Active gastrointestinal bleeding: Use of hemostatic forceps beyond endoscopic submucosal dissection

The Usefulness and Reliability of Coagrasper for Artery Bleeding during Endoscopic Necrosectomy

Although endoscopic necrosectomy (EN) is a less invasive therapy for walled-off necrosis (WON), arterial bleeding can occur during EN. A 60-year-old man with infected WON underwent the EN procedure. During EN, the artery in the WON cavity was injured. As the artery was directly visible, we grasped it using a Coagrasper and coagulated the bleeding point. However, the bleeding was aggravated after coagulation owing to an extension of the vessel damage. The entire vessel was grasped, and complete hemostasis was achieved. The Coagrasper is useful for managing arterial bleeding; however, it should be employed only on the basis of its characteristics and in suitable scenarios.

Piezoelectric Single Crystal Ultrasonic Transducer for Endoscopic Drug Release in Gastric Mucosa

Modern advanced minimally invasive surgery has been implemented for most of the significant gastrointestinal diseases. However, patients with coagulopathy or unresectable tumors cannot be cured by current treatment methods. Moreover, other existing medical devices for targeted drug release are too large to be applied in gastric endoscope because the diameter of the biopsy channel is smaller than 3 mm. To address it, in this work, we developed a piezoelectric single crystal ultrasonic transducer (the diameter was only 2.2 mm and the mass was 0.076 g) to produce acoustic waves, which could promote the drug release in the designed position of the digestive tract through an endoscope. It exhibited the electromechanical coupling coefficient of 0.36 and the center frequency of 6.9 MHz with the -6-dB bandwidth of 23%. In in vitro sonophoresis experiment, the gastric mucosa permeability to Bovine Serum Albumin increased about 5.6 times when the ultrasonic transducer was activated at 40 [Formula: see text] and 60% duty ratio, proving that employment of this transducer could facilitate drug penetration in the gastric mucosa. Meanwhile, the permeability could be adjusted by tuning the duty ratio of the ultrasonic transducer. The corresponding sonophoresis mechanism was related to the acoustic streaming and the thermal effect produced by the transducer. In addition, the measured maximum power density was 128 mW/cm² and the mechanical index of the ultrasonic transducer was 0.02. The results held a great implication for applications of the transducer for targeted drug release in the gastrointestinal tract.

A case of the lower gastrointestinal bleeding due to Dieulafoy’s ulcer in the cecum

Gastrointestinal Dieulafoy’s ulcer is a rare disease of unknown etiology. Dieulafoy’s ulcer often presents in the stomach and is thought to cause about 5% of all gastrointestinal bleeds in adults, but can be found in any part of the gastrointestinal tract. Dieulafoy’s ulcer corresponds to an arterial malformation in the submucosal space and can cause life-threatening hemorrhage. We report a case of the lower gastrointestinal bleeding from a cecal Dieulafoy’s ulcer that was successfully treated with endoscopic clips. An 82-year-old woman had been diagnosed with hypertension and cerebral infarction. She had been using aspirin to prevent recurrent infarction. She was admitted to our hospital with hematochezia. Urgent colonoscopy revealed a small, reddish vascular malformation in the cecum. The lesion was suggestive of Dieulafoy’s ulcer and was treated with endoscopic clips. The patient has since been discharged from our hospital without experiencing any further bleeding. Endoscopy is a useful method for diagnosing and treating Dieulafoy’s ulcer.

Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding

Monopolar hemostatic forceps with soft coagulation (MHFSC) have been compared with hemoclips, heater probe, and argon plasma coagulation (APC) for the treatment of peptic ulcer bleeding. In this systematic review and meta-analysis, we compared MHFSC with other modalities in the treatment of peptic ulcer bleeding. We reviewed MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Scopus from inception to 7 January 2019 to identify studies comparing MHFSC with other modalities for peptic ulcer bleeding. The primary outcome of interest was achievement of initial hemostasis. Secondary outcomes were rebleeding, adverse events, procedure time, and length of hospital stay. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed by I statistic. We included five randomized controlled trials and one observational study comprising 693 patients with endoscopically confirmed actively bleeding ulcers (spurting or oozing) or nonbleeding visible vessel. MHFSC was superior to other modalities in achieving initial hemostasis (OR 0.25; 95% CI 0.08-0.81; I = 67%) and prevention of rebleeding (OR 0.28; 95% CI 0.09-0.86; I = 46%). Rates of adverse events were similar between MHFSC and other modalities. Procedure times were shorter with MHFSC (mean difference -4.15 min; 95% CI -4.83 to -3.47; I= 59%). Length of hospital stay was also shorter with MHFSC. MHFSC appears to be more effective than other modalities for achievement of initial hemostasis and reduction of rebleeding among patients with peptic ulcer bleeding.

