, Teeratorn N, Maytapa J, Kimtrakool S, Pakvisal P, Kongtub N, Rerknimitr R, Barkun A. Hemostatic Powder vs Standard Endoscopic Treatment for Gastrointestinal Tumor Bleeding: A Multicenter Randomized Trial. Gastroenterology 2023; 165:762-772.e2. [PMID: 37277078 DOI: 10.1053/j.gastro.2023.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/14/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Current guidelines vary as to their recommendations addressing the role of hemostatic powders when managing patients with malignant gastrointestinal (GI) bleeding because these are based on very-low- to low-quality evidence, in large part due to a paucity of randomized trial data. METHODS This was a patient- and outcome assessor-blinded, multicenter, randomized controlled trial. Patients presenting with active bleeding from an upper or lower GI lesion suspected to be malignant at index endoscopy between June 2019 and January 2022 were randomly allocated to receive either TC-325 alone or standard endoscopic treatment (SET). The primary outcome was 30-day rebleeding, and secondary objectives included immediate hemostasis and other clinically relevant endpoints. RESULTS Overall, 106 patients made up the study population (55 TC-325 and 51 SET, after 1 exclusion in the TC-325 group and 5 in the SET group). Baseline characteristics and endoscopic findings did not differ between the groups. Thirty-day rebleeding was significantly lower in the TC-325 (2.1% TC-325 vs 21.3% SET; odds ratio, 0.09; 95% confidence interval [CI], 0.01-0.80; P = .003). Immediate hemostasis rates were 100% in the TC-325 group vs 68.6% in the SET group (odds ratio, 1.45; 95% CI, 0.93-2.29; P < .001). Other secondary outcomes did not differ between the 2 groups. Independent predictors of 6-month survival included the Charlson comorbidity index (hazard ratio, 1.17; 95% CI, 1.05-1.32; P = .007) and receiving an additional nonendoscopic hemostatic or oncologic treatment during 30 days after the index endoscopy (hazard ratio, 0.16; 95% CI, 0.06-0.43; P < .001) after adjustment for functional status, Glasgow-Blatchford score, and an upper GI source of bleeding. CONCLUSION The TC-325 hemostatic powder results in greater immediate hemostasis rates followed by lower 30-day rebleeding rates when compared to contemporary SET. (ClinicalTrials.gov, Number: NCT03855904).
Collapse
Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand.
| | | | | | | | | | | | | | | | | | - Natanong Kongtub
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada; McGill University Health Center, Montreal, Quebec, Canada
| |
Collapse
|
4
|
Andleeb A, Fatima K, Nasreen S, Sofi MA, Najmi AM, Qadri S, Siraj F. Bleeding Control in Advanced Gastric Cancer; Role of Radiotherapy. Indian J Palliat Care 2023; 29:279-284. [PMID: 37700893 PMCID: PMC10493693 DOI: 10.25259/ijpc_1_2023] [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: 01/01/2023] [Accepted: 03/26/2023] [Indexed: 09/14/2023] Open
Abstract
Objectives The aim of our study is to see the efficacy of palliative radiotherapy (RT) for bleeding control in patients with advanced gastric cancer (AGC). Materials and Methods It is a retrospective review based on observations of 74 AGC patients with a median age of 60 years (range 50-82 years) who had active tumour bleeding and were treated with palliative RT. Treatment response was assessed by both subjective symptom relief and objective change in parameters. Objective response to RT was defined by an increase in the median haemoglobin (Hb) level of patients and a decrease in number of packed red blood cell (RBC) units needed by patients after RT. Results Response to haemostatic RT was observed in 52 patients out of 74 patients (70.27%). We observed a significant increase in mean Hb level after palliative RT. Pre-RT mean Hb was 6.14 ± 1.01 and post-RT mean Hb was 7.19 ± 1.75 (P < 0.05). Response to RT was also evident in a significant decrease in the number of packed RBC units post-haemostatic RT. The mean number of pre-RT transfused packed RBC units was 8.28 ± 3.76 and post-RT, it was 4.34 ± 2.91 (P < 0.05). The median overall survival was 90 days and the median transfusion-free survival was 40 days. Conclusion RT may be an effective treatment option for bleeding control in AGC. In our study, we observed fair and reasonably durable haemostasis. A success rate of 70.24% was documented with clinical palliation, a higher Hb level and fewer transfusions after RT. This modality for bleeding control is more important and reliable in situations where alternative modalities are not feasible.
