Use of hemostatic powder in treatment of upper gastrointestinal bleeding: a systematic review and meta-analysis

Ionically assembled hemostatic powders with rapid self-gelation, strong acid resistance, and on-demand removability for upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is bleeding in the upper part of the gastrointestinal tract with an acidic and dynamic environment that limits the application of conventional hemostatic materials. This study focuses on the development of N-[(2-hydroxy-3-trimethylammonium) propyl] chitosan chloride/phytic acid (HTCC/PA, HP) powders with fast hemostatic capability and strong acid resistance, for potential applications in managing UGIB. Upon contact with liquids within 5 seconds, HP powders rapidly transform into hydrogels, forming ionic networks through electrostatic interactions. The ionic crosslinking process facilitates the HP powders with high blood absorption (3.4 times of self-weight), sufficient tissue adhesion (5.2 and 6.1 kPa on porcine skin and stomach, respectively), and hemostasis (within 15 seconds for in vitro clotting). Interestingly, the PA imparts the HP powders with strong acid resistance (69.8% mass remaining after 10 days of incubation at pH 1) and on-demand removable sealing while HTCC contributes to fast hemostasis and good wet adhesion. Moreover, the HP powders show good biocompatibility and promote wound healing. Therefore, these characteristics highlight the promising clinical potential of HP powders for effectively managing UGIB.

Haemostatic spray in the management of acute nonvariceal upper gastrointestinal bleeding in children: A single-centre experience in Singapore

Introduction/Objectives

Haemostatic spray (HS; Hemospray) is a powder agent for endoscopic haemostasis in patients with acute upper gastrointestinal bleeding (UGIB). It has been shown to be effective and easy to administer. However, published data on efficacy and safety in children remain scarce. Our aim was to describe our experience with the use of HS in the management of UGIB.

Patients and Methods

A retrospective review was conducted of patients aged 0-18 receiving HS for endoscopic haemostasis from January 2017 to December 2021. Information was obtained on demographics, clinical presentation and comorbidities. Outcomes were successful initial haemostasis and rates of re-bleeding.

Results

A total of 25 applications of HS occurred in 23 patients. The median patient age was 8 years (range: 4 months to 16 years). HS was used in 17/25 (68%) applications as monotherapy. Other treatments employed were clip application and adrenaline injection. One hundred per cent initial haemostasis was achieved with three (13.0%) patients who experienced re-bleeding. All patients tolerated HS applications with no adverse events.

Conclusions

Our finding supports the use of HS in the management of UGIB in children. HS, either as monotherapy or in combination with other conventional therapy, could potentially be the treatment of choice in children with UGIB with its excellent feasibility and good safety profile.

Hemostatic powder for acute upper gastrointestinal bleeding: Recent research advances

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.

Best Supportive Care of the Patient with Oesophageal Cancer

BACKGROUND

Oesophageal cancer patients have poor survival, and most are unfit for curative or systemic palliative treatment. This article aims to review the best supportive care for oesophageal cancer, focusing on the management of its most frequent or distinctive symptoms and complications.

METHODS

Evidence-based review on palliative supportive care of oesophageal cancer, based on Pubmed search for relevant clinical practice guidelines, reviews and original articles, with additional records collected from related articles suggestions, references and societies recommendations.

RESULTS

We identified 1075 records, from which we screened 138 records that were related to oesophageal cancer supportive care, complemented with 48 additional records, finally including 60 records. This review summarizes the management of oesophageal cancer-related main problems, including dysphagia, malnutrition, pain, nausea and vomiting, fistula and bleeding. In recent years, several treatments have been developed, while optimal management is not yet standardized.

CONCLUSION

This review contributes toward improving supportive care and decision making for oesophageal cancer patients, presenting updated summary recommendations for each of their main symptoms. A robust body of evidence is still lacking, and the best supportive care decisions should be individualized and shared.

