Clinical evaluation of emergency endoscopic hemostasis with bipolar forceps in non-variceal upper gastrointestinal bleeding

Coagulation with hemostatic forceps after endoscopic injection sclerotherapy in a pediatric patient with esophageal varices

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Bipolar haemostatic forceps versus standard therapy by haemoclip + / - epinephrine injection as initial endoscopic treatment in active non-variceal upper GI bleeding: study protocol for a prospective, randomized multicentre trial (BeBop-Trial)

BACKGROUND

Patients with active nonvariceal upper gastrointestinal bleeding (NVUGIB) usually require urgent endoscopic treatment. Standard therapy (ST) using haemoclip + / - epinephrine injection is not always successful. Bipolar haemostatic forceps (HemoStat/Pentax®) are an approved medical device for the treatment of gastrointestinal bleeding. However, their use as a primary endoscopic treatment for active NVUGIB has not yet been proven in a randomized prospective study.

METHODS

This is a prospective, randomized, multicentre superiority trial (n ≥ 5). Patients with active NVUGIB will be randomized (1:1) to ST and to experimental therapy (ET) by application of bipolar haemostatic forceps. In the case of failed initial treatment within 15 min, crossover treatment will be attempted first. Rescue treatment (e.g. via over-the-scope-clip) will then be allowed after 30 min. All patients will also receive standard therapy with proton pump inhibitors. Forty-five patients per treatment arm are required to demonstrate an absolute difference of 25.4% with a power of 80% and a significance level of 0.05.

DISCUSSION

The hypothesis of the study is that bipolar haemostatic forceps are superior to ST in terms of successful primary haemostasis and the absence of recurrent bleeding within 30 days (combined endpoint). The 1:1 randomization is also ethically justifiable for this study, as both procedures are approved for the intervention in question. To further increase the safety of the patients in the study, crossover treatment and rescue treatment are planned. The prospective design seems feasible in a reasonable time frame (recruitment period of 12 months), as nonvariceal upper gastrointestinal bleeding is common. Anticoagulants and/or antiplatelet drugs could be an important confounding factor in the statistical analysis that needs to be taken into account and calculated if necessary. In conclusion, this randomized, prospective, multicentre study could make an important contribution to answering the question of whether bipolar haemostatic forceps could be the first-line therapy in the endoscopic treatment of stage Forrest I a + b NVUGIB.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05353062. Registered on April 30 2022.

Current status of endoscopic diagnosis and treatment for superficial non-ampullary duodenal epithelial tumors

Though superficial non-ampullary duodenal epithelial tumors (SNADETs) have been traditionally considered rare, there is a growing detection under the development and widespread of endoscopic techniques in recent times. Many case studies have revealed early manifestations of lesions through advanced endoscopic technology, however, because of the low incidence of duodenal tumors and challenges in diagnosing, the preoperative diagnosis criteria have not been established so far. In spite of this, recently the increasing detection rate of early duodenal epithelial lesions enhances the demand for minimally invasive treatment as well. The most suitable therapeutic endoscopic modality to remove duodenal lesions should be selected according to the size, location and histological invasive depth of duodenal lesions. Nevertheless, due to the special anatomical structure of the duodenum, the incidence of complications is much higher than in any other part of the digestive tract. To prevent these adverse events prophylactically, a few novel strategies have been applied effectively after resection. This review describes the current status of preoperative endoscopic diagnosis and endoscopic resection approaches, as well as countermeasures for avoiding procedure-related complications.

Endoscopic thermocoagulation hemostasis for acute non-varicose upper gastrointestinal hemorrhage: a randomized controlled study

OBJECTIVE

This study evaluated the application of the bipolar electrocoagulation catheter via a peripheral-to-central (3 + 1) technique, relative to directly pressing only at the center of the bleeding site (direct-stroke), to effect endoscopic hemostasis of acute non-varicose gastrointestinal bleeding (ANVUGIB).

METHODS

Patients (n = 148) with endoscopically diagnosed ANVUGIB were randomly apportioned to receive treatment by 3 + 1 (n = 78) or direct-stroke (n = 70) application of the bipolar electrocoagulation catheter. The 3 + 1 strategy required pressing at3 narrowly restricted sites equidistant peripheral and center to the site of bleeding. The rates of initial success, hemostasis time, and number of compressions were compared according to intention-to-treat (ITT) or per protocol (PP).

RESULTS

The ITT (PP) rate of initial hemostatic success in patients receiving the 3 + 1 catheter was 91.02% (95.9%); and for the direct-stroke group was 71.42% (76.9%). For Forrest IIa lesions specifically, these rates were respectively 91.70% (97.1%) and 63.9% (67.6%). The ITT (PP) hemostasis times of the 3 + 1 and direct-stroke groups were 10.96 ± 3.28 (10.65 ± 2.90) and 14.27 ± 6.58 (14.12 ± 6.67) min; and the number of compressions numbered 5.73 ± 1.98 (5.42 ± 1.46) and 6.47 ± 2.82 (6.16 ± 2.47).

