Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding

Efficacy of hemostasis by gastroduodenal covered metal stent placement for hemorrhagic duodenal stenosis due to pancreatobiliary cancer invasion: a retrospective study

BACKGROUND/AIMS

Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis.

METHODS

Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival.

RESULTS

The technical and clinical success rates were 100%. All 10 patients achieved a gastric outlet obstruction scoring system score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20-220 days) and 66.5 days (range, 31-220 days), respectively.

CONCLUSIONS

Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life.

Application of a New Hemostatic Clip to Prevent Delayed Bleeding After Endoscopic Sphincterotomy: A Propensity Score-matched Analysis

BACKGROUND AND AIM

Delayed bleeding after endoscopic sphincterotomy (ES) is a serious adverse event of endoscopic retrograde cholangiopancreatography. The aim of this study is to evaluate the effect of prevent delayed bleeding of hemostatic clip (Sureclip) after ES.

METHODS

Consecutive patients diagnosed with common bile duct stones with a high risk of delayed bleeding who received ES from January 1, 2013, to July 31, 2022, were analyzed retrospectively. A 1:1 propensity score-matching analysis and logistic regression analysis were used. The patients were allocated into the hemostatic clip and control groups. The rate of delayed bleeding, hyperamylasemia, pancreatitis, and hemostatic clip closing the bile duct or pancreatic duct by mistake were compared between the 2 groups.

RESULTS

Overall, 161 and 232 patients were allocated to the control and hemostatic clip groups, respectively, propensity score matching created 120 matched pairs. The rate of delayed bleeding was significantly lower in the hemostatic clip group than in the control group (1.67% vs. 7.5%, P =0.031). After adjusting for confounding factors, logistic regression showed hemostatic clip was associated with decreased odds of delayed bleeding (0.134, 95% CI: 0.025-0.719). No case of hemostatic clip closing the bile duct or pancreatic duct by mistake occurred in the hemostatic clip group. No significant differences were observed in postoperative hyperamylasemia and pancreatitis between the 2 groups.

CONCLUSIONS

This study indicated that the prophylactic application of a hemostatic clip is associated with a significantly reduced rate of delayed bleeding after ES in high-risk patients. This approach did not increase the risk of adverse event.

Hemostasis for postendoscopic sphincterotomy hemorrhage using a stone exaction balloon filled with ice-cold water

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Endoscopic Hemostatic Treatment with a Novel Self-Assembling Peptide Gel for Precut Fistulotomy-Related Bleeding

Introduction

Precut fistulotomy is of interest as one of the salvage techniques for selective bile duct cannulation using endoscopic retrograde cholangiopancreatography. Of the various endoscopic treatments reported to date for bleeding associated with papillotomy incision, endoscopic hemostasis treatment with a novel self-assembling peptide (SAP) matrix-forming gel (TDM-621) (3-D Matrix Ltd., Tokyo, Japan) remains only insufficiently reported in the literature.

Case Presentation

We herein report 6 cases of precut fistulotomy-related bleeding successfully treated with endoscopic hemostasis treatment with TDM-621, i.e., 5 and 1 cases during and after precut fistulotomy, respectively, in 2 males and 4 females aged 68-96 years (mean age, 85 years), 3 of whom had been on antithrombotic drugs. Types of bleeding treated included oozing bleeding (n = 5) and oozing bleeding from a visible vessel (n = 1). In all cases, complete hemostasis was achieved with TDM-621 without causing rebleeding.

Conclusion

Endoscopic hemostasis with TDM-621 may prove effective for precut fistulotomy-related bleeding and represent a potential modality of first choice in hemostasis. In addition, endoscopic hemostasis with combined modality therapy using TDM-621 and endoscopic hemoclips may prove effective for bleeding from visible vessels.

Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

Comparison of Endoscopic Hemostasis for Endoscopic Sphincterotomy Bleeding between a Novel Self-Assembling Peptide and Conventional Technique

Introduction: Recently, a novel self-assembling peptide hemostatic gel has become available in Japan. However, the safety and efficacy of this novel self-assembling peptide hemostatic gel remain unclear for bleeding after EST. The aim of this study was to evaluate the safety and efficacy of a novel self-assembling peptide hemostatic gel for bleeding after EST, and to perform a comparison to a conventional endoscopic hemostasis technique. Method: This retrospective study was carried out between January 2019 and October 2022. Patients who developed bleeding associated with EST were enrolled. The patients were divided into two groups based on the hemostasis technique used: a conventional hemostasis technique (Group A) or a novel self-assembling peptide hemostatic gel hemostasis technique (Group B). Result: A total of 62 patients (Group A, n = 36; Group B, n = 26) were included. Endoscopic hemostasis was initially obtained in 72.2% (26/32) of patients in Group A and in 88.4% (23/26) of patients in Group B, which was not significantly different (p = 0.1320). However, the procedure time was significantly shorter in Group B (mean, 9.38 min) compared with Group A (mean, 15.4 min) (p = 0.0103). There were no significant differences in the severity of bleeding between the two groups (p = 0.4530). Post-EST bleeding was observed in six patients (Group A, n = 4; Group B, n = 2). Adverse events were more frequently observed in Group A (n = 12) than in Group B (n = 1) (p = 0.0457). Conclusions: PuraStat application for EST bleeding might be safe and effective, and is comparable to the conventional endoscopic hemostasis technique, although further prospective randomized trials are needed.

Pancreatic cancer with pseudoaneurysm after duckbill-shaped anti-reflux metal stent placement: A case report

A 74-year-old man was diagnosed with unresectable pancreatic cancer with obstructive jaundice. Chemotherapy with gemcitabine and nab-paclitaxel was initiated after placement of a duckbill-shaped anti-reflux metal stent (D-ARMS). A period of 1 month after D-ARMS placement, the patient developed hematemesis and entered severe shock following emergency admission for further evaluation. Contrast-enhanced computed tomography revealed a pseudoaneurysm in the gastroduodenal artery, coincident with the site of D-ARMS placement, and bleeding from the same site was diagnosed. Angiography was performed, and the pseudoaneurysm was successfully treated by transcatheter arterial embolization using coils. The patient was subsequently discharged from hospital and experienced no further bleeding until his death due to an aggravation of the pancreatic cancer after 2 months. We report a case of pancreatic cancer with pseudoaneurysm after D-ARMS placement.

Successful hemostasis for post-endoscopic sphincterotomy bleeding following endoscopic papillary large balloon dilation using 12-mm-diameter fully covered self-expandable metal stent

A 12-mm-diameter fully covered self-expandable metal stent may be effective for securing hemostasis in post-endoscopic sphincterotomy bleeding following endoscopic papillary large balloon dilation.

Endoscopic-catheter-directed infusion of diluted (-)-noradrenaline for atypical hemobilia caused by liver abscess: A case report

BACKGROUND

Hemobilia occurs when there is a fistula between hepatic blood vessels and biliary radicles, and represents only a minority of upper gastrointestinal hemorrhages. Causes of hemobilia are varied, but liver abscess rarely causes hemobilia and only a few cases have been reported. Here, we present a case of atypical hemobilia caused by liver abscess that was successfully managed by endoscopic hepatobiliary intervention through endoscopic retrograde cholangiopancreatography (ERCP).

CASE SUMMARY

A 54-year-old man presented to our emergency department with a history of right upper quadrant abdominal colic and repeated fever for 6 d. Abdominal sonography and enhanced computed tomography revealed that there was an abscess in the right anterior lobe of the liver. During hospitalization, the patient developed upper gastrointestinal bleeding. Upper gastrointestinal endoscopy revealed a duodenal ulcer bleeding that was treated with three metal clamps. However, the hemodynamics was still unstable. Hence, upper gastrointestinal endoscopy was performed again and fresh blood was seen flowing from the ampulla of Vater. Selective angiography did not show any abnormality. An endoscopic nasobiliary drainage (ENBD) tube was inserted into the right anterior bile duct through ERCP, and subsequently cold saline containing (-)-noradrenaline was infused into the bile duct lumen through the ENBD tube with no episode of further bleeding.

