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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.
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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
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Ahmed K, Abdallah M, Abbas D, Jaber F, Abdalla AO, Mohamed M, McDonald N, Hanson BJ, Bilal M. Analysis of Reported Adverse Events Related to Hemospray: An FDA MAUDE Database Study. J Clin Gastroenterol 2024; 58:402-406. [PMID: 37267458 DOI: 10.1097/mcg.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/31/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Topical hemostatic powder is a mineral powder that forms an adherent barrier and coagulates active bleeding in the gastrointestinal (GI) tract. Hemospray is the first hemostatic powder approved by the Food and Drug Administration (FDA) in the United States. Hemospray has been increasingly used to manage GI bleeding. However, data on the adverse events of hemostatic powders are lacking. Therefore, we aim to report and analyze adverse events associated with Hemospray using the FDA's "Manufacturer and User Facility Device Experience" database. METHODS We analyzed the postmarketing surveillance data from the FDA's Manufacturer and User Facility Device Experience database for Hemospray, initially known as TC-325, from June 2018 through April 2022. Results of the search were classified into device-related technical issues, patient-related adverse events and health care staff-related adverse events. RESULTS Five hundred two medical device reporting claims were identified from June 2018 through April 2022. Seven duplicate claims were identified, and some claims included more than one event type. Therefore, there were 558 device-related problems, 28 patient-related adverse events, and 2 adverse events in health care staff members. The most common device-related problems were activation failure or failure to fire (n = 385, 70.0%) and obstruction of carbon dioxide flow (n = 121, 21.7). The most common patient-related adverse events included tissue injury or bleeding (n = 21) and perforation (n = 5). CONCLUSION Although Hemospray is a valuable tool in the armamentarium for endoscopists in managing GI bleeding, endoscopists must be mindful of deice-related problems and potential patient-related adverse events.
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Affiliation(s)
- Khalid Ahmed
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA
| | - Mohamed Abdallah
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
| | - Daniyal Abbas
- Department of Internal Medicine, East Carolina University, Greenville, NC
| | - Fouad Jaber
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Abubaker O Abdalla
- Division of Gastroenterology and Hepatology, Emory University, Atlanta, GA
| | - Mouhand Mohamed
- Brown University, Warren Alpert Medical School, Providence, RI
| | - Nicholas McDonald
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
| | - Brian J Hanson
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
- Division of Gastroenterology and Hepatology, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
| | - Mohammad Bilal
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
- Division of Gastroenterology and Hepatology, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
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Wehbe H, Gutta A, Gromski MA. Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon. Gastrointest Endosc Clin N Am 2024; 34:363-381. [PMID: 38395489 DOI: 10.1016/j.giec.2023.09.008] [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: 02/25/2024]
Abstract
Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.
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Affiliation(s)
- Hisham Wehbe
- Department of Internal Medicine, Indiana University School of Medicine, 550 University Boulevard, UH 3533, Indianapolis, IN 46202, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA
| | - Mark A Gromski
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA.
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Dang F, Monachese M. Endoscopic Management of Tumor Bleeding: Techniques and Strategies. Gastrointest Endosc Clin N Am 2024; 34:155-166. [PMID: 37973226 DOI: 10.1016/j.giec.2023.07.005] [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: 11/19/2023]
Abstract
Endoscopic management of gastrointestinal (GI) tumor-related bleeding is challenging for many reasons including high rebleeding rates, poor tissue response to endoscopic therapies, altered wound healing and underlying coagulopathy. However, endoscopic treatment may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy. This article explores various endoscopic techniques in managing tumor bleeding from more traditional approaches of using thermal or mechanical therapy with injection therapy to newer topical agents.