Collapse
Affiliation(s)
- Asifa Andleeb
- Department of Radiation Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Kaneez Fatima
- Department of Radiation Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shahida Nasreen
- Department of Radiation Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mushtaq Ahmad Sofi
- Department of Radiation Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arshad Manzoor Najmi
- Department of Radiation Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Sumaira Qadri
- Department of Pathology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Farhana Siraj
- Department of General Medicine, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
5
|
Karna R, Deliwala S, Ramgopal B, Mohan BP, Kassab L, Becq A, Dhawan M, Adler DG. Efficacy of topical hemostatic agents in malignancy-related GI bleeding: a systematic review and meta-analysis. Gastrointest Endosc 2023; 97:202-208.e8. [PMID: 35944608 DOI: 10.1016/j.gie.2022.07.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/15/2022] [Accepted: 07/30/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite advances in endoscopic therapies, malignancy-related GI bleeding remains difficult to manage with high rates of treatment failure and rebleeding. Topical hemostatic agents (THAs) are easier to apply to the wide bleeding surface of tumors. We conducted this systematic review and meta-analysis to evaluate the efficacy of THAs in malignancy-related GI bleeding. METHODS We conducted a comprehensive search of multiple electronic databases to identify studies reporting on the use of THAs in malignancy-related GI bleeding. The primary outcome was the achievement of hemostasis; secondary outcomes were early rebleeding (≤3 days), delayed rebleeding (>3 days), aggregate rebleeding, all-cause mortality, and GI bleeding-related mortality. A meta-analysis of proportions was done for all outcomes. RESULTS Out of 355 citations, 16 studies with 530 patients were included. Primary hemostasis was achieved in 94.1% (95% confidence interval [CI], 91.5-96.0). Early rebleeding was seen in 13.9% (95% CI, 9.7-19.4) and delayed rebleeding in 11.4% (95% CI, 5.8-21.1). Aggregate rebleeding was seen in 24.2% (95% CI, 18.5-31.0). All-cause mortality was 33.1% (95% CI, 23.7-44.0), whereas GI bleeding-related mortality occurred in 5.9% (95% CI, 2.2%-14.8). CONCLUSIONS THAs are highly effective for achieving primary hemostasis in malignancy-related GI bleeding. It should be considered as an alternative to traditional endotherapy methods in malignancy-related GI bleeding. Future studies should be designed to evaluate its efficacy and safety as a primary method of hemostasis as compared with traditional endotherapy measures.
Collapse
Affiliation(s)
- Rahul Karna
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Smit Deliwala
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan, USA
| | | | - Babu P Mohan
- Department of Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Lena Kassab
- Department of Internal Medicine, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Aymeric Becq
- Endoscopy Unit, Sorbonne University, AP-HP, Saint-Antoine Hospital, Paris, France; Gastroenterology Department, UPEC University, AP-HP, Henri Mondor Hospital, Creteil, France
| | - Manish Dhawan
- Division of Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, Colorado, USA
| |
Collapse
|
6
|
Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010143. [PMID: 36676767 PMCID: PMC9863809 DOI: 10.3390/medicina59010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.
Collapse
|
7
|
Rosa F, Schena CA, Laterza V, Quero G, Fiorillo C, Strippoli A, Pozzo C, Papa V, Alfieri S. The Role of Surgery in the Management of Gastric Cancer: State of the Art. Cancers (Basel) 2022; 14:cancers14225542. [PMID: 36428634 PMCID: PMC9688256 DOI: 10.3390/cancers14225542] [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: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.
Collapse
Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Carmelo Pozzo
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
8
|
Martins BC, Abnader Machado A, Scomparin RC, Paulo GA, Safatle-Ribeiro A, Naschold Geiger S, Lenz L, Lima MS, Pennacchi C, Ribeiro U, Barkun AN, Maluf-Filho F. TC-325 hemostatic powder in the management of upper gastrointestinal malignant bleeding: a randomized controlled trial. Endosc Int Open 2022; 10:E1350-E1357. [PMID: 36262517 PMCID: PMC9576337 DOI: 10.1055/a-1906-4769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
Background and study aims Upper gastrointestinal bleeding (UGIB) from malignancy is associated with high rebleeding and mortality rates. Recently, TC-325 powder has shown promising results in the treatment of UGIB, including malignant bleeding. The aim of this study was to compare the efficacy of TC-325 versus best clinical management. Patients and methods From August 2016 to February 2020, all patients with evidence of UGIB from malignancy were randomized to receive TC-325 therapy or control group, in which endoscopic treatment was not mandatory. Exclusion criteria were hemoglobin drop without overt bleeding and UGIB from non-tumor origin. The primary outcome was 30-day mortality. Secondary outcomes were 30-day rebleeding, blood transfusion and length of hospital stay. Results Sixty-two patients were randomized, three were excluded and 59 were included in the final analysis (TC-325 group = 28; control = 31). Groups were similar at baseline. Active bleeding was observed in 22 patients in the TC-325 group and 19 in the control group ( P = 0.15). Successful initial hemostasis with TC-325 was achieved in all cases. Additional therapy (radiotherapy, surgery or arterial embolization) was equally performed in both groups (42.9 % vs 58.1 %; P = 0.243). There were no differences in 30-day mortality (28.6 % vs. 19.4 %, P = 0.406) or 30-day rebleeding rates (32.1 % vs. 19.4 %, P = 0.26). Logistic regression identified no significant predictors of rebleeding. Age, Eastern Cooperative Oncology Group (ECOG) score 3 to 4 and AIMS65 score > 1 predicted greater mortality. Conclusions TC-325 was effective in achieving immediate hemostasis in malignant gastrointestinal bleeding but did not reduce 30-day mortality, 30-day rebleeding, blood transfusion or length of hospital stay. Age, ECOG 3-4, and AIMS65 > 1 were predictive factors of mortality.