CONCLUSION

Hemobilia should be considered in the development of liver abscess, and endoscopy is essential for diagnosis and management of some cases.

A case of refractory tumor bleeding from an ampullary adenocarcinoma: Compression hemostasis with a self‐expandable metallic stent

Although patients with ampullary cancers frequently experience obstructive jaundice and tumor bleeding, there have been few reports on efficient management of refractory hemorrhage after conservative treatment. In this report, we describe a case of refractory bleeding from a 15‐mm ampullary adenocarcinoma. A Japanese woman in her 60s was urgently hospitalized for cholangitis, pancreatitis, and sepsis treatment. Investigation with a side‐viewing duodenoscope revealed an ulcerated ampullary adenocarcinoma. After the patient underwent anticoagulation therapy for pulmonary thromboembolism, the tumor bleeding gradually increased, resulting in severe anemia. Because the anemia did not improve with fasting or discontinuation of the anticoagulation therapy, the patient underwent repeated red blood cell transfusions. As no hemobilia was observed in the bile juice aspirated during endoscopic retrograde cholangiography, we supposed that the bleeding originated from the ulcerative cancer surface. We did not perform thermal therapy because we considered that it would worsen the bleeding. Abdominal angiography showed no pseudoaneurysms or extravasation. Ultimately, we performed transpapillary placement of a fully covered self‐expandable metallic stent (SEMS) with an anchoring double pigtail plastic stent that resulted in successful hemostasis. In this case, the mechanism of hemostasis was not presumably explained by direct compression of the bleeding point but by indirect compression. When tumor volume is small, the radial force of the SEMS may cause compression of the tumor volume, leading to shrinkage of the bleeding blood vessels. In conclusion, covered SEMS placement could be an efficient treatment for refractory ampullary cancer bleeding, even from an ulcerated cancer surface.

Novel Hemostatic Gel As Rescue Therapy for Postsphincterotomy Bleeding Refractory to Self-Expanding Metallic Stent Placement

Endoscopic sphincterotomy (ES) is commonly performed during endoscopic retrograde cholangiopancreatography, and bleeding is a severe adverse event. PuraStat is a peptide developed as a hemostatic agent for endoscopy. We report its use as a hemostatic strategy in post-ES bleeding refractory to combined hemostasis. A patient with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography for stone removal. After the ES, severe bleeding refractory to the injection of diluted epinephrine around the bleeding source and metal stent placement occurred. Hemostasis was achieved with the application of the hemostatic gel. We reported the use of novel self-assembling hemostatic gel as an effective therapeutic tool for post-ES refractory bleeding.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

Hemostatic materials in wound care

Blood plays an essential role in the human body. Hemorrhage is a critical cause of both military and civilian casualties. The human body has its own hemostatic mechanism that involves complex processes and has limited capacity. However, in emergency situations such as battlefields and hospitals, when the hemostatic mechanism of the human body itself cannot stop bleeding effectively, hemostatic materials are needed for saving lives. In this review, the hemostatic mechanisms and performance of the most commonly used hemostatic materials, (including fibrin, collagen, zeolite, gelatin, alginate, chitosan, cellulose and cyanoacrylate) and the commercial wound dressings based on these materials, will be discussed. These materials may have limitations, such as poor tissue adhesion, risk of infection and exothermic reactions, that may lessen their hemostatic efficacy and cause secondary injuries. High-performance hemostatic materials, therefore, have been designed and developed to improve hemostatic efficiency in clinical use. In this review, hemostatic materials with advanced performances, such as antibacterial capacity, superhydrophobicity/superhydrophilicity, superelasticity, high porosity and/or biomimicry, will be introduced. Future prospects of hemostatic materials will also be discussed in this review.

Biliary Self-Expandable Metal Stent Could Be Recommended as a First Treatment Modality for Immediate Refractory Post-Endoscopic Retrograde Cholangiopancreatography Bleeding

Background/Aims

Recent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding.

Methods

Patients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis.

Results

A total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min.

Conclusions

Temporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.

Practical Experiences of Unsuccessful Hemostasis with Covered Self-Expandable Metal Stent Placement for Post-Endoscopic Sphincterotomy Bleeding

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Early Covered Self-Expandable Metal Stent Placement Is Effective for Massive Post-endoscopic Sphincterotomy Bleeding

BACKGROUND

Placement of covered self-expandable metallic stent (CSEMS) for post-endoscopic sphincterotomy (ES) bleeding achieves excellent hemostasis results. Although CSEMS placement is typically performed after failure of conventional endoscopic combination therapy, its excellent outcomes may justify earlier placement.

AIMS

We aimed to examine the efficacy of "early" CSEMS placement for massive post-ES bleeding.

METHODS

The medical records of 2750 patients who underwent ES between 2005 and 2019 were reviewed retrospectively, and 61 patients who developed massive post-ES bleeding were enrolled. These patients were divided into those who underwent early CSEMS placement (E-CSEMS group) and those who underwent conventional endoscopic combination therapy (Conventional group). The outcomes of hemostasis procedures were compared between the groups.

RESULTS

The primary success rates of endoscopic hemostasis were 100% (21/21) and 98% (39/40) in the E-CSEMS group and Conventional group, respectively, without significant differences (P = 1.000). However, in the E-CSEMS group, re-bleeding was significantly less frequent (5% vs. 31%; P = 0.023), the median hemostasis procedure time was significantly shorter (14 min vs. 26 min; P < 0.001), and transfusion after initial hemostasis treatment was less commonly required (10% vs. 38%; P = 0.034). Multivariate analyses showed that hemodialysis was associated with a significantly higher re-bleeding rate (P = 0.029), while CSEMS placement was associated with a significantly lower re-bleeding rate (P = 0.039).

CONCLUSIONS

Early CSEMS placement may be effective for improving the clinical outcomes of massive post-ES bleeding by decreasing re-bleeding and the extent of bleeding.

Antiplatelet and/or anticoagulant treatment does not increase hemorrhagic adverse events during EUS-guided biliary drainage

BACKGROUND AND AIMS

No data appear to have been reported regarding bleeding risk among patients receiving antiplatelet and/or anticoagulant treatment (AP/AC) during EUS-guided biliary drainage (BD) procedures. The aim of this study was to assess whether hemorrhagic adverse events associated with EUS-BD are increased in patients on AP/AC.

METHODS

Patients receiving AP/AC who underwent EUS-BD were retrospectively enrolled between May 2015 and August 2019. Patients who did not receive AP/AC and underwent EUS-BD in the same period were also enrolled as a control group.

RESULTS

One hundred ninety-five patients who underwent EUS-BD were enrolled in this study. Among these, 154 patients were allocated to the control group and 41 patients to the AP/AC group. Overall frequency of adverse events did not differ significantly between the control group (16.2%, 25/154) and AC/AP group (17.1%, 6/41; P = .80). The overall bleeding event rate was 3.6% (7/195), with no significant difference between the 2 groups. No thromboembolic events were observed with or without interruption of AP/AC. According to logistic regression analysis, the use of AP/AC was not a risk factor significantly associated with bleeding events (odds ratio, 2.96; 95% confidence interval, .56-14.0; P = .18). On the other hand, a long procedure time (>20 minutes) was an independent risk factor associated with bleeding events.

CONCLUSIONS

Bleeding events appear to be infrequent among patients who undergo EUS-BD while continuing AP/AC.

Is insertion of a plastic stent better and safer than epinephrine injection in post sphincterotomy bleeding?

OBJECTIVES

Epinephrine injection is the therapy of first choice in post sphincterotomy bleeding (PSB), but may not be efficient in all cases and can cause postprocedural myocardial infarction. Plastic stent insertion (PSI) may be a better treatment. The aim of this retrospective study was to compare epinephrine injection with PSI with respect to efficacy and safety.

METHODS

Clinical success, number of reinterventions and hospital stays after therapy, postprocedural myocardial infarction, bilirubin increase, and pancreatitis as well as factors influencing PSB were analyzed.

RESULTS

Seventy-nine PSBs in 5798 endoscopic retrograde cholangiopancreaticographies (ERCPs) from August 2002 through October 2018 were treated by epinephrine injection, PSI or both (n = 34, 30, 15). Clinical success of PSB therapy showed no difference: 33/34 (97%), 30/30 (100%), 14/15 (93%). Reinterventions were more frequent (n = 30 versus n = 1; P ≤ 0.0001) and hospital stay was longer [median: 3 (2-10) versus 2 (1-3) days; P = 0.0357] in patients who received PSI (versus epinephrine injection). Postprocedural adverse events were very rare: bilirubin increase (1/2/0) and pancreatitis (0/2/1). Intraprocedural episodes of hypertension (≥180 mmHg) were documented in 45-54%.

CONCLUSIONS

Epinephrine injection is better than PSI in PSB. PSI may be an adequate treatment in patients with otherwise indicated stent insertion. Intraprocedural episodes of hypertension may be a risk factor for PSB.

Biliary tract bleeding with obstructive jaundice after endoscopic ultrasound-guided fine-needle aspiration of a pancreatic head tumor

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe procedure and extraintestinal bleeding after EUS-FNA is rare. Two cases of biliary tract bleeding after EUS-FNA was reported, but no case of biliary hemorrhage with obstructive jaundice after EUS-FNA of pancreatic head tumor has been reported. We discuss one such case, the pitfalls encountered during EUS-FNA and how they were overcome.

CASE PRESENTATION

A 78-year-old man suspected of pancreatic head cancer was introduced to our hospital for pathological examination by EUS-FNA. Because he took antithrombotic drugs, we performed EUS-FNA after withdrawal of the drugs and replacement by heparin. The next day after EUS-FNA, obstructive jaundice was suspected by hematologic examination. Endoscopic retrograde cholangio-pancreatography was carried out and biliary tract bleeding was observed. We diagnosed obstructive jaundice due to hemobilia and inserted an endonasal biliary drainage tube. During the following period, the bleeding stopped and total bilirubin decreased. On the 15th hospital day, he was transferred to another hospital for pre-operative examination.

CONCLUSION

Biliary tract bleeding after EUS-FNA is quite rare but endosonographers must appreciate and deal appropriately with this adverse event.

Complications of endoscopic retrograde cholangiopancreatography: an imaging review

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist's armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

Biliary endoscopic sphincterotomy: Techniques and complications

Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

Factors associated with delayed hemorrhage after endoscopic sphincterotomy: Japanese large single-center experience

BACKGROUND

Hemorrhage is one of the serious adverse events of endoscopic sphincterotomy (EST). However, the risk factors for delayed hemorrhage after EST have not been clarified. The aim of this study was to examine the risk factors for delayed hemorrhage after EST.

METHODS

Consecutive patients who underwent EST between January 2011 and December 2015 were analyzed retrospectively. The incidence, treatment outcomes, and risk factors for delayed hemorrhage were evaluated. Delayed hemorrhage was defined as symptomatic hemorrhage occurring 24 h after an endoscopic procedure.

