Endoscopic hemostatic spray for uncontrolled bleeding after complicated endoscopic mucosal resection or endoscopic submucosal dissection: a report of 2 cases

ABSTRACT:

Background and Aims

There is a significant bleeding risk after gastric endoscopic submucosal dissection (ESD) and EMR cases. This case series describes the use of an endoscopic hemostasis spray, which is not typically used to treat this type of bleeding, after multiple attempts with other modalities failed.

Methods

We present 2 patient cases of ESD and EMR used to treat a gastric adenoma (case 1) and 2 gastric hyperplastic masses (case 2) with refractory bleeding after use of multiple other treatment modalities. Both patients were not surgical candidates because of their medical comorbidities.

Results

Bleeding was eventually controlled with the use of endoscopic hemostasis spray after attempts were made using SB Knife Jr tip, Coagrasper Hemostatic Forceps, Argon Photocoagulation, and scope tamponade.

Conclusions

In very specific cases, endoscopic hemostasis spray may have some utility for refractory bleeding after dissection of gastric lesions. After using this spray, it became technically challenging to suture endoscopically because of the mