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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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2
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Sebastian SA, Co EL, Panthangi V, Bansal R, Narayanan V, Paudel S, Raja R, Padda I, Mohan BP. Colonic diverticular bleeding: An update on pathogenesis and management. Dis Mon 2023; 69:101543. [PMID: 36918300 DOI: 10.1016/j.disamonth.2023.101543] [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: 03/14/2023]
Abstract
Colonic diverticular bleeding is the most common cause of lower gastrointestinal (GI) bleeding, which can be life-threatening and frequently recurrent. In recent years, the prevalence of diverticulosis has increased in developed countries, with a documented incidence of 50% in patients older than 60 years. Based on the evidence, the use of anticoagulants and/or antiplatelets in the elderly population has resulted in an increased incidence of acute diverticular bleeding. According to the literature, about 50% of patients with diverticular bleeding require a blood transfusion, and 18% - 53% need emergency surgery. Although endoscopic identification of the culprit diverticula and appropriate intervention is a challenge, the newer treatment modality, over-the-scope clip method (OTSC) has been demonstrated to be an effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures. In this review, we summarize the pathophysiology of colonic diverticulosis and diverticular bleeding, recent evidence in its management, and existing theories on various preventive strategies to control diverticular bleeding. We also discuss the efficacy and treatment outcome of the OTSC technique in controlling diverticular bleeding.
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Affiliation(s)
| | - Edzel Lorraine Co
- University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines
| | | | - Radha Bansal
- Government Medical College & Hospital, Chandigarh, India
| | | | | | - Rabab Raja
- All Saints University School of Medicine, Dominica
| | - Inderbir Padda
- Richmond University Medical Center, Staten Island, New York, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah School of Medicine, Utah, USA
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3
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Kuellmer A, Mangold T, Bettinger D, Schiemer M, Mueller J, Wannhoff A, Caca K, Wedi E, Kleemann T, Thimme R, Schmidt A. Reduced mortality for over-the-scope clips (OTSC) versus surgery for refractory peptic ulcer bleeding: a retrospective study. Surg Endosc 2023; 37:1854-1862. [PMID: 36253626 PMCID: PMC10017662 DOI: 10.1007/s00464-022-09679-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgery or transcatheter arterial embolization or are both considered as standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-The-Scope clips (OTSC) have shown superiority to standard endoscopic treatment but a comparison with surgery has not been performed, yet. PATIENTS AND METHODS In this retrospective, multicenter study, 103 patients treated with OTSC (n = 66) or surgery (n = 37) for refractory PUB in four tertiary care centers between 2009 and 2019 were analyzed. Primary endpoint was clinical success (successful hemostasis and no rebleeding within seven days). Secondary endpoints were adverse events, length of ICU-stay and in-hospital mortality. Univariable and multivariable regression models were performed to define predictive factors for allocation to surgical therapy and for mortality. RESULTS Age, comorbidities, anticoagulation therapy, number of pretreatments, ulcer location, and Rockall-Score were similar in both groups. In the surgical group, there were significantly more patients in shock at rebleeding (78.1% vs. 43.9%; p = 0.002), larger ulcers (18.6 ± 7.4 mm vs. 23.0 ± 9.4 mm; p = 0.017) and more FIa bleedings (64.9% vs. 19.7%; p < 0.001) were detected. Clinical success was comparable (74.2% vs. 83.8%; p = 0.329). In the surgical group, length of ICU-stay (16.2 ± 18.0 days vs. 4.7 ± 6.6 days; p < 0.001), severe adverse events (70.3% vs. 4.5%; p < 0.001) and in-hospital mortality (35.1% vs. 9.1%; p = 0.003) were significantly higher. Multivariable analysis defined shock at rebleeding as the main predictor for allocation to surgical therapy (OR 4.063, 95%CI {1.496-11.033}, p = 0.006). Postsurgical adverse events were the main reason for the in-hospital mortality (OR 5.167, 95% CI {1.311-20.363}, p = 0.019). CONCLUSION In this retrospective study, OTSC compared to surgical treatment showed comparable clinical success but was associated with shorter ICU-stay, less severe adverse events and lower in-hospital mortality.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Tobias Mangold
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Moritz Schiemer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Julius Mueller
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Andreas Wannhoff
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Medizinische Klinik II / IV, Sana Klinikum Offenbach, Offenbach, Germany
| | - Tobias Kleemann
- Medinische Klinik IV, Carl-Thiem-Klinikum Cottbus, Cottbus, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
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Kuellmer A, Mangold T, Bettinger D, Maruschke L, Wannhoff A, Caca K, Wedi E, Hosseini ASA, Kleemann T, Schulz T, Jung C, Thimme R, Schmidt A. Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis. United European Gastroenterol J 2021; 9:1048-1056. [PMID: 34432392 PMCID: PMC8598957 DOI: 10.1002/ueg2.12135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/02/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment. OBJECTIVE To compare OTSC treatment to TAE in refractory peptic ulcer bleeding. PATIENTS AND METHODS In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics. RESULTS Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant. CONCLUSIONS OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tobias Mangold
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Dominik Bettinger
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
- Berta‐Ottenstein‐ProgrammeUniversity of FreiburgFreiburgGermany
| | - Lars Maruschke
- Department of RadiologySt.‐Josef HospitalRkK‐KlinikumFreiburgGermany
| | - Andreas Wannhoff
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Karel Caca
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Edris Wedi
- Medizinische Klinik II / IVSana Klinikum OffenbachOffenbachGermany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional RadiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Tobias Kleemann
- Medinische Klinik IVCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Thomas Schulz
- Institut für RadiologieCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy UnitForlì‐Cesena HospitalsAUSL RomagnaForlì‐CesenaItaly
| | - Robert Thimme
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Arthur Schmidt
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
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5
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Silva JC, Pinho R, Gomes AC, Leite S, Carvalho J. Bleeding malignant gastric ulcer: successful endoscopic hemostasis with an over-the-scope clip. VideoGIE 2020; 5:146-147. [PMID: 32258844 PMCID: PMC7125396 DOI: 10.1016/j.vgie.2019.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- João Carlos Silva
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Rolando Pinho
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Ana Catarina Gomes
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Sónia Leite
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - João Carvalho
- Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
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Goenka MK, Rodge GA, Tiwary IK. Endoscopic Management with a Novel Over-The-Scope Padlock Clip System. Clin Endosc 2019; 52:574-580. [PMID: 31766822 PMCID: PMC6900306 DOI: 10.5946/ce.2019.122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background/Aims: The Padlock clip is a recently introduced over-the-scope clip (OTSC) that requires the use of an alternate technique and has a different design from previous OTSCs. However, data regarding its clinical use are limited. The aim of this study is to present our clinical experience using this novel Padlock clip system.