RESULTS

After analyzing 1113 patients who underwent EST, delayed hemorrhage was seen to occur in 30 (2.7%) patients. The median period before presentation of delayed hemorrhage was 2 days (range 1-6) after EST, and its severity was mild in four, moderate in 20, and severe in six patients. All patients with delayed hemorrhage received successful endoscopic hemostasis. Univariate analysis showed that delayed hemorrhage occurred more frequently in patients with hemodialysis (p = 0.013), heparin replacement of antithrombotic agents (p = 0.012), or early hemorrhage occurring just after EST (p < 0.001). Among these, hemodialysis (OR 6.44, 95% CI 1.67-24.8; p = 0.007), heparin replacement (OR 3.76, 95% CI 1.42-9.98; p = 0.008), and early hemorrhage (OR 4.35, 95% CI 1.90-9.96; p < 0.001) proved to be independent risk factors for delayed hemorrhage on multivariate analysis.

CONCLUSIONS

The incidence of delayed hemorrhage after EST was 2.7%. Hemodialysis, heparin replacement, and early hemorrhage were the risk factors for delayed hemorrhage.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding

GOAL AND BACKGROUND

A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia.

STUDY

A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia.

RESULTS

The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option.

CONCLUSIONS

With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

Endoscopic radiofrequency ablation combined with fully covered self-expandable metal stent for inoperable periampullary carcinoma in a liver transplant patient: A case report

RATIONALE

Postliver transplant periampullary carcinoma is an extremely uncommon disease.

PATIENT CONCERNS

Cutaneous jaundice in a patient who had received a liver transplant 4 years earlier.

DIAGNOSIS

Periampullary carcinoma.

INTERVENTIONS

Radiofrequency ablation plus fully covered self-expanding metal stents (FCSEMS).

OUTCOMES

The treatment of malignant neoplasm of the ampulla of Vater is the patient by radiofrequency ablation plus FCSEMS placement was successful. No complications occurred.

LESSONS

This is the first reported case of a liver transplant patient with inoperable periampullary carcinoma successfully treated by radiofrequency ablation plus FCSEMS placement. Our experience will be useful to other surgeons in managing similar patients in the future.

Comparing endoscopic intervention against fully covered self-expanding metal stent placement for post-endoscopic sphincterotomy bleed (CEASE Study)

Background and study aims: Limited data exist for the use of fully covered self-expanding metal stent (FCSEMS) as an intervention for immediate bleeds post-endoscopic sphincterotomy (ES) after primary endoscopic intervention failure or to reduce the number of delayed bleeding events in patient with increased risk of bleeding post-ES. Patients and methods: We evaluated a retrospective cohort of individuals who had ES performed from 2011 to 2014. A total of 700 patients were identified with 67 patients having post-ES bleeding. The FCSEMS treatment group included 23 patients and the non-FCSEMS treatment group included 44 patients. The primary end point was rate of change of Hgb at 72 hours after ES in the FCSEMS group and the primary endoscopic intervention-only group. A comparison also was made between the FCSEMS and non-FCSEMS group with regards to proportion of coagulopathy and number of delayed bleeding events. Results: The FCSEMS treatment group had a lower bleeding rate at 72 hours (0.66 g/dL vs 1.98 g/dL P < 0.001), increased proportion of patients at high risk of bleeding (40 % vs 9 % P value 0.008), and increased frequency of bleeding events that were moderately severe (52 % vs 9 % P = 0.0002) compared to the non-FCSEMS treatment group. The FCSEMS group included 9 patients at increased risk of bleeding and no patients with delayed bleed compared to the non-FCSEMS group, in which all 4 patients at increased risk of bleeding developed a delayed bleed. Conclusion: FCSEMS can provide homeostasis after primary endoscopic intervention failure, thus reducing the need for high-risk procedures. FCSEMS can reduce delayed bleeding events in patients at high risk of post-ES bleeding.

New Endoscopic Technologies and Procedural Advances for Endoscopic Hemostasis

Endoscopic interventions are first-line therapy for upper and lower gastrointestinal bleeding. Injection therapy in combination with a second endoscopic modality has reduced re-bleeding, need for surgery and mortality in non-variceal bleeding. For variceal bleeding endoscopic banding or cyanoacrylate injection techniques are recommended interventions. However, despite ease of application and general acceptance of these techniques, there is an ongoing re-bleeding rate associated with significant in-hospital mortality. We discuss current literature on new advances in endoscopic technologies and procedural techniques that have emerged to improve patient outcomes.