Collapse
Affiliation(s)
- Bruno Costa Martins
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Andressa Abnader Machado
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Corsato Scomparin
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gustavo Andrade Paulo
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Adriana Safatle-Ribeiro
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sebastian Naschold Geiger
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luciano Lenz
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcelo Simas Lima
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Caterina Pennacchi
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alan N. Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Quebec, Canada,Department of Clinical Epidemiology, McGill University, Montréal, Quebec, Canada
| | - Fauze Maluf-Filho
- Endoscopy Unit, Instituto do Cancer do Estado de Sao Paulo ICESP, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
9
|
Jiang SX, Chahal D, Ali-Mohamad N, Kastrup C, Donnellan F. Hemostatic powders for gastrointestinal bleeding: a review of old, new, and emerging agents in a rapidly advancing field. Endosc Int Open 2022; 10:E1136-E1146. [PMID: 36238531 PMCID: PMC9552790 DOI: 10.1055/a-1836-8962] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/20/2022] [Indexed: 10/26/2022] Open
Abstract
Background and study aims Hemostatic powders are increasingly used to address limitations in conventional endoscopic techniques for gastrointestinal bleeding. Various agents exist with different compositions, characteristics, efficacy, and adverse events (AEs). We sought to review existing hemostatic powders, from preclinical to established agents. Methods A literature review on hemostatic powders for gastrointestinal bleeding was undertaken through a MEDLINE search from 2000-2021 and hand searching of articles. Relevant literature was critically appraised and reviewed for mechanism of action, hemostasis and rebleeding rate, factors associated with hemostatic failure, and AEs. Results The most established agents are TC-325 (Hemospray), EndoClot, and Ankaferd Blood Stopper (ABS). These agents have been successfully applied to a variety of upper and lower gastrointestinal bleeding etiologies, in the form of primary, combination, salvage, and bridging therapy. Few AEs have been reported, including visceral perforation, venous embolism, and self-limited abdominal pain. Newer agents include CEGP-003 and UI-EWD, which have shown results similar to those for the older agents in initial clinical studies. All aforementioned powders have high immediate hemostasis rates, particularly in scenarios not amenable to conventional endoscopic methods, but are limited by significant rates of rebleeding. Other treatments include TDM-621 (PuraStat) consisting of a liquid hemostatic agent newly applied to endoscopy and self-propelling thrombin powder (CounterFlow Powder), a preclinical but promising agent. Conclusions Rapid development of hemostatic powders and growing clinical expertise has established these agents as a valuable strategy in gastrointestinal bleeding. Further research will continue to refine the efficacy and applicability of these agents.
Collapse
Affiliation(s)
- Shirley X. Jiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daljeet Chahal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, United States
| | - Nabil Ali-Mohamad
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christian Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| |
Collapse
|
10
|
Hussein M, Alzoubaidi D, O'Donnell M, de la Serna A, Bassett P, Varbobitis I, Hengehold T, Ortiz Fernandez-Sordo J, Rey JW, Hayee B, Despott EJ, Murino A, Graham D, Latorre M, Moreea S, Boger P, Dunn J, Mainie I, Mullady D, Early D, Ragunath K, Anderson J, Bhandari P, Goetz M, Kiesslich R, Coron E, Rodriguez de Santiago E, Gonda T, Gross SA, Lovat LB, Haidry R. Hemostatic powder TC-325 treatment of malignancy-related upper gastrointestinal bleeds: International registry outcomes. J Gastroenterol Hepatol 2021; 36:3027-3032. [PMID: 34132412 DOI: 10.1111/jgh.15579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/18/2021] [Accepted: 06/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. METHODS Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. RESULTS One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7-12). The median Rockall score was 8 (IQR, 7-9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P < 0.001) when comparing the number of units transfused 3 weeks before and after treatment. The mean reduction was one unit per patient. CONCLUSIONS Hemospray achieved high rates of immediate hemostasis, with comparable rebleed rates following treatment of tumor-related upper gastrointestinal bleeds. Hemospray helped in improving transfusion requirements in these patients. This allows for patient stabilization and bridges towards definitive surgery or radiotherapy to treat the underlying tumor.
Collapse
Affiliation(s)
- Mohamed Hussein
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Department of Gastroenterology, University college London hospital (UCLH), London, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | | | - Alvaro de la Serna
- Department of Gastroenterology and Hepatology, Ramon y Cajal University Hospital, IRYCIS, University of Alcala, Madrid, Spain
| | | | - Ioannis Varbobitis
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals, Nottingham, UK
| | - Tricia Hengehold
- Department of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Johannes W Rey
- Department of Gastroenterology, Osnabrück Clinic, Osnabrück, Germany
| | - Bu'Hussain Hayee
- Department of Gastroenterology, Kings College Hospital, London, UK
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, Royal Free NHS Foundation Trust, London, UK
| | - Alberto Murino
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, Royal Free NHS Foundation Trust, London, UK
| | - David Graham
- Department of Gastroenterology, University college London hospital (UCLH), London, UK
| | | | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Phillip Boger
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jason Dunn
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Inder Mainie
- Department of Gastroenterology, Belfast Health and Social Care Trust, Belfast, UK
| | - Daniel Mullady
- Department of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Dayna Early
- Department of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals, Nottingham, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust - Cheltenham General Hospital, Cheltenham, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Martin Goetz
- Sindelfingen-Böblingen Clinic, Böblingen, Germany
| | | | - Emmanuel Coron
- Department of Gastroenterology, University Hospital Center, Nantes, France
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Ramon y Cajal University Hospital, IRYCIS, University of Alcala, Madrid, Spain
| | - Tamas Gonda
- Columbia University Medical Centre, New York, USA
| | | | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Department of Gastroenterology, University college London hospital (UCLH), London, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Department of Gastroenterology, University college London hospital (UCLH), London, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| |
Collapse
|
11
|
Efficacy of Hemospray (TC-325) in the Treatment of Gastrointestinal Bleeding: An Updated Systematic Review and Meta-analysis. J Clin Gastroenterol 2021; 55:492-498. [PMID: 34049382 DOI: 10.1097/mcg.0000000000001564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hemospray (TC-325) is now approved for use in gastrointestinal bleeding. Data regarding their use pattern, efficacy, complications, and impact on clinical outcomes is limited. METHODS Electronic search from relevant databases was conducted up to January 2019. Etiologies, therapy characteristics, hemostasis rates, rebleed rates, additional procedures, complications and mortality rates were extracted and pooled. RESULTS Twenty-seven articles were included for analysis (n=1916). Pooled hemostasis was 94.5%. Pooled rebleed rate within 3 days was 9.9%, and within 30 days 17.6%. Pooled repeat Hemospray use was 13.6%. Radiology guided embolization was required with rate of 3.3% and surgery at rate of 4.7%. Rate of adverse events directly attributable to Hemospray was 0.7%. 30-day mortality was 11.8%. Comparison of conventional endoscopic therapy to Hemospray augmented therapy demonstrated that Hemospray therapy had increased immediate hemostasis [odds ratio (OR) 4.40]. There was no difference in rate of rebleeding at 8 days (OR 0.52) or overall mortality at 30 days (OR 0.53). Benign nonvariceal bleeds, malignant bleeds, and postprocedural bleeds had similar rates of hemostasis but rebleed rate at 30 days was less for postprocedural bleeding. CONCLUSIONS The addition of Hemospray to conventional therapy appears to increase immediate hemostasis but does not decrease rebleeding or mortality. As such, the use of Hemospray will likely be limited to clinical situations requiring urgent, but temporary, hemostasis to bridge to more definitive therapy.