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Affiliation(s)
- Frances Dang
- University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, Ontario, M5S 3H2, Canada.
| | - Marc Monachese
- Trillium Health Partners, 101 Queensway West, Unit 200, Mississauga, Ontario, L5B2P7, Canada
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Wang AY. Hemostatic Powder Offers Patients Respite From Malignant Gastrointestinal Bleeding. Gastroenterology 2023; 165:536-537. [PMID: 37393023 DOI: 10.1053/j.gastro.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
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Su DS, Li CK, Gao C, Qi XS. Hemostatic powder for acute upper gastrointestinal bleeding: Recent research advances. Shijie Huaren Xiaohua Zazhi 2023; 31:249-255. [DOI: 10.11569/wcjd.v31.i7.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is a clinically common emergency condition. The common causes of AUGIB are peptic ulcer and esophagogastric variceal bleeding. Despite continuous improvements in endoscopic hemostasis techniques, endoscopic treatment is still unsuccessful in 5%-15% of patients. Hemostatic powder, a new drug for endoscopic hemostasis that is sprayed on the bleeding site with the assistance of an air pump, can absorb water to promote clotting substance aggregation and then adhere over the lesion, forming a mechanical barrier and then achieving hemostasis. It is convenient to spray hemostatic powder under endoscopy, where precise positioning is not warranted. The immediate hemostasis rate of hemostatic powder is often high, and it can be used as a remedy after the failure of conventional hemostasis. However, until now, there have been no recommendations in China regarding the use of hemostatic powder for the treatment of AUGIB. This article summarizes the mechanism, clinical applicability, and side effects of five major types of hemostatic powder by reviewing the existing evidence, with an aim to strengthen endoscopists' understanding of this drug.
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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: 9] [Impact Index Per Article: 9.0] [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.
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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
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Villaescusa Arenas D, Rodríguez de Santiago E, Rodríguez Gandía MÁ, Parejo Carbonell S, Peñas García B, Guerrero García A, Foruny Olcina JR, García García de Paredes A, González Martín JÁ, Vázquez-Sequeiros E, Albillos A. Over-the-scope-clip (OTSC®) as a rescue treatment for gastrointestinal bleeding secondary to peptic ulcer disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:70-74. [PMID: 35469413 DOI: 10.17235/reed.2022.8722/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS over-the-scope-clips (OTSC®) have been proposed as a rescue treatment for bleeding peptic ulcers. However, their effectiveness has not been evaluated in Spain. METHODS this retrospective and single-center study (January 2018-December 2021) assessed the technical success, clinical success and safety of the device within 30 days. All patients with upper gastrointestinal bleeding due to a peptic ulcer and treated with the OTSC® clip (OVESCO) as a rescue therapy were included in the study. RESULTS a total of eleven patients were included in the study, nine due to rebleeding and two due to persistent bleeding. Technical success was 81.9 % (9/11, confidence interval [CI] 95 %: 52-95 %). The per-protocol and intention-to-treat clinical success were 88.9 % (8/9, CI 95 %: 57-98 %) and 72.7 % (8/11, CI 95 %: 43-90 %), respectively. No device-related adverse effects were recorded. CONCLUSION the OTSC® clip was an effective and safe rescue therapy for bleeding peptic ulcers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Agustín Albillos
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal
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Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010143. [PMID: 36676767 PMCID: PMC9863809 DOI: 10.3390/medicina59010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.