CONCLUSION

During thermocoagulation treatment of ANVUGIB via bipolar electrocoagulation catheter, the 3 + 1 strategy showed a significantly higher rate of successful initial hemostasis relative to the direct-stroke technique, and shorter hemostasis time, with no increase in total procedural steps.

Current Challenge: Endoscopic Submucosal Dissection of Superficial Non-ampullary Duodenal Epithelial Tumors

With the widespread use of esophagogastroduodenoscopy in recent years, the detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) is increasing. Most SNADETs are early-stage adenocarcinoma or benign conditions, including adenoma. Therefore, endoscopic resection is desirable from the perspective of quality of life. However, endoscopic resection for SNADETs has not yet been established. Endoscopic submucosal dissection (ESD) is the most promising method for the treatment of SNADETs, because ESD provides a high rate of en bloc resection and a low rate of recurrence regardless of the tumor size. However, the difficulty of the procedure and a high rate of severe adverse events including perforation and bleeding have become major problems. Various preventive countermeasures for adverse events, such as use of specific devices, endoscope stabilization methods, and endoscopic closure of the post-ESD ulcer using clips, are reported to reduce the risk of the adverse events of ESD for SNADETs. This article reviews and highlights the current state of ESD for SNADETs and new challenges towards safe and effective ESD.

Novel mouthpiece for reducing the gag reflex during esophagogastroduodenoscopy

BACKGROUND AND AIM

Discomfort associated with the gag reflex during transoral endoscopy can be troublesome. To overcome this problem during esophagogastroduodenoscopy (EGD), we recently developed a novel mouthpiece. The aim of the present study was to compare acceptance and tolerability of transoral EGD with conventional and new mouthpieces in unsedated patients and analyze the effects of the new mouthpiece.

METHODS

This study consisted of two phases of cephalometric and EGD examinations to analyze the effects of the new mouthpiece. Cephalometry was carried out in six subjects to evaluate differences in the size of the pharynx (anteroposterior diameter of the oropharynx and longitudinal diameter of the oral cavity) when subjects held the conventional mouthpiece (MAJ674) or the new mouthpiece in their mouths. EGD was done in 10 subjects using the conventional or new mouthpiece to evaluate the number of times the gag reflex occurred, examinee discomfort, and endoscope operability during EGD using a visual analogue scale (VAS).

RESULTS

Anteroposterior diameter of the oropharynx and longitudinal diameter of the oral cavity were significantly larger with the new mouthpiece than with the conventional mouthpiece (oropharynx: P = 0.03; oral cavity: P = 0.03). With the new mouthpiece during EGD, subjects had significantly fewer instances of the gag reflex (P = 0.01); VAS score for discomfort was significantly lower (P < 0.01) and score for endoscope operability was significantly higher (P = 0.04).

CONCLUSION

The new mouthpiece we developed reduced the gag reflex during EGD by extending the pharynx, thus decreasing examinee discomfort and increasing endoscopic operability.

Safety of endoscopic procedures with monopolar versus bipolar instruments in an ex vivo porcine model

Background

Monopolar instruments are generally used in colorectal endoscopic mucosal resection (EMR). Bipolar instruments have previously been reported to be as safe as monopolar instruments. We sought to compare the safety of the monopolar and bipolar snare and hemostatic forceps in an animal model.

Methods

We created 5-mm, 10-mm, and 15-mm target lesions on an ex vivo porcine rectum. Two lesions of each size were resected via monopolar polypectomy (M-P), monopolar EMR (M-E), bipolar polypectomy (B-P), and bipolar EMR (B-E). We performed a pathological evaluation of the conditions of perforation and the effects of burning on the tissues. In addition, we burned the muscularis propria covered with submucosal layer using monopolar and bipolar hemostatic forceps and performed pathological evaluations.

Results

Polypectomy and EMR were performed in a total of 24 target lesions. A perforation was found on histology in one case of M-P and one case of M-E after removing target lesions of 15 mm in diameter. There were no perforations during endoscopic resection using the bipolar snare. The thermal denaturation in B-P did not reach the muscularis propria layer regardless of the size of the target lesion. Although thermal damage after using monopolar hemostatic forceps was extensive, thermal denaturation was only seen on the surface of the submucosal layer when bipolar hemostatic forceps were used.

Conclusions

Bipolar instruments cause less damage to the tissue than monopolar instruments. Our results also suggest that bipolar instruments may be safer than monopolar instruments in endoscopic procedures for colorectal lesions.