Collapse
|
12
|
Ali-Mohamad N, Cau M, Baylis J, Zenova V, Semple H, Beckett A, McFadden A, Donnellan F, Kastrup C. Severe upper gastrointestinal bleeding is halted by endoscopically delivered self-propelling thrombin powder: A porcine pilot study. Endosc Int Open 2021; 9:E693-E698. [PMID: 33937509 PMCID: PMC8062227 DOI: 10.1055/a-1374-5839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Hemostatic powders have emerged recently to treat upper gastrointestinal bleeding (UGIB). Previously, we developed a novel self-propelling thrombin powder (SPTP) that effectively manages external pulsatile arterial bleed without compression, by effervescing and carrying thrombin into the wound. Here, we tested if SPTP, sprayed endoscopically, can manage severe UGIB in a live porcine model. Materials and methods Anesthetized pigs underwent laparotomy to insert the gastroepiploic vascular bundles into the stomach lumen via a gastrotomy. Bleeding was initiated endoscopically in the stomach by needle knife. SPTP was delivered to the site of bleeding from a CO 2 -powered spray device using a 7 FR catheter. Successful primary hemostasis, time to hemostasis, and the mass of SPTP delivered were measured. Results Hemostasis was achieved at all bleeding sites using SPTP. Mean time to hemostasis was 4.2 ± 0.9 minutes (mean ± standard error of the mean, n = 12). The average mass of SPTP delivered was 2.4 ± 0.6 g. Conclusions In this pilot study, SPTP successfully stopped 12 cases of severe UGIB, demonstrating early promise asa novel hemostatic powder.
Collapse
Affiliation(s)
- Nabil Ali-Mohamad
- The University of British Columbia – Michael Smith Laboratories, Vancouver, British Columbia, Canada
| | - Massimo Cau
- The University of British Columbia – Michael Smith Laboratories, Vancouver, British Columbia, Canada,The University of British Columbia – School of Biomedical Engineering, Vancouver, British Columbia, Canada
| | - James Baylis
- The University of British Columbia – Michael Smith Laboratories, Vancouver, British Columbia, Canada,The University of British Columbia – School of Biomedical Engineering, Vancouver, British Columbia, Canada
| | - Veronika Zenova
- The University of British Columbia – Michael Smith Laboratories, Vancouver, British Columbia, Canada
| | - Hugh Semple
- Defense Research and Development Canada Suffield Research Centre – Suffield Research Centre, Medicine Hat, Alberta, Canada
| | - Andrew Beckett
- University of Toronto Faculty of Medicine – Department of Surgery, Toronto, Ontario, Canada
| | - Andrew McFadden
- The University of British Columbia Faculty of Medicine – Department of Surgery, Vancouver, British Columbia, Canada
| | - Fergal Donnellan
- The University of British Columbia Faculty of Medicine – Division of Gastroenterology, Vancouver, British Columbia, Canada
| | - Christian Kastrup
- The University of British Columbia – Michael Smith Laboratories, Vancouver, British Columbia, Canada,The University of British Columbia Faculty of Medicine, Department of Biochemistry and Molecular Biology, Vancouver, British Columbia, Canada
| |
Collapse
|
13
|
The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2021; 55:e37-e45. [PMID: 33470608 DOI: 10.1097/mcg.0000000000001379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/10/2020] [Indexed: 01/11/2023]
Abstract
GOALS/BACKGROUND Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. STUDY We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. RESULTS A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I2=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I2=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I2=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. CONCLUSIONS Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.
Collapse
|
14
|
Shin J, Cha B, Park JS, Ko W, Kwon KS, Lee JW, Kim HK, Shin YW. Efficacy of a novel hemostatic adhesive powder in patients with upper gastrointestinal tumor bleeding. BMC Gastroenterol 2021; 21:40. [PMID: 33509102 PMCID: PMC7842074 DOI: 10.1186/s12876-021-01611-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/13/2021] [Indexed: 01/06/2023] Open
Abstract
Background Gastrointestinal tumor bleeding remains a clinical challenge because it is difficult to treat with conventional endoscopic hemostatic options. Recently, an endoscopic hemostatic powder (UI-EWD) was developed and reported to provide effective control of upper gastrointestinal bleeding. The aim of current study was to evaluate the feasibility and efficacy of this novel hemostatic powder in tumor bleeding.