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Abu-Sbeih H, Szafron D, Elkafrawy AA, Garcia-Rodriguez V, Ma W, Xu A, Khurana S, Numan L, Chen E, Goldstein R, Tsen A, Peng Y, Blum M, Kopetz ES, Ikoma N, Shatila M, Qiao W, Raju GS, Ross WA, Ge PS, Coronel E, Wang Y. Endoscopy for the diagnosis and treatment of gastrointestinal bleeding caused by malignancy. J Gastroenterol Hepatol 2022; 37:1983-1990. [PMID: 35730192 DOI: 10.1111/jgh.15922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 06/13/2022] [Accepted: 06/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The diagnosis and treatment of gastrointestinal (GI) bleeding secondary to malignancy can be challenging. Endoscopy is the gold standard to diagnose and treat gastrointestinal bleeding but clinical characteristics and outcomes of patients with malignancy-related bleeding are not well understood. This study aims to look at clinical characteristics, endoscopic findings, safety and clinical outcomes of endoscopic interventions for GI malignancy-related bleeding. METHODS We retrospectively reviewed outcomes of patients with confirmed GI malignancies who underwent endoscopy for GI bleeding at MD Anderson Cancer Center between 2010 and 2019. Cox hazard analysis was conducted to identify factors associated with survival. RESULTS A total of 313 patients were included, with median age of 59 years; 74.8% were male. The stomach (30.0%) was the most common tumor location. Active bleeding was evident endoscopically in 47.3% of patients. Most patients (77.3%) did not receive endoscopic treatment. Of the patients who received endoscopic treatment, 57.7% had hemostasis. No endoscopy-related adverse events were recorded. Endoscopic treatment was associated with hemostasis (P < 0.001), but not decreased recurrent bleeding or mortality. Absence of active bleeding on endoscopy, stable hemodynamic status at presentation, lower cancer stage, and surgical intervention were associated with improved survival. CONCLUSIONS This study indicates that endoscopy is a safe diagnostic tool in this patient population; while endoscopic treatments may help achieve hemostasis, it may not decrease the risk of recurrent bleeding or improve survival.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Internal Medicine, The University of Missouri, Kansas City, Missouri, USA
| | - David Szafron
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ahmed A Elkafrawy
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Victor Garcia-Rodriguez
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, Texas, USA
| | - Weijie Ma
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann Xu
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Shruti Khurana
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, Texas, USA
| | - Laith Numan
- Department of Internal Medicine, The University of Missouri, Kansas City, Missouri, USA
| | - Ellie Chen
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ryan Goldstein
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, Texas, USA
| | - Adrianne Tsen
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, Texas, USA
| | - Yuanzun Peng
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Bioscience, Rice University, Houston, Texas, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edmund S Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Malek Shatila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - William A Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Phillip S Ge
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Emmanuel Coronel
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Jiang SX, Chahal D, Ali-Mohamad N, Kastrup C, Donnellan F. Hemostatic powders for gastrointestinal bleeding: a review of old, new, and emerging agents in a rapidly advancing field. Endosc Int Open 2022; 10:E1136-E1146. [PMID: 36238531 PMCID: PMC9552790 DOI: 10.1055/a-1836-8962] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/20/2022] [Indexed: 10/26/2022] Open
Abstract
Background and study aims Hemostatic powders are increasingly used to address limitations in conventional endoscopic techniques for gastrointestinal bleeding. Various agents exist with different compositions, characteristics, efficacy, and adverse events (AEs). We sought to review existing hemostatic powders, from preclinical to established agents. Methods A literature review on hemostatic powders for gastrointestinal bleeding was undertaken through a MEDLINE search from 2000-2021 and hand searching of articles. Relevant literature was critically appraised and reviewed for mechanism of action, hemostasis and rebleeding rate, factors associated with hemostatic failure, and AEs. Results The most established agents are TC-325 (Hemospray), EndoClot, and Ankaferd Blood Stopper (ABS). These agents have been successfully applied to a variety of upper and lower gastrointestinal bleeding etiologies, in the form of primary, combination, salvage, and bridging therapy. Few AEs have been reported, including visceral perforation, venous embolism, and self-limited abdominal pain. Newer agents include CEGP-003 and UI-EWD, which have shown results similar to those for the older agents in initial clinical studies. All aforementioned powders have high immediate hemostasis rates, particularly in scenarios not amenable to conventional endoscopic methods, but are limited by significant rates of rebleeding. Other treatments include TDM-621 (PuraStat) consisting of a liquid hemostatic agent newly applied to endoscopy and self-propelling thrombin powder (CounterFlow Powder), a preclinical but promising agent. Conclusions Rapid development of hemostatic powders and growing clinical expertise has established these agents as a valuable strategy in gastrointestinal bleeding. Further research will continue to refine the efficacy and applicability of these agents.