Analyses of the Temperature Field of a Piezoelectric Micro Actuator in the Endoscopic Biopsy Channel

Micro actuators have been used to realize the arrival of digestive tract lesions for the local targeted application of drugs in endoscopes. However, there still exists a key safety issue that casts a shadow over the practical and safe implementation of actuators in the human body, namely an overheated environment caused by actuators’ operation. Herein, with the aim of solving the temperature rising problem of a piezoelectric micro actuator operating in an endoscopic biopsy channel (OLYMPUS, Tokyo, Japan), a thermal finite element method (FEM) based on COMSOL Multiphysics software is proposed. The temperature distribution and its rising curves are obtained by the FEM method. Both the simulated and experimental maximum temperatures are larger than the safety value (e.g., 42 °C for human tissues) when the driving voltage of the actuator is 200 Vpp, which proves that the overheating problem really exists in the actuator. Furthermore, the results show that the calculated temperature rising curves correspond to the experimental results, proving the effectiveness of this FEM method. Therefore, we introduce a temperature control method through optimizing the duty ratio of the actuator. In comparison with a 100% duty ratio operation condition, it is found that a 60% duty ratio with a driving voltage of 200 Vpp can more effectively prevent the temperature rising issue in the first 3 min, as revealed by the corresponding temperatures of 44.4 and 41.4 °C, respectively. When the duty ratio is adjusted to 30% or less, the temperature rise of the actuator can be significantly reduced to only 36.6 °C, which is close to the initial temperature (36.4 °C). Meanwhile, the speed of the actuator can be well-maintained at a certain level, demonstrating its great applicability for safe operation in the human body.

Dieulafoy's lesion of the duodenum: a comparative review of 37 cases

Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying epithelium without primary ulceration or erosion. The lesion predominantly occurs in the proximal stomach but it is also reported in extragastric sites. The pathogenesis and precipitating factors are poorly understood. Patients frequently present with gastrointestinal haemorrhage that can range from being self-limited to massive life threatening. Although there are no standard guidelines, endoscopy has significantly impacted the diagnosis and management. This review outlines our current understanding of the epidemiology of and risk factors for Dieulafoy's lesion of the duodenum, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.

Duodenal diverticular bleeding: an endoscopic challenge

Duodenal diverticula are an uncommon cause of upper gastrointestinal bleeding. Until recently, it was primarily managed with surgery, but advances in the field of endoscopy have made management increasingly less invasive. We report a case of duodenal diverticular bleeding that was endoscopically managed, and review the literature about the various endoscopic therapies thus far described.

The Dieulafoy's Lesion: An Update on Evaluation, Diagnosis, and Management

Dieulafoy's lesion (DL) is a persistently wide caliber artery that is observed more frequently at the fifth decade of life in the male population with multiple comorbidities. There are a variety of endoscopic therapies that have been used to treat DL; however, there are no clear guidelines on the best treatment modality. This article systematically reviews the diagnosis, the most commonly reported therapies of DL, and offers a suggested algorithm based upon efficacy of treatment such as initial hemostasis, rebleeding rates, and mortality.

Injection and Cautery Methods for Nonvariceal Bleeding Control

Upper gastrointestinal bleeding remains one of the most common challenges faced by gastroenterologists and endoscopists in daily clinical practice. Endoscopic management of nonvariceal bleeding has been shown to improve clinical outcomes, with significant reduction of recurrent bleeding, need for surgery, and mortality. Early upper gastrointestinal endoscopy is recommended in all patients presenting with upper gastrointestinal bleeding within 24 hours of presentation, although appropriate resuscitation, stabilization of hemodynamic parameters, and optimization of comorbidity before endoscopy are essential.

Management of polypectomy complications

The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.

Management of bleeding and perforation after colonoscopy

Bleeding is a relatively rare complication occurring mainly after snare polypectomy. The majority of cases can be managed successfully by endoscopic means leaving very few cases which will ultimately need an operation. Colonic perforation, on the other hand is a serious complication that requires intensive and careful management. Prompt recognition of the perforation during the procedure allows, in selected cases, immediate endoscopic closure with an uneventful and full recovery followed by close monitoring and surgical management in case of clinical deterioration. The criteria for the right selection of perforation cases amenable to endoscopic treatment do still need to be confirmed by prospective studies and further experience is required before a standard algorithm on the endoscopic management of perforations is developed.

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.