Biliary hemostasis using an endoscopic plastic stent placement for uncontrolled hemobilia caused by transpapillary forceps biopsy (with video)

A 78-year-old woman was referred to our hospital for the examination and treatment of jaundice. A transpapillary forceps biopsy for a long distal bile duct stricture was performed using endoscopic retrograde cholangiopancreatography. Immediately after the biopsy, massive bleeding was observed from the orifice of the papilla. Although hemobilia was pulsatile, an endoscopic biliary plastic stent placement was very effective in achieving hemostasis. However, a nasal biliary catheter was required because a blood clot clogged the stent on the following day. Although covered self-expandable metal stent (CSEMS) placement has been reported for achieving endoscopic hemostasis for bleeding, we chose to use a plastic stent to reduce the risk of post-procedure pancreatitis. The placement of both an endoscopic biliary plastic stent and a nasobiliary drainage catheter can be an alternative hemostatic tool to CSEMSs.

Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis. ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation (EPLBD) with a size of 15 mm. Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla. Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis. Therefore, we placed a 10 mm fully covered self-expandable metallic stent (SEMS) across the duodenal papilla, and the hemorrhage stopped immediately. After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct. A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct. We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.

Novel biliary self-expanding metal stents: indications and applications

Endoscopic insertion of a self-expanding metal stent (SEMS) through a malignant common bile duct stricture is the first line of palliation for malignant jaundice. Patency of these stents remains a major concern. SEMS dysfunction can result from tumor ingrowth, overgrowth and/or clogging. Initial SEMS modifications involved covering the central part of the stent in order to reduce ingrowth and ultimately increase patency. Fully covered stents became available shortly after reports of their use in human patients. The potential removability and radial strength of SEMS have led to evaluation of their use in new indications including benign biliary strictures, post sphincterotomy bleeding and perforation. Other aspects of development include the addition of features such as anti-reflux valves, drug elution and spontaneous biodegradability. These aspects and their clinical implications are reviewed and discussed.

Achieving hemostasis and the risks associated with therapy

Acute gastrointestinal bleeding is a common cause for hospitalization. Endoscopic hemostasis plays a central role in the management of lesions with active bleeding or high-risk stigmata for rebleeding. The efficacy and safety of endoscopic hemostasis rely on the identification of lesions suitable for endoscopic therapy, selection of the appropriate hemostatic devices, attention to technique, and prompt recognition and management of procedure-related adverse events. In this article, practical applications of hemostatic devices and pitfalls related to endoscopic hemostasis are discussed.

Endoscopic retrograde cholangiopancreatography-related adverse events: general overview

Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.

Emerging endoscopic therapies for nonvariceal upper gastrointestinal bleeding

Several new devices and innovative adaptations of existing modalities have emerged as primary, adjunctive, or rescue therapy in endoscopic hemostasis of gastrointestinal hemorrhage. These techniques include over-the-scope clip devices, hemostatic sprays, cryotherapy, radiofrequency ablation, endoscopic suturing, and endoscopic ultrasound-guided angiotherapy. This review highlights the technical aspects and clinical applications of these devices in the context of nonvariceal upper gastrointestinal bleeding.

Endoscopic haemostasis: an overview of procedures and clinical scenarios

Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.