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Affiliation(s)
- Shirley X. Jiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daljeet Chahal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, United States
| | - Nabil Ali-Mohamad
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christian Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada,Blood Research Institute, Versiti, Milwaukee, Wisconsin, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
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Paoluzi OA, Cardamone C, Aucello A, Neri B, Grasso E, Giannelli M, Di Iorio L, Monteleone G, Del Vecchio Blanco G. Efficacy of hemostatic powders as monotherapy or rescue therapy in gastrointestinal bleeding related to neoplastic or non-neoplastic lesions. Scand J Gastroenterol 2021; 56:1506-1513. [PMID: 34511014 DOI: 10.1080/00365521.2021.1974088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hemostatic powder (HP) in gastrointestinal bleeding (GIB) is mainly used as rescue therapy after failure of conventional hemostatic procedures (CHP). AIM To define the best field of application and the efficacy of HP as first choice monotherapy or rescue therapy. METHODS We compared the efficacy of HP monotherapy, HP rescue therapy, and CHP in the management of active GIB due to neoplastic and non-neoplastic lesions. RESULTS A total of 108 patients, 43 treated with HP as either first choice or rescue therapy and 65 with CHP, were included in the study. The most frequent sources of bleeding were peptic ulcer and malignancy. Immediate hemostasis rates were: HP monotherapy = 100% in peptic ulcer and 100% in malignancy; HP rescue therapy = 93.2% in peptic ulcer and 85.7% in malignancy; CHP = 77.9% in peptic ulcer and 41.7 in malignancy. Definitive hemostasis rates were: HP monotherapy = 50% in peptic ulcer and 45.5% in malignancy; HP rescue therapy = 73.3% in peptic ulcer and 85.7% in malignancy; CHP = 69.1% in peptic ulcer and 33.3% in malignancy. No difference was found in terms of additional intervention between the three groups. CONCLUSIONS HP is highly effective as monotherapy and rescue therapy in GIB. GIB related to malignancy may be the best field of application of HP, but confirmatory studies are necessary.
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Affiliation(s)
- Omero Alessandro Paoluzi
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Carla Cardamone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Antonio Aucello
- Endoscopy Unit, Istituto Figlie di San Camillo Ospedale Vannini, Roma, Italy
| | - Benedetto Neri
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Enrico Grasso
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Giannelli
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Laura Di Iorio
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
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Guo XF, Yu XA, Hu JC, Lin DZ, Deng JX, Su ML, Li J, Liu W, Zhang JW, Zhong QH. Endoscopic management of delayed bleeding after polypectomy of small colorectal polyps: two or more clips may be safe. Gastroenterol Rep (Oxf) 2021; 10:goab051. [PMID: 35382164 PMCID: PMC8972999 DOI: 10.1093/gastro/goab051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/14/2022] Open
Abstract
Background The resection of small colorectal polyps (≤10 mm) is routine for endoscopists. However, the management of one of its main complications, namely delayed (within 14 days) postpolypectomy bleeding (DPPB), has not been clearly demonstrated. We aimed to assess the role of coloscopy in the management of DPPB from small colorectal polyps and identify the associated factors for initial hemostatic success. Methods We conducted a retrospective study of 69 patients who developed DPPB after the removal of colorectal polyps of ≤10 mm and underwent hemostatic colonoscopy at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between April 2013 and June 2021. Demographics, clinical variables, and colonoscopic features were collected independently. We applied univariate and multivariate analyses to assess factors associated with initial hemostatic success. Results General colonoscopy without oral bowel preparation was successfully performed in all the patients, with a median duration of 23.9 (12.5–37.9) minutes. Among 69 patients, 62 (89.9%) achieved hemostasis after initial hemostatic colonoscopy and 7 (10.1%) rebled 2.7 ± 1.1 days after initial colonoscopic hemostasis and had rebleeding successfully controlled by one additional colonoscopy. No colonoscopy-related adverse events occurred. Multivariate analysis showed that management with at least two clips was the only independent prognostic factor for initial hemostatic success (odds ratio, 0.17; 95% confidence interval, 0.03–0.91; P = 0.04). All the patients who had at least two clips placed at the initial hemostatic colonoscopy required no further hemostatic intervention. Conclusions Colonoscopy is a safe, effective, and not too time-consuming approach for the management of patients with DPPB of small colorectal polyps and management with the placement of at least two hemoclips may be beneficial.