Effectiveness of Endoscopic Hemostasis with Soft Coagulation for Non-Variceal Upper Gastrointestinal Bleeding over a 12-Year Period

BACKGROUND/AIMS

In this study, investigations were carried out to ascertain whether soft coagulation hemostasis for non-variceal upper gastrointestinal bleeding (UGIB) has ever been performed in a time-dependent manner.

METHODS

Medical records of 502 patients who had undergone emergency endoscopic hemostasis for non-variceal UGIB from 2003 to 2014 were checked and the modalities were used to achieve hemostasis compared between the first period from 2003 to 2008 (197 patients) and the second period from 2009 to 2014 (305 patients).

RESULTS

Endoscopic hemostasis was successfully achieved in 96.0% of study patients. Peptic ulcers were the main cause of bleeding (89.4%). Endoscopic hemostasis was performed by soft coagulation significantly more frequently during the second (71.1%) than the first period (11.7%; p < 0.001). Endoscopic hemostasis was mainly achieved by trainees during the second period (76.1%); these trainees comprised a significantly greater proportion of endoscopists than during the first period (56.3%; p < 0.001). Endoscopic-related complications did not differ between the 2 periods. The only risk factor for rebleeding after hemostasis was Helicobacter pylori infection; the use of soft coagulation and the fact that endoscopists were just trainees were not risk factors.

CONCLUSION

Our findings suggest that using soft coagulation to achieve endoscopic hemostasis for non-variceal UGIB is safe and effective, even when it is performed by trainees.

Clinical Backgrounds and Outcomes of Elderly Japanese Patients with Gastrointestinal Bleeding

OBJECTIVE

Elderly gastrointestinal bleeding (GIB) patients sometimes cannot be discharged home. In some cases, they die after hemostasis, even following appropriate treatment. This study investigates the clinical backgrounds and outcomes of elderly Japanese GIB patients.

METHODS

The medical records of 185 patients (123 men, 62 women; mean age 68.2 years; range 10-99 years) with GIB symptoms who underwent esophagogastroduodenoscopy or colonoscopy to detect or treat the source of GIB were retrospectively reviewed. We compared the outcomes between patients ≤70 (n=85) and >70 (n=100) years. The clinical backgrounds of the patients who died or changed hospitals to undergo rehabilitation or receive palliative care were evaluated, as were the association of four factors with these poor outcomes: GIB (re-bleeding or uncontrolled bleeding), endoscopic procedure-related complications, exacerbation of the pre-existing comorbidity, and any complications that were not directly related to GIB.

RESULTS

Of the patients ≤70 and >70 years of age, three (3.5%) and 17 (17.0%), respectively, were transferred to another hospital (p=0.003). One (1.2%) and five (5.0%), respectively, died (p=0.144). All three patients ≤70 years old that changed hospitals did so because their comorbidities became worse. The reasons for changing hospitals in the 17 patients >70 years of age included exacerbation of a pre-existing comorbidity (41.1%, 7/17), other complications (35.4%, 6/17), GIB itself (17.6%, 3/17), and endoscopic procedure-related complications (5.9%, 1/17).

CONCLUSION

Although non-elderly and elderly GIB patients had similar mortality rates, many more elderly patients could not be discharged home for various reasons.

Duodenal ESD: conquering difficulties

Duodenal endoscopic submucosal dissection (ESD) is technically difficult due to the unique anatomic features. The risks include intraprocedural complications, delayed bleeding, and perforation. A small-caliber-tip transparent hood is useful. Mechanical stretching of the submucosal tissue allows safe dissection and effective prevention of bleeding with minimum muscle injury under direct visualization of the submucosal tissue and blood vessels. A short double-balloon endoscope is useful to stabilize control of the endoscope tip in distal duodenal ESD. Selection of ESD in the duodenum should be made cautiously considering both benefits and risks of the procedure.

Low-dose aspirin and comorbidities are significantly related to bleeding peptic ulcers in elderly patients compared with nonelderly patients in Japan

OBJECTIVE

The present study was conducted using data accumulated from our earlier study of bleeding peptic ulcers, focusing on elderly patients.

METHODS

A total of 461 patients with bleeding peptic ulcers underwent emergency endoscopy at Saga Medical School Hospital between 1999 and 2011. Risk factors for bleeding peptic ulcers were compared between two groups: an elderly group (≥65 years old) and a nonelderly group (<65 years old). The relationship between drug use and age was examined using multiple logistic regression models. In the elderly group, the factors were compared between Period I (1999-2005) and Period II (2006-2011).

RESULTS

The proportion of men and the incidence of Helicobacter pylori infection were lower in the elderly group than in the nonelderly group. The use of low-dose aspirin, antithrombotic drugs and corticosteroids, but not nonsteroidal anti-inflammatory drugs, was higher in the elderly group. A multiple logistic regression analysis of prescribed medications indicated that low-dose aspirin was more frequently used in the elderly group. The rate of comorbidities was higher and the hemoglobin levels were lower in the elderly group. The rates of rebleeding within one week and death within one month did not differ in the elderly group. Compared with that observed in Period I, the incidence of Helicobacter pylori infection was decreased and the rate of comorbidities was increased in Period II.

CONCLUSION

This study indicates that factors related to bleeding peptic ulcers in elderly patients have shifted from Helicobacter pylori infection to comorbidities associated with low-dose aspirin, suggesting a close relationship between low-dose aspirin therapy and comorbidities in elderly patients with peptic ulcers.

Clinical features of gastroduodenal injury associated with long-term low-dose aspirin therapy

Low-dose aspirin (LDA) is clinically used for the prevention of cardiovascular and cerebrovascular events with the advent of an aging society. On the other hand, a very low dose of aspirin (10 mg daily) decreases the gastric mucosal prostaglandin levels and causes significant gastric mucosal damage. The incidence of LDA-induced gastrointestinal mucosal injury and bleeding has increased. It has been noticed that the incidence of LDA-induced gastrointestinal hemorrhage has increased more than that of non-aspirin non-steroidal anti-inflammatory drug (NSAID)-induced lesions. The pathogenesis related to inhibition of cyclooxygenase (COX)-1 includes reduced mucosal flow, reduced mucus and bicarbonate secretion, and impaired platelet aggregation. The pathogenesis related to inhibition of COX-2 involves reduced angiogenesis and increased leukocyte adherence. The pathogenic mechanisms related to direct epithelial damage are acid back diffusion and impaired platelet aggregation. The factors associated with an increased risk of upper gastrointestinal (GI) complications in subjects taking LDA are aspirin dose, history of ulcer or upper GI bleeding, age > 70 years, concomitant use of non-aspirin NSAIDs including COX-2-selective NSAIDs, and Helicobacter pylori (H. pylori) infection. Moreover, no significant differences have been found between ulcer and non-ulcer groups in the frequency and severity of symptoms such as nausea, acid regurgitation, heartburn, and bloating. It has been shown that the ratios of ulcers located in the body, fundus and cardia are significantly higher in bleeding patients than the ratio of gastroduodenal ulcers in patients taking LDA. Proton pump inhibitors reduce the risk of developing gastric and duodenal ulcers. In contrast to NSAID-induced gastrointestinal ulcers, a well-tolerated histamine H2-receptor antagonist is reportedly effective in prevention of LDA-induced gastrointestinal ulcers. The eradication of H. pylori is equivalent to treatment with omeprazole in preventing recurrent bleeding. Continuous aspirin therapy for patients with gastrointestinal bleeding may increase the risk of recurrent bleeding but potentially reduces the mortality rates, as stopping aspirin therapy is associated with higher mortality rates. It is very important to prevent LDA-induced gastroduodenal ulcer complications including bleeding, and every effort should be exercised to prevent the bleeding complications.

Endoscopic submucosal dissection--current success and future directions

More than 10 years have passed since endoscopic submucosal dissection (ESD) was first developed in Japan. ESD enables en bloc complete resection of superficial gastrointestinal neoplasms regardless of the size and location of the lesions. With improvements in techniques and devices, excellent therapeutic results have been achieved despite the inherent technical difficulties of this procedure. ESD aiming for curative treatment can be performed for gastrointestinal neoplasms without risk of lymph node metastasis. Accurate histopathologic examination of the resected specimen is required to determine the risk of lymph node metastasis, for which en bloc resection is beneficial. Owing to the high success rate of en bloc complete resection and accurate histopathologic examination, tumour recurrence rates after ESD are reported to be very low in Japan. Excellent results of ESD in a large number of cases have also been reported from other Asian countries such as South Korea, Taiwan and China. Although scepticism exists among Western clinicians regarding the application of ESD, it is developing slowly and reports indicate promising results in some European countries. With further development of technologies, such as endoscopic robotics, ESD could become the worldwide treatment of choice for early gastrointestinal neoplasms.

Supportive techniques and devices for endoscopic submucosal dissection of gastric cancer

The indications for endoscopic treatment have expanded in recent years, and relatively intestinal-type mucosal stomach carcinomas with a low potential for metastasis are now often resected en bloc by endoscopic submucosal dissection (ESD), even if they measure over 20 mm in size. However, ESD requires complex maneuvers, which entails a long operation time, and is often accompanied by complications such as bleeding and perforation. Many technical developments have been implemented to overcome these complications. The scope, cutting device, hemostasis device, and other supportive devices have been improved. However, even with these innovations, ESD remains a potentially complex procedure. One of the major difficulties is poor visualization of the submucosal layer resulting from the poor countertraction afforded during submucosal dissection. Recently, countertraction devices have been developed. In this paper, we introduce countertraction techniques and devices mainly for gastric cancer.

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.