Endoscopic Ultrasound-Guided Biliary Interventions

Endoscopic ultrasound (EUS)-guided biliary interventions have evolved to become an integral part of advanced gastrointestinal endoscopy units. EUS-guided biliary drainage is an accepted alternative for patients with failed ERCP or altered surgical anatomy. The potential advantages of EUS-guided interventions include choice of biliary access from stomach or duodenum, choice of stent exit in stomach and duodenum, and possibility of avoiding traversing through the obstruction. A variety of procedures have been described depending on the level of obstruction. Maximum evidence is available for distal malignant obstruction, and more studies are needed for hilar obstruction and benign indications.

Use of topical mineral powder as monotherapy for treatment of active peptic ulcer bleeding

BACKGROUND AND AIMS

The aim of this study was to evaluate the safety and effectiveness of Hemospray (Cook Medical, Winston-Salem, NC, USA), a hemostatic powder, as monotherapy for active peptic ulcer bleeding.

METHODS

In this prospective, multicenter, single-arm study, patients with Forrest Ia or Ib peptic ulcers underwent endoscopic application of Hemospray as treatment of first intent. Effectiveness endpoints were successful hemostasis at the end of the index endoscopy, recurrent bleeding within 72 hours and from 72 hours to 30 days, adverse events requiring reintervention or resulting in morbidity or mortality, and 30-day mortality.

RESULTS

Hemospray was successfully administered in 98.5% of patients (66/67). Hemostasis was achieved at the index endoscopy in 90.9% of patients (60/66) with Hemospray alone and in an additional 4 patients treated with additional modalities, yielding an overall hemostasis rate of 97.0% (64/66). Rebleeding occurred in 13.3% of patients (8/60), 5 within 72 hours and 3 between 72 hours and 30 days. Two cases of perforation and 2 patient deaths occurred during the study, but none of these cases or any other adverse events were attributed to the use of Hemospray. The rate of early rebleeding was significantly higher in patients with Forrest Ia ulcers compared with patients with Forrest Ib ulcers. Higher rates of early bleeding in patients with Forrest Ia ulcers is consistent with results from studies where Hemospray was used as rescue after failure of conventional methods.

CONCLUSIONS

Hemospray is an effective initial treatment for patients with active peptic ulcer bleeding, but care should be taken to monitor for recurrent bleeding. (Clinical trial registration number: NCT01306864.).

Managing adverse events after endoscopic ultrasound-guided drainage of the biliary tract and pancreatic fluid collections: Narrative review (with video)

Endoscopic ultrasound (EUS)-guided therapeutic procedures have become increasingly common in clinical practice. The development of EUS-guided fine needle aspiration cytology led to the concept of interventional EUS. However, it carries a considerable risk of adverse events (AEs), which occur in approximately 23% of the procedures performed for the drainage of pancreatic fluid collections and 2.5-37.0% of those performed for drainage of the biliary tract. Although the vast majority of AEs occurring after EUS-guided drainage are mild, a deep understanding of such events is necessary for their appropriate management. Because EUS-guided drainage is a novel procedure, there have been few studies of the topic. To our knowledge, this is the first narrative review that focuses on the management and resolution of AEs occurring after EUS-guided drainage of pancreatic fluid collections or the biliary tract. We also include an explanatory video.

Balloon Tamponade Utilization for Severe Esophagitis Causing Hemorrhagic Shock

Esophagitis causing upper gastrointestinal bleeding (UGIB) is associated with significant morbidity. We present a case report of two patients with hemorrhagic shock secondary to esophagitis. Both patients underwent esophagogastroduodenoscopy demonstrating severe bleeding pan-esophagitis complicated by hemodynamic instability. Balloon tamponade for hemostasis was performed with resultant hemodynamic improvement. Severe UGIB secondary to esophagitis is difficult to control, with a high risk of complications and limited available endoscopic therapies in extensive mucosal injury. Treatments such as angiography are ineffective due to collateralization and surgery carries high morbidity and mortality. Balloon tamponade provides a rescue option for severe, refractory UGIB secondary to esophagitis.

Effectiveness of hemostatic powders in lower gastrointestinal bleeding: a systematic review and meta-analysis

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.

Efficacy of Hemospray (TC-325) in the Treatment of Gastrointestinal Bleeding: An Updated Systematic Review and Meta-analysis

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.