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Affiliation(s)
- Xue-Feng Guo
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiang-An Yu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jian-Cong Hu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - De-Zheng Lin
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Xin Deng
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Ming-Li Su
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Juan Li
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei Liu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Wei Zhang
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qing-Hua Zhong
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Corresponding author. Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-20-38254166; Fax: +86-20-38254166;
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Facciorusso A, Bertini M, Bertoni M, Tartaglia N, Pacilli M, Pavone G, Ambrosi A, Sacco R. Efficacy of hemostatic powders in lower gastrointestinal bleeding: Clinical series and literature review. Dig Liver Dis 2021; 53:1327-1333. [PMID: 34120857 DOI: 10.1016/j.dld.2021.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/12/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited evidence on the efficacy of hemostatic powders in the management of lower gastrointestinal bleeding. AIMS to revise our series of patients with lower gastrointestinal bleeding treated with hemostatic powders and to provide a pooled estimate of their efficacy based on the current literature. METHODS Sixty-five patients underwent topical endoscopic application of hemostatic powder between 2016 and 2020. The primary endpoint was treatment success, with 7- and 30-day rebleeding rate, adverse events and mortality as secondary outcomes. Literature review was based on computerized bibliographic search on the main databases through December 2020. Pooled effects were calculated using a random-effects model. RESULTS Overall, the powder was applied as monotherapy in 37 patients (56.9%), as combination therapy in 15 patients (23.4%), and as rescue therapy in 13 cases (19.9%). Hemostasis was achieved in 100% of patients. Rebleeding rate at 7- and 30-day was 7.7% and 9.2%, respectively. A total of 10 studies with 259 patients were included in the meta-analysis. Immediate hemostasis was achieved in 96.3% (93.4%-99.2%) patients, whereas pooled 7- and 30-day rebleeding rates were 9.6% (4.5%-14.6%) and 12.9% (7.2%-18.5%), respectively. CONCLUSION Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy.
| | - Marco Bertini
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Michele Bertoni
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Nicola Tartaglia
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Mario Pacilli
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Giovanna Pavone
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Antonio Ambrosi
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Rodolfo Sacco
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
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15
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Experience with the use of a hemostatic powder in 152 patients undergoing urgent endoscopy for gastrointestinal bleeding. Clin Res Hepatol Gastroenterol 2021; 45:101558. [PMID: 33168481 DOI: 10.1016/j.clinre.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/02/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS In the recent years, topical hemostatic powders have been used for the management of upper gastrointestinal bleeding. The aim of this study was to report on the use of an hemostatic powder (Hemospray®), outside regular hours, by on-call endoscopists during urgent endoscopic procedures. MATERIAL AND METHODS In this retrospective multicenter cohort study, consecutive patients having undergone an urgent endoscopy with the use of Hemospray® from November 2015 to December 2018 in the Paris and suburbs area were included. We collected clinical, biological and endoscopic variables. The outcomes such as the recurrence, repeat endoscopy and hemostatic treatment need, complications and survival were also collected. RESULTS A total of 152 patients (mean 65 years old, 70.4% male) were included. Amongst the 31 endoscopists, 11 were "more experienced", and performed 48% of the endoscopies. The most common causes of bleeding were peptic ulcer (47.7%), malignancy (22.2%) and esophagitis (12.4%). Most bleedings originated from the upper GI tract (95.0%). Hemospray® was used as a salvage therapy in 60.8% of cases. Other hemostatic techniques were used in 52.9% of cases. Immediate bleeding cessation was noted in 79.0% of cases, recurrence in 39.9% of cases, and 26.4% of patients benefited from a repeat endoscopic hemostasis. 34 (23.0%) patients required a non-endoscopic treatment. At day 30, the survival rate was 71.6%. One complication was reported (perforation). CONCLUSIONS Hemostatic powder application by on-call endoscopists outside regular hours is technically feasible, but comes with a high risk of rebleeding in severely ill patients.