Methods A total of 41 consecutive patients with upper gastrointestinal tumor bleeding were included. UI-EWD was applied in all patients as an auxiliary hemostatic method as a salvage therapy or monotherapy during endoscopic treatment. Hemostasis success rates, adverse event related to UI-EWD, and rates of re-bleeding were evaluated. Results In all cases, UI-EWD application was successful at tumor bleeding sites. Immediate hemostasis occurred in 40/41 (97.5%) patients, and re-bleeding within 28 days occurred in 10 of 40 (22.5%) patients that achieved initial hemostasis. The success rate of immediate hemostasis for UI-EWD monotherapy was 100% (23/23). The re-bleeding rate at 28 days after UI-EWD monotherapy was 26.1% (6/23). No adverse events associated with UI-EWD application were encountered. Conclusions The success rate of UI-EWD for immediate hemostasis in cases of GI tumor bleeding was excellent and UI-EWD produced promising results with respect to the prevention of re-bleeding. Based on these results, we suggest that UI-EWD be considered an effective salvage therapy or even monotherapy for GI tumor bleeding.
Collapse
Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Boram Cha
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea.
| | - Weonjin Ko
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Kye Sook Kwon
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Jin-Woo Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Hyung Kil Kim
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Yong Woon Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| |
Collapse
|
15
|
Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.
Collapse
Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| |
Collapse
|
16
|
Rai M, Cooper M, Shulman S, Kottachchi D, Nelles S, Macmillan M, Heitman S, Barkun A, Tse F, Hookey L. Canadian Association of Gastroenterology Communique: After-Hours Endoscopy Cart. J Can Assoc Gastroenterol 2020; 3:222-227. [PMID: 32905048 PMCID: PMC7465551 DOI: 10.1093/jcag/gwz032] [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: 06/18/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background Endoscopic procedures performed after-hours often require therapeutic interventions that are technically demanding for the endoscopist. The aim of this position paper is to provide guidance on the minimum standard of equipment that should be available on a mobile endoscopy cart for provision of a safe and effective after-hours emergency endoscopy service. The guidance is based on consensus among academic and community gastroenterologists in Canada. Methods A modified Delphi process was used to establish consensus among 9 participants. A list of statements was prepared by an expert panel of endoscopists. The statements were divided into three broad sections for what should be on an after-hours endoscopy cart including medications, nonendoscopic tools and therapeutic/diagnostic equipment. Consensus for being on the endoscopy cart was achieved when 75% or more of voting members indicated ‘agree’. Results For nonendoscopic tools, there was agreement for having sterile saline, sterile water, endoscope lubricant, various syringes, bite blocks (paediatric and adult size), a water pump with foot peddle, formalin jars for biopsy specimens, digital photo and printing capability and an overtube. For medications, there was agreement for having hyoscine butylbromide and epinephrine on the cart. For therapeutic/diagnostic tools, there was agreement for having biopsy forceps (standard and jumbo), polypectomy snares, sclerotherapy needles and agent (for a variceal bleed), band ligation kit, multipolar electrocautery probes, heater probe catheter, endoscopic clips, hemostatic powder and retrieval devices. Interpretation This position paper provides guidance on the minimum standard of items that should be on an after-hours endoscopy cart. Standardization of equipment may help improve safety and quality of after-hours endoscopic procedures.
Collapse
Affiliation(s)
- Mandip Rai
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
| | - Mary Cooper
- Division of Gastroenterology, North Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Scott Shulman
- Division of Gastroenterology, North Bay Regional Health Centre, North Bay, Ontario, Canada
| | - Dan Kottachchi
- Division of Gastroenterology, Guelph General Hospital, Guelph, Ontario, Canada
| | - Sandra Nelles
- Division of Gastroenterology, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Mark Macmillan
- Division of Gastroenterology, Dalhousie University, Memorial University, Fredericton, New Brunswick, Canada
| | - Steven Heitman
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
| | - Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Hookey
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
17
|
Aziz M, Weissman S, Mehta TI, Hassan S, Khan Z, Fatima R, Tsirlin Y, Hassan A, Sciarra M, Nawras A, Rastogi A. Efficacy of Hemospray in non-variceal upper gastrointestinal bleeding: a systematic review with meta-analysis. Ann Gastroenterol 2020; 33:145-154. [PMID: 32127735 PMCID: PMC7049242 DOI: 10.20524/aog.2020.0448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Recently, amongst other hemostatic modalities, Hemospray (TC-325) has emerged as an effective method for managing patients with non-variceal upper gastrointestinal bleeding (GIB). We conducted this systematic review and meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB. Methods Our primary outcomes were clinical and technical success; secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality, and treatment failure. A meta-analysis of proportions was conducted for all reported primary and secondary outcomes. A relative risk meta-analysis was conducted for studies reporting direct comparisons between Hemospray and other hemostatic measures. Results A total of 20 studies with 1280 patients were included in the final analysis. Technical success of Hemospray was seen in 97% of cases (95% confidence interval [CI] 94-98%, I2=52.89%) and a significant trend towards increasing technical success was seen during publication years 2011-2019. Clinical success of Hemospray was seen in 91% of cases (95%CI 88-94%, I2=47.72%), compared to 87% (95%CI 75-94%, I2=0.00%) for other hemostatic measures. The secondary outcomes of aggregate rebleeding, early rebleeding, delayed rebleeding, refractory rebleeding, mortality and treatment failure following the use of Hemospray were seen in 27%, 20%, 9%, 8%, 8%, and 31% of cases, respectively. Conclusion Hemospray is safe, effective and non-inferior to traditional hemostatic measures for the management of non-variceal upper GIB, and can thus be used as an alternative option.