Clinical Use of the Self-Assembling Peptide RADA16: A Review of Current and Future Trends in Biomedicine

RADA16 is a synthetic peptide that exists as a viscous solution in an acidic formulation. In an acidic aqueous environment, the peptides spontaneously self-assemble into β-sheet nanofibers. Upon exposure and buffering of RADA16 solution to the physiological pH of biological fluids such as blood, interstitial fluid and lymph, the nanofibers begin physically crosslinking within seconds into a stable interwoven transparent hydrogel 3-D matrix. The RADA16 nanofiber hydrogel structure closely resembles the 3-dimensional architecture of native extracellular matrices. These properties make RADA16 formulations ideal topical hemostatic agents for controlling bleeding during surgery and to prevent post-operative rebleeding. A commercial RADA16 formulation is currently used for hemostasis in cardiovascular, gastrointestinal, and otorhinolaryngological surgical procedures, and studies are underway to investigate its use in wound healing and adhesion reduction. Straightforward application of viscous RADA16 into areas that are not easily accessible circumvents technical challenges in difficult-to-reach bleeding sites. The transparent hydrogel allows clear visualization of the surgical field and facilitates suture line assessment and revision. The shear-thinning and thixotropic properties of RADA16 allow its easy application through a narrow nozzle such as an endoscopic catheter. RADA16 hydrogels can fill tissue voids and do not swell so can be safely used in close proximity to pressure-sensitive tissues and in enclosed non-expandable regions. By definition, the synthetic peptide avoids potential microbiological contamination and immune responses that may occur with animal-, plant-, or mineral-derived topical hemostats. In vitro experiments, animal studies, and recent clinical experiences suggest that RADA16 nanofibrous hydrogels can act as surrogate extracellular matrices that support cellular behavior and interactions essential for wound healing and for tissue regenerative applications. In the future, the unique nature of RADA16 may also allow us to use it as a depot for precisely regulated drug and biopharmaceutical delivery.

Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims

Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic.

Methods

A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results

Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I²=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I²=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I²=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I²=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events.

Conclusions

EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.

Efficacy of Intragastric Balloons for Weight Loss in Overweight and Obese Adults: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Intragastric balloons (IGB) are the most widely used endoscopic bariatric and metabolic therapies. We aimed to evaluate the efficacy of IGB in comparison with sham or lifestyle interventions for weight loss in overweight and obese patients. This systematic review and meta-analysis was performed following the PRISMA guidelines. Electronic searches were performed to identify randomized controlled trials, which compared IGB with sham or lifestyle intervention. Thirteen RCTs with 1523 patients were included. The difference in mean %EWL and %TWL at follow-up was 17.98%, and 4.40%, respectively, which was significantly higher in the IGB group. Similarly, the difference in mean AWL and BMIL was 6.12 kg, and 2.13 kg/m², respectively. IGB therapy is more effective than lifestyle intervention alone for weight loss in overweight and obese adults.

Novel endoscopic papillectomy for reducing postoperative adverse events (with videos)

BACKGROUND

Pancreatic adenoma can potentially transform into adenocarcinoma, so it is recommended to be resected surgically or endoscopically. Endoscopic papillectomy is one of the main treatments for papillary adenoma, and bleeding, perforation, and pancreatitis are the most frequent and critical adverse events that restrict its wider use. There is no standard procedure for endoscopic papillectomy yet. The procedure is relevant to postoperative adverse events.

AIM

To reduce the postoperative adverse event rates and improve patients’ postoperative condition, we developed a standard novel procedure for endoscopic papillectomy.

METHODS

The novel endoscopic papillectomy had two main modifications based on the conventional method: The isolation of bile from pancreatic juice with a bile duct stent and wound surface protection with metal clips and fibrin glue. We performed a single-center retrospective comparison study on the novel and conventional methods to examine the feasibility of the novel method for reducing postoperative adverse events.

RESULTS

A total of 76 patients, of whom 23 underwent the novel procedure and 53 underwent the conventional procedure, were retrospectively evaluated in this study. The postoperative bleeding and pancreatitis rates of the novel method were significantly lower than those of the conventional method (0 vs 20.75%, P = 0.028, and 17.4% vs 41.5%, P = 0.042, respectively). After applying the novel method, the most critical adverse event, perforation, was entirely prevented, compared to a prevalence of 5.66% with the conventional method. Several postoperative symptoms, including fever, rapid pulse, and decrease in hemoglobin level, were significantly less frequent in the novel group (P = 0.042, 0.049, and 0.014, respectively). Overall, the total adverse event rate of the novel method was lower (0 vs 24.5%, P = 0.007) than that of the conventional method.

CONCLUSION

Patients who underwent the novel procedure had lower postoperative adverse event rates. This study demonstrates the potential efficacy and safety of the novel endoscopic papillectomy in reducing postoperative adverse events.

Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients with cirrhosis frequently require sedation for elective endoscopic procedures. Several sedation protocols are available, but choosing an appropriate sedative in patients with cirrhosis is challenging.

AIM

To conduct a systematic review and meta-analysis to compare propofol and midazolam for sedation in patients with cirrhosis during elective endoscopic procedures in an attempt to understand the best approach.

METHODS

This systematic review and meta-analysis was conducted using the PRISMA guidelines. Electronic searches were performed using MEDLINE, EMBASE, Central Cochrane, LILACS databases. Only randomized control trials (RCTs) were included. The outcomes studied were procedure time, recovery time, discharge time, and adverse events (bradycardia, hypotension, and hypoxemia). The risk of bias assessment was performed using the Revised Cochrane Risk-of-Bias tool for randomized trials (RoB-2). Quality of evidence was evaluated by GRADEpro. The meta-analysis was performed using Review Manager.

RESULTS

The search yielded 3,576 records. Out of these, 8 RCTs with a total of 596 patients (302 in the propofol group and 294 in the midazolam group) were included for the final analysis. Procedure time was similar between midazolam and propofol groups (MD: 0.25, 95%CI: -0.64 to 1.13, P = 0.59). Recovery time (MD: -8.19, 95%CI: -10.59 to -5.79, P < 0.00001). and discharge time were significantly less in the propofol group (MD: -12.98, 95%CI: -18.46 to -7.50, P < 0.00001). Adverse events were similar in both groups (RD: 0.02, 95%CI: 0-0.04, P = 0.58). Moreover, no significant difference was found for bradycardia (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.16), hypotension (RD: 0.03, 95%CI: -0.01 to 0.07, P = 0.17), and hypoxemia (RD: 0.00, 95%CI: -0.04 to 0.04, P = 0.93). Five studies had low risk of bias, two demonstrated some concerns, and one presented high risk. The quality of the evidence was very low for procedure time, recovery time, and adverse events; while low for discharge time.

CONCLUSION

This systematic review and meta-analysis based on RCTs show that propofol has shorter recovery and patient discharge time as compared to midazolam with a similar rate of adverse events. These results suggest that propofol should be the preferred agent for sedation in patients with cirrhosis.

Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review

Left ventricular assist devices (LVAD) are increasingly become common as life prolonging therapy in patients with advanced heart failure. Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps. Unfortunately, continuous flow LVADs are fraught with complications such as gastrointestinal (GI) bleeding that are primarily attributed to the formation of arteriovenous malformations. With frequent GI bleeding, antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events. Small bowel bleeds account for 15% as the source and patients often undergo multiple endoscopic procedures. Treatment strategies include resuscitative measures and endoscopic therapies. Medical treatment is with octreotide. Novel treatment options include thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based hormonal therapies, doxycycline, desmopressin and bevacizumab. Current research has explored the mechanism of frequent GI bleeds in this population, including destruction of von Willebrand factor, upregulation of tissue factor, vascular endothelial growth factor, tumor necrosis factor-α, tumor growth factor-β, and angiopoetin-2, and downregulation of angiopoetin-1. In addition, healthcare resource utilization is only increasing in this patient population with higher admissions, readmissions, blood product utilization, and endoscopy. While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages, these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.