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16
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Facciorusso A, Bertini M, Bertoni M, Tartaglia N, Pacilli M, Ramai D, Mohan BP, Chandan S, Ambrosi A, Sacco R. Effectiveness of hemostatic powders in lower gastrointestinal bleeding: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1283-E1290. [PMID: 34447877 PMCID: PMC8383089 DOI: 10.1055/a-1495-4764] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/14/2021] [Indexed: 12/16/2022] Open
Abstract
Background and study aims There is limited evidence on the effectiveness of hemostatic powders in the management of lower gastrointestinal bleeding (LGIB). We aimed to provide a pooled estimate of their effectiveness and safety based on the current literature. Patients and methods Literature review was based on computerized bibliographic search of the main databases through to December 2020. Immediate hemostasis, rebleeding rate, adverse events, and mortality were the outcomes of the analysis. Pooled effects were calculated using a random-effects model. Results A total of 9 studies with 194 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95 % of patients (95 % confidence interval [CI] 91.6 %-98.5 %), with no difference based on treatment strategy or bleeding etiology. Pooled 7- and 30-day rebleeding rates were 10.9 % (95 %CI 4.2 %-17.6 %) and 14.3 % (95 %CI 7.3 %-21.2 %), respectively. Need for embolization and surgery were 1.7 % (95 %CI 0 %-3.5 %) and 2.4 % (95 %CI 0.3 %-4.6 %), respectively. Overall, two patients (1.9 %, 95 %CI 0 %-3.8 %) experienced mild abdominal pain after powder application, and three bleeding-related deaths (2.3 %, 95 %CI 0.2 %-4.3 %) were registered in the included studies. Conclusion Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Marco Bertini
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Michele Bertoni
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Nicola Tartaglia
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Mario Pacilli
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, Brooklyn Hospital Medical Center, Brooklyn, New York, United States
| | - Babu P. Mohan
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, United States
| | - Saurabh Chandan
- Gastroenterology Unit, CHI Health Creighton University Medical Center, Omaha, Nebraska, United States
| | - Antonio Ambrosi
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Rodolfo Sacco
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
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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.
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Sung JJY, Laine L, Kuipers EJ, Barkun AN. Towards personalised management for non-variceal upper gastrointestinal bleeding. Gut 2021; 70:818-824. [PMID: 33649044 DOI: 10.1136/gutjnl-2020-323846] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
Guidelines from national and international professional societies on upper gastrointestinal bleeding highlight the important clinical issues but do not always identify specific management strategies pertaining to individual patients. Optimal treatment should consider the personal needs of an individual patient and the pertinent resources and experience available at the point of care. This article integrates international guidelines and consensus into three stages of management: pre-endoscopic assessment and treatment, endoscopic evaluation and haemostasis and postendoscopic management. We emphasise the need for personalised management strategies based on patient characteristics, nature of bleeding lesions and the clinical setting including available resources.
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Affiliation(s)
- Joseph J Y Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, Connecticut, USA
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alan N Barkun
- Gastroenterology, McGILL University health centre, Montreal, Quebec, Canada
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19
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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.