Collapse
Affiliation(s)
- Muhammad Aziz
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Zubair Khan, Rawish Fatima)
| | - Simcha Weissman
- Department of Medicine, Hackensack University-Palisades Medical Center, North Bergen, New Jersey (Simcha Weissman)
| | - Tej I Mehta
- Department of Medicine, University of South Dakota Sanford school of Medicine, Sioux Falls, South Dakota (Tej I. Mehta)
| | - Shafae Hassan
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio (Shafae Hassan, Ali Nawras)
| | - Zubair Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Zubair Khan, Rawish Fatima)
| | - Rawish Fatima
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Zubair Khan, Rawish Fatima)
| | - Yuriy Tsirlin
- Department of Gastroenterology, Maimonides Medical Center, Brooklyn, New York (Yuriy Tsirlin)
| | - Ammar Hassan
- Division of Gastroenterology and Hepatology, Hackensack University-Palisades Medical Center, North Bergen, New Jersey (Ammar Hassan, Michael Sciarra)
| | - Michael Sciarra
- Division of Gastroenterology and Hepatology, Hackensack University-Palisades Medical Center, North Bergen, New Jersey (Ammar Hassan, Michael Sciarra)
| | - Ali Nawras
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio (Shafae Hassan, Ali Nawras)
| | - Amit Rastogi
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas (Amit Rastogi), USA
| |
Collapse
|
18
|
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.
Collapse
|
19
|
Chen YI, Wyse J, Lu Y, Martel M, Barkun AN. TC-325 hemostatic powder versus current standard of care in managing malignant GI bleeding: a pilot randomized clinical trial. Gastrointest Endosc 2020; 91:321-328.e1. [PMID: 31437456 DOI: 10.1016/j.gie.2019.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS TC-325 (Hemospray; Cook Medical, Winston-Salem, NC, USA), an endoscopic hemostatic powder, exhibits possible benefits in patients with malignant GI bleeding. Our aim is to assess feasibility and determine estimates of efficacy of TC-325 compared with standard of care (SOC) in terms of initial hemostasis and recurrent bleeding rates in comparable groups of patients with malignant GI bleeding. METHODS Adult patients presenting with acute malignant upper or lower GI bleeding were randomized to TC-325 or SOC. Measured outcomes included feasibility of recruitment and randomization in the urgent care setting, immediate hemostasis, recurrent bleeding, need for additional treatment modalities, and mortality. RESULTS A preplanned 20 patients (upper GI source in 85%) were randomized 1:1 to TC-325 or SOC (25% women, age 67.2 ± 15.9 years, oozing in 95%) over 20 months. Immediate hemostasis was achieved in 90% of patients treated initially with TC-325 versus 40% in the SOC group (P = .057). Overall, 83.3% crossed over to TC-325, with hemostasis then achieved at index endoscopy in 80%. Overall, hemostasis at index endoscopy (before or after crossover) was obtained in 87.7% of patients treated with TC-325. Recurrent bleeding over the next 180 days was 20% in the TC-325 group compared with 60% in the SOC group (P = .170). CONCLUSIONS This pilot trial demonstrates the feasibility of TC-325 in malignant GI bleeding and provides results to help inform a larger randomized trial. Although not powered for such, results suggest that use of TC-325 is a very promising modality in malignant GI bleeding in achieving immediate hemostasis and may even result in decreased subsequent recurrent bleeding. (Clinical trial registration number: NCT02135627.).
Collapse
Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Jonathan Wyse
- Division of Gastroenterology, Jewish General Hospital, McGill University, Montréal, Quebec, Canada
| | - Yidan Lu
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Quebec, Canada; Department of Clinical Epidemiology, McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| |
Collapse
|
20
|
Naseer M, Lambert K, Hamed A, Ali E. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World J Gastrointest Endosc 2020; 12:1-16. [PMID: 31942229 PMCID: PMC6939122 DOI: 10.4253/wjge.v12.i1.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/28/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.
Collapse
Affiliation(s)
- Maliha Naseer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Karissa Lambert
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Ahmed Hamed
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Eslam Ali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| |
Collapse
|
21
|
de Rezende DT, Brunaldi VO, Bernardo WM, Ribeiro IB, Mota RCL, Baracat FI, de Moura DTH, Baracat R, Matuguma SE, de Moura EGH. Use of hemostatic powder in treatment of upper gastrointestinal bleeding: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E1704-E1713. [PMID: 31803822 PMCID: PMC6887646 DOI: 10.1055/a-0977-2897] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/27/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background and study aims TC-325 is a novel mineral hemostatic powder that creates a mechanical barrier by absorbing blood components and promoting clotting. Recently approved for use in humans, it has shown promise for treatment of upper gastrointestinal bleeding (UGIB). However, because there have been no large studies of TC-325, its true efficacy and safety profile remain unknown. We performed a systematic review and meta-analysis to determine the safety and efficacy of TC-325 in treating UGIB, based on rates of initial hemostasis, rebleeding, and adverse events (AEs).
Methods We searched the MEDLINE/PubMed, EMBASE, CENTRAL, Latin-American and Caribbean Health Sciences Literature databases, as well as the gray literature, to identify articles describing use of TC-325 up to October 2018. Primary outcomes were initial hemostasis and rebleeding. AEs were described as a secondary outcome. Risk of bias was assessed with international scores.
Results We identified 2077 records after removal of duplicates. We included 50 studies, involving a collective total of 1445 patients, in the quantitative synthesis. Primary hemostasis and rebleeding rates were 90.7 % and 26.1 %, respectively. Subgroup analyses showed similar results. Only eight AEs were reported.