Methods: Between September 2018 and June 2019, 7 consecutive patients underwent Padlock clip application at our center by an experienced endoscopist. A Padlock clip was used for achieving hemostasis in 4 patients presenting with gastrointestinal (GI) bleeding, as well as for endoscopic full-thickness resection in the remaining 3 patients.
Results: All 7 patients achieved technical as well as clinical success, with absence of complications or rebleeding, during a follow-up of a minimum of 3 weeks. All patients were hospitalized post procedure for a minimum of 48 hours, and an absence of adverse events was noted in our patient population throughout the procedure and post-procedure period. Antiplatelet therapy was reinstated shortly after the application of the Padlock clip, with no GI bleeding observed.
Conclusions: The Padlock clip is a novel OTSC, with benefits that include safe, simple, and rapid deployment. Antiplatelet therapy may be reinstated for patients, when necessary, shortly after applying the Padlock clip due to full-thickness closure of the tissue.
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Affiliation(s)
- Mahesh Kumar Goenka
- Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata, India
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Weiland T, Rohrer S, Schmidt A, Wedi E, Bauerfeind P, Caca K, Khashab MA, Hochberger J, Baur F, Gottwald T, Schurr MO. Efficacy of the OTSC System in the treatment of GI bleeding and wall defects: a PMCF meta-analysis. MINIM INVASIV THER 2019; 29:121-139. [PMID: 30957599 DOI: 10.1080/13645706.2019.1590418] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.
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Affiliation(s)
| | | | - Arthur Schmidt
- Faculty of Medicine, Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Goettingen, Germany
| | - Peter Bauerfeind
- Department of Gastroenterology and Hepatology, Triemli Hospital, Zurich, Switzerland
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MA, USA
| | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Berlin, Germany
| | | | - Thomas Gottwald
- Ovesco Endoscopy AG, Tuebingen, Germany.,Medical Faculty, Eberhard Karls University, Tuebingen, Germany
| | - Marc O Schurr
- Ovesco Endoscopy AG, Tuebingen, Germany.,Steinbeis University, Berlin, IHCI-Institute, Tuebingen, Germany
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Wedi E, Ho CN, Conrad G, Weiland T, Freidinger S, Wehrmann M, Meining A, Ellenrieder V, Gottwald T, Schurr MO, Hochberger J. Preclinical evaluation of a novel thermally sensitive co-polymer (LiftUp) for endoscopic resection. MINIM INVASIV THER 2019; 28:277-284. [PMID: 30663522 DOI: 10.1080/13645706.2018.1535440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Endoscopic resection techniques can successfully resect large lesions either in "en bloc" fashion or in "piece-meal" technique by using a submucosal injection solution. The aim of this study was to evaluate the safety of a novel injectable, containing thermally sensitive co-polymer from ethylenoxide and propylenoxide (LiftUp) used as submucosal injection solution.Material and methods: We conducted an in vivo animal trial in the porcine model to evaluate the LiftUp gel in a preclinical setting and to study the effectiveness of mucosal lifting and the safety of the new injectable. In seven animals a total of 63 injections and endoscopic resections were carried out in different anatomical locations (esophagus, stomach and rectum). The resection sites were controlled endoscopically one and four weeks after resection and a histopathological evaluation of the resection sites was performed after four weeks.Results: The application of LiftUp was safe and there were no negative effects on wound healing after injection and resection. A major procedural complication rate (defined as perforation and major haemorrhage) of 3.2% was registered, which undercuts the anticipated mean complication rate of 4-8%. Furthermore, there was no necessity of reinjection after the initial submucosal injection in 90.5% and no procedural complications in 98.8%. The histopathological examination of the tissue samples indicated normal wound healing with granulation tissue and epithelialisation.Conclusion: The use of LiftUp as submucosal injection solution was feasible for different endoscopic resection techniques, with high and long-lasting elevation and fewer procedural adverse events than expected at trial planning. The new injectable is a practical advancement over the current state-of-the-art of submucosal injection and could fasten up the resection procedure and make endoscopic 'en bloc' resection safer.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre, Goettingen, Germany
| | | | | | - Timo Weiland
- Novineon CRO & Consulting Ltd, Tuebingen, Germany
| | | | | | - Alexander Meining
- Interventional and Experimental Endoscopy (InExEn), Medizinische Klinik I, University Medical Centre Ulm, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre, Goettingen, Germany
| | | | | | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University, Berlin, Germany
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