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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
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Rodríguez de Santiago E, Hernández-Tejero M, Rivero-Sánchez L, Ortiz O, García de la Filia-Molina I, Foruny-Olcina JR, Prieto HMM, García-Prada M, González-Cotorruelo A, De Jorge Turrión MA, Jiménez-Jurado A, Rodríguez-Escaja C, Castaño-García A, Outomuro AG, Ferre-Aracil C, de-Frutos-Rosa D, Pellisé M. Management and Outcomes of Bleeding Within 30 Days of Colonic Polypectomy in a Large, Real-Life, Multicenter Cohort Study. Clin Gastroenterol Hepatol 2021; 19:732-742.e6. [PMID: 32272252 DOI: 10.1016/j.cgh.2020.03.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/17/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Management of delayed (within 30 days) postpolypectomy bleeding (DPPB) has not been standardized. Patients often undergo colonoscopies that do not provide any benefit. We aimed to identify factors associated with therapeutic intervention and active bleeding after DPPB. METHODS We performed a retrospective study of 548 patients with bleeding within 30 days after an index polypectomy (DPPB; 71.9% underwent colonoscopy, 2.6% underwent primary angiographic embolization, and 25.5% were managed without intervention) at 6 tertiary centers in Spain, from January 2010 through September 2018. We collected demographic and medical data from patients. The primary outcomes were the need for therapeutic intervention and the presence of active bleeding during colonoscopy. RESULTS A need for therapeutic intervention was associated independently with the use of antithrombotic agents, hemoglobin decrease greater than 2 g/dL, hemodynamic instability, and comorbidities (P < .05). The bleeding point during colonoscopy was identified in 344 patients; 74 of these patients (21.5%) had active bleeding. Active use of anticoagulants (odds ratio [OR], 2.6; 95% CI, 1.5-4.5), left-sided polyps (OR, 1.95; 95% CI, 1-3.8), prior use of electrocautery (OR, 2.6; 95% CI, 1.1-6.1), and pedunculated polyp morphology (OR, 1.8, 95% CI, 1-3.2) significantly increased the risk of encountering active bleeding. We developed a visual nomogram to estimate the risk of active bleeding. Overall, 43% of the cohort did not require any hemostatic therapy. Rebleeding (<6%) and transfusion requirements were low in those managed without intervention. CONCLUSIONS In a study of patients with DPPB, we found that almost half do not warrant any therapeutic intervention. Colonoscopy often is overused for patients with DPPB. We identified independent risk factors for active bleeding that might be used to identify patients most likely to benefit from colonoscopy.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria Universidad de Alcalá, Madrid, Spain
| | - Maria Hernández-Tejero
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain
| | - Liseth Rivero-Sánchez
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain
| | - Oswaldo Ortiz
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain
| | - Irene García de la Filia-Molina
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria Universidad de Alcalá, Madrid, Spain
| | - Jose Ramon Foruny-Olcina
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria Universidad de Alcalá, Madrid, Spain
| | - Hector Miguel Marcos Prieto
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Maria García-Prada
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Almudena González-Cotorruelo
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | | | | | - Carlos Rodríguez-Escaja
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Andres Castaño-García
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ana Gómez Outomuro
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Carlos Ferre-Aracil
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid
| | - Diego de-Frutos-Rosa
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universitat de Barcelona, Barcelona, Spain.
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21
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Mullady DK, Wang AY, Waschke KA. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. Gastroenterology 2020; 159:1120-1128. [PMID: 32574620 DOI: 10.1053/j.gastro.2020.05.095] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/19/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.
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Affiliation(s)
- Daniel K Mullady
- Division of Gastroenterology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Kevin A Waschke
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
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Law R, Cardenas A. Hemostatic Powder for Gastrointestinal Bleeding: Time to believe the hype or more false hope? Dig Liver Dis 2020; 52:702-703. [PMID: 32423848 DOI: 10.1016/j.dld.2020.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andres Cardenas
- GI/Liver Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Spain.
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24
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Burgos-Santamaría D, Rodríguez de Santiago E. Response. Gastrointest Endosc 2020; 91:956-957. [PMID: 32204819 DOI: 10.1016/j.gie.2019.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Diego Burgos-Santamaría
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
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- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
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Vellanki M, Gapp J, Chandra S. Hemostatic spray powder TC-325 for endoscopic hemostasis, bridge, or definitive intervention. Gastrointest Endosc 2020; 91:956. [PMID: 32204820 DOI: 10.1016/j.gie.2019.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Meghana Vellanki
- Division of Gastroenterology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Jonathan Gapp
- Division of Gastroenterology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Subhash Chandra
- Division of Gastroenterology, Creighton University School of Medicine, Omaha, Nebraska, USA
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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.