Conclusions TC-325 appears to be a safe, effective treatment for UGIB. The overall rate of initial hemostasis after TC-325 use is high, regardless of etiology of bleeding or whether TC-325 is used as a primary or rescue therapy. Although it is also associated with high rebleeding rates, rates of AEs and equipment failure after TC-325 use are extremely low.
Collapse
Affiliation(s)
- Daniel Tavares de Rezende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Raquel Cristina Lins Mota
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Felipe Iankelevich Baracat
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Renato Baracat
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | |
Collapse
|
22
|
Facciorusso A, Straus Takahashi M, Eyileten Postula C, Buccino VR, Muscatiello N. Efficacy of hemostatic powders in upper gastrointestinal bleeding: A systematic review and meta-analysis. Dig Liver Dis 2019; 51:1633-1640. [PMID: 31401022 DOI: 10.1016/j.dld.2019.07.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited evidence on the efficacy of hemostatic powders in the management of upper gastrointestinal bleeding. AIMS Provide a pooled estimate of the efficacy and safety profile of hemostatic powders in digestive endoscopy. METHODS A computerized bibliographic search on the main databases was performed through December 2018. Pooled effects were calculated using a random-effects model. The primary outcome was immediate hemostasis rate. Secondary outcomes were rebleeding rate (either at 7 and 30 days), bleeding-related mortality, and all-cause mortality rate. RESULTS A total of 24 studies, of which three were randomized-controlled trials, with 1063 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95.3% (93.3%-97.3%) of patients, with no difference based on treatment strategy, hemostatic agent used, bleeding etiology. Success rate was slightly lower in spurting bleeding (91.9%). Hemostatic powders showed similar efficacy as compared to conventional endoscopic therapy (odds ratio: 0.84, 0.06-11.47; p = 0.9). Thirty-day rebleeding rate was 16.9% (9.8%-24%) with no difference in comparison to other endoscopic treatments (odds ratio 1.59, 0.35-7.21; p = 0.55). All-cause and bleeding-related mortality rates were 7.6% (4%-10.8%) and 1.4% (0.5%-2.4%), respectively. CONCLUSION Novel hemostatic powders represent a user-friendly and effective tool in the management of upper gastrointestinal bleeding.
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Upper gastrointestinal bleeding (UGIB) is a common and life-threatening condition in the United States and worldwide. RECENT FINDINGS There have been several exciting recent advances in the endoscopic management of UGIB. One such advance is the recent approval of Hemospray by US Food and Drug Administration in May 2018. Another one is the emerging role of video capsule endoscopy as a triage and localization tool for UGIB patients. Finally, the development of new reversal agents for antithrombotic medications is an important advance in the management of life-threatening upper gastrointestinal bleed. SUMMARY In this article, we will broadly review the management of nonvariceal UGIB, focusing primarily on the data addressing these new advances.
Collapse
|
24
|
Hemostatic spray powder TC-325 for GI bleeding in a nationwide study: survival and predictors of failure via competing risks analysis. Gastrointest Endosc 2019; 90:581-590.e6. [PMID: 31220444 DOI: 10.1016/j.gie.2019.06.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS TC-325 (Hemospray, Cook Medical, Winston-Salem, NC) is an inorganic hemostatic powder recently approved by the U.S. Food and Drug Administration. This study aimed to examine the effectiveness, safety, and predictors of TC-325 failure in a large real-life cohort. METHODS This was a retrospective study conducted at 21 Spanish centers. All patients treated with TC-325 until September 2018 were included. The primary outcome was treatment failure, defined as failed intraprocedural hemostasis or recurrent bleeding within the first 30 postprocedural days. Secondary outcomes included safety and survival. Risk and predictors of failure were assessed via competing-risk models. RESULTS The cohort comprised 261 patients, of whom 219 (83.9%) presented with upper gastrointestinal bleeding (GIB). The most common causes were peptic ulcer (28%), malignancy (18.4%), and therapeutic endoscopy-related GIB (17.6%). TC-325 was used as rescue therapy in 191 (73.2%) patients. The rate of intraprocedural hemostasis was 93.5% (95% confidence interval [CI], 90%-96%). Risks of TC-325 failure at postprocedural days 3, 7, and 30 were 21.1%, 24.6%, and 27.4%, respectively. On multivariate analysis, spurting bleeding (P = .004), use of vasoactive drugs (P = .02), and hypotension (P = .008) were independent predictors of failure. Overall 30-day survival was 81.9% (95% CI, 76%-86%) and intraprocedural hemostasis was associated with a better prognosis (adjusted hazard ratio, 0.29; P = .006). Two severe adverse events were noted. CONCLUSION TC-325 was safe and effective for intraprocedural hemostasis in more than 90% of patients, regardless of the cause or site of bleeding and its use as rescue therapy. In this high-risk cohort treated with TC-325, the 30-day failure rate exceeded 25% and was highest with spurting bleeding or hemodynamic instability.
Collapse
|
25
|
Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018. Gastrointest Endosc 2019; 90:35-43. [PMID: 30928425 DOI: 10.1016/j.gie.2019.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.