Emergencies after endoscopic procedures

Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

Highlights of international digestive endoscopy network 2013

Rapid advances in the technology of gastrointestinal endoscopy as well as the evolution of science have made it necessary for us to continue update in either various endoscopic techniques or state of art lectures relevant to endoscopy. International Digestive Endoscopy Network (IDEN) 2013 was held in conjunction with Korea-Japan Joint Symposium on Gastrointestinal Endoscopy (KJSGE) during June 8 to 9, 2013 at Seoul, Korea. Two days of impressive scientific program dealt with a wide variety of basic concerns from upper gastrointestine (GI), lower GI, pancreaticobiliary endoscopy to advanced knowledge including endoscopic submucosal dissection forum. IDEN seems to be an excellent opportunity to exchange advanced information of the latest issues on endoscopy with experts from around the world. In this special issue of Clinical Endoscopy, we prepared state of art review articles from contributing authors and the current highlights will skillfully deal with very hot spots of each KJSGE, upper GI, lower GI, and pancreaticobiliary sessions by associated editors of Clinical Endoscopy.

Factors affecting the success of endoscopic treatment of sphincterotomy bleeding

BACKGROUND AND AIM

Endoscopic methods are effective in the control of endoscopic sphincterotomy (ES) bleeding. Initial failure or recurrent bleeding may develop in some patients, which may require angiographic or surgical interventions. We aimed to determine the factors leading to failure of endoscopic treatment methods.

METHODS

Forty-six patients (1.37%) had endoscopic and/or clinically significant bleeding among a total of 3354 ESs (2998 primary, 356 re-ES) performed within 3 years. Forty-one patients (21 immediate, 20 late onset bleeding) underwent endoscopic treatment. Nineteen patients were treated initially by epinephrine injection and 22 with heat probe. The relation between demographic, laboratory parameters, presence of comorbidity, cholangitis, coagulopathy, and juxtapapillary diverticula, pre-cutting, type of ES, time and pattern of bleeding, treatment modality, the success and relapse of endoscopic treatment were evaluated.

RESULTS

The first method was successful in the treatment of bleeding in 18 patients with heat probe and epinephrine injection, each. Presence of cholangitis, coagulopathy and increased international normalized ratio (INR) levels were found to determine the success of first treatment method. Bleeding could be stopped in all of the patients either with initially preferred or combined methods. Five patients developed recurrent bleeding. Presence of cholangitis, coagulopathy, increased INR levels, low thrombocyte counts and performance of precutting were factors predicting recurrence. Both of the treatment methods were 100% effective in patients without coagulopathy and none of the patients developed recurrent bleeding.

CONCLUSIONS

Treatment of ES bleeding in patients with high risks such as coagulopathy require new effective methods. Patients with coagulopathy must be carefully followed for the development of recurrent bleeding.

Post-sphincterotomy bleeding: fully-covered metal stents for hemostasis

BACKGROUND/OBJECTIVES

In endoscopic retrograde cholangiopancreatography, post-sphincterotomy bleeding (PSB) is a common complication of biliary sphincterotomy. Recently, the temporary placement of fully-covered metal stents (FCMS) into the biliary tree in order to achieve a tamponade effect has been described as an additional therapeutic option for PSB. The aim of this article is to review the literature on FCMS for hemostasis in PSB and update the treatment algorithm for this complication.

METHODS

A PubMed literature search was conducted using the search terms post-sphincterotomy, bleeding, and stent. 33 articles were reviewed, along with their references, and four were found to describe the use of FCMS for hemostasis in PSB.

RESULTS

A total of 21 patient cases were described in the four articles. All patients received FCMS for PSB hemostasis following the application and subsequent failure of traditional therapies (conventional pharmacologic injection, thermal or electrocoagulation, and mechanical therapy (balloon tamponade or endoclip)). Successful hemostasis was achieved in all patients through FCMS placement. No major complications were observed.   

CONCLUSION

These 21 cases demonstrate that FCMS are a viable therapeutic option for PSB.  It is reasonable to consider stent placement for patients in which traditional interventions fail in order to avoid the need for angiographic or surgical hemostasis.

Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent

Background

Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.

Case presentation

We report a case of an immediate internal spurting arterial bleeding precipitated during EUS-guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self-expandable metal stent through mechanical hemostasis.

Conclusion

In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during pseudocyst drainage, the placement of an expandable metal stent proved to be useful.