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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
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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Response. Gastrointest Endosc 2020; 91:458-459. [PMID: 32036955 DOI: 10.1016/j.gie.2019.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
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29
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Chan SM, Lau JYW. Is hemospray the ultimate answer to malignant GI bleeding? Gastrointest Endosc 2020; 91:329-331. [PMID: 32036940 DOI: 10.1016/j.gie.2019.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - James Yun Wong Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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30
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Liu Y, Zhou Y. The potential use of hemostatic spray powder TC-325 in pediatric patients with GI bleeding. Gastrointest Endosc 2020; 91:458. [PMID: 32036954 DOI: 10.1016/j.gie.2019.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Yi Liu
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Yin Zhou
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Digestive Surgery, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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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.
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Kuellmer A, Behn J, Meier B, Wannhoff A, Bettinger D, Thimme R, Caca K, Schmidt A. Over-the-scope clips are cost-effective in recurrent peptic ulcer bleeding. United European Gastroenterol J 2019; 7:1226-1233. [PMID: 31700635 DOI: 10.1177/2050640619871754] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/31/2019] [Indexed: 12/31/2022] Open
Abstract
Background A recent prospective randomised controlled trial ('STING') showed superiority of over-the-scope clips compared to standard treatment in recurrent peptic ulcer bleeding. Cost-effectiveness studies on haemostasis with over-the-scope clips have not been reported so far. Objective The aim of this study was to investigate whether the higher efficacy of the over-the-scope clips treatment outweighs the higher costs of the device compared to standard clips. Methods For the analysis, the study population of the STING trial was used. Costs for the hospital stay in total as well as treatment-related costs were obtained. The average cost-effectiveness ratio, representing the mean costs per designated outcome, and the incremental cost-effectiveness ratio, expressing the additional costs of a new treatment strategy per difference in outcome were calculated. The designated outcome was defined as successful haemostasis without rebleeding within seven days, which was the primary endpoint of the STING trial. Average cost-effectiveness ratio and incremental cost-effectiveness ratio were calculated for total costs of the hospital stay as well as the haemostasis treatment alone. The cost-effectiveness analysis is taken from the perspective of the care provider.Results: Total costs and treatment-related costs per patient were 13,007.07 € in the standard group vs 12,808.56 € in the over-the-scope clip group (p = 0.812) and 2084.98 € vs 1984.71 € respectively (p = 0.663). The difference was not statistically significant. Total costs per successful haemostasis (average cost-effectiveness ratio) were 30,677.05 € vs 15,104.43 € and 4917.41 € vs 2340.46 € for the haemostasis treatment. The additional costs per successful haemostasis with over-the-scope clip treatment (incremental cost-effectiveness ratio) is -468.18 € for the whole treatment and -236.49€ for the haemostasis treatment. Conclusions Over-the-scope clip treatment is cost-effective in recurrent peptic ulcer bleeding.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juliane Behn
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Benjamin Meier
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Gutta A, Gromski MA. Endoscopic Management of Post-Polypectomy Bleeding. Clin Endosc 2019; 53:302-310. [PMID: 31525836 PMCID: PMC7280838 DOI: 10.5946/ce.2019.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022] Open
Abstract
Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. There are multiple risk factors related to patient and polyp characteristics that should be considered. In most cases, immediate PPB can be effectively managed endoscopically when recognized and managed promptly. Delayed PPB can manifest in a myriad of ways. In severe delayed PPB, resuscitation for hemodynamic stabilization should be prioritized, followed by endoscopic evaluation and therapy once the patient is stabilized. Future areas of research in PPB include the risks of direct oral anticoagulants and of specific electrosurgical settings for hot-snare polypectomy vs. cold-snare polypectomy, benefits of closure of post-polypectomy mucosal defects using through-the-scope clips, and prospective comparative evaluation of newer hemostasis agents such as hemostatic spray powder and over-the-scope clips.
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Affiliation(s)
- Aditya Gutta
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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