Collapse
|
26
|
Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68:776-789. [PMID: 30792244 DOI: 10.1136/gutjnl-2018-317807] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
Collapse
Affiliation(s)
| | | | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada.,Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | - Magdalena Metzner
- Department of Gastroenterology, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - A John Morris
- Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Tony Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - James Wheeler
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College, London, UK
| |
Collapse
|
27
|
Baracat FI, de Moura DTH, Brunaldi VO, Tranquillini CV, Baracat R, Sakai P, de Moura EGH. Randomized controlled trial of hemostatic powder versus endoscopic clipping for non-variceal upper gastrointestinal bleeding. Surg Endosc 2019; 34:317-324. [PMID: 30927124 DOI: 10.1007/s00464-019-06769-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 03/18/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Despite advances in pharmacological and endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB), mortality is still relevant. TC-325 (Hemospray-Cook Medical) is a mineral powder with adsorptive properties, designed for endoscopic hemostasis. There are still no comparative trials studying this new hemostatic modality. The objective of this research was to compare the use of TC-325 (associated with epinephrine injection) with the combined technique of endoscopic clipping and epinephrine injection for the treatment of patients with NVUGIB. METHODS We conducted a pilot randomized controlled trial with patients that presented NVUGIB with an actively bleeding lesion at the endoscopic evaluation. Patients were randomized either to the Hemospray or Hemoclip group. The randomization list was generated by a computer program and remained unknown throughout the entire trial. All patients underwent second-look endoscopy. RESULTS Thirty-nine patients were enrolled. Peptic ulcer was the most frequent etiology. Primary hemostasis was achieved in all Hemospray cases and in 90% of Hemoclip group (p = 0.487). Five patients in Hemospray group underwent an additional hemostatic procedure during second-look endoscopy, while no patient in the Hemoclip group needed it (p = 0.04). Rebleeding, emergency surgery and mortality rates were similar in both groups. No toxicity, allergy events, or gastrointestinal obstruction signs were observed in Hemospray group. CONCLUSIONS TC-325 presents similar hemostatic results when compared with conventional dual therapy for patients with NVUGIB. Hemospray's excellent primary hemostasis rate certifies it as a valuable tool in arduous situations of severe bleeding or difficult location site.
Collapse
Affiliation(s)
- Felipe Iankelevich Baracat
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil.
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil
| | - Vítor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil
| | - Caio Vinicius Tranquillini
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil
| | - Renato Baracat
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255. Cerqueira César, São Paulo, 05403-000, Brazil
| |
Collapse
|
28
|
Abstract
Background and Aims Bleeding from diffuse esophageal ulcerations can be difficult to treat. Hemospray is a hemostatic powder, and its mechanism of hemostasis is thought to be through concentrating clotting factors and forming mechanical plugs on bleeding vessels. Methods The authors present 3 consecutive cases of diffusely ulcerated esophagus with clinically significant bleeding. The first 2 cases failed conventional hemostatic treatment including clipping and injection therapy. In the third case, Hemospray was used as the first-line monotherapy. Results Immediate hemostasis was achieved in all 3 patients, and they did not develop recurrent bleeding for more than 2 months. Conclusions The authors propose that Hemospray application should be considered as the first-line therapy in diffuse esophageal ulcerations with clinically significant bleeding, potentially reducing the need to repeat endoscopy. Once the Hemospray achieves hemostasis, it provides a cyto-protective barrier on the diffusely ulcerated mucosa against ongoing acid reflux, allowing the new tissue to grow more efficiently during the ulcer healing period.
Collapse
Affiliation(s)
- Shou-Jiang Tang
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Pegah Hosseini-Carroll
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Telciane S Vesa
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
29
|
Gweon TG, Kim J. Comprehensive review of outcomes of endoscopic treatment of gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tae-Geun Gweon
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jinsu Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
30
|
Meng ZW, Marr KJ, Mohamed R, James PD. Long-Term Effectiveness, Safety and Mortality Associated with the Use of TC-325 for Malignancy-Related Upper Gastrointestinal Bleeds: A Multicentre Retrospective Study. J Can Assoc Gastroenterol 2018; 2:91-97. [PMID: 31294371 PMCID: PMC6507283 DOI: 10.1093/jcag/gwy031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Study Aims Malignant-related upper gastrointestinal bleeding (MRUGIB) is difficult to treat by conventional endoscopic methods. We sought to determine the efficacy, safety and mortality associated with the use of TC-325 for the treatment of MUGIB. Patients and Methods This is a multicentre, retrospective study at the University of Calgary and University of Ottawa performed between January 1, 2010, and July 30, 2016. TC-325 use was identified via staff polling, product order forms and endoscopic records review. Once identified, patient charts and online records were examined to identify MRUGIB cases and to assess our primary and secondary endpoints. Outcomes The primary outcome was hemostasis at seven days. Secondary outcomes include immediate hemostasis, early hemostasis, hemostasis at 14 days, 30-day mortality, adverse events related to TC-325 therapy and the need for repeat endoscopic intervention, surgery or transarterial embolization. Results Twenty-five patients were identified. The median age was 62 years (interquartile range [IQR] 52.5–76), and most were male (64%). TC-325 was the primary treatment modality in 20 patients (80%). Hemostasis was 88%, 89%, 58% and 50% at 24 hours, 72 hours, 7 days and 14 days, respectively. Five patients underwent repeat endoscopy, two patients required surgical intervention, and transarterial embolization was not required. Twelve patients died by 30 days (48%). There were no complications directly attributed to the use of TC-325. Conclusions TC-325 is effective for achieving and maintaining hemostasis in patients with malignancy-related upper gastrointestinal bleeding, and most patients do not require additional interventions. The 30-day mortality risk in this group of patients is high.
Collapse
Affiliation(s)
- Zhao Wu Meng
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kaleb J Marr
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Rachid Mohamed
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Paul D James
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.,Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| |
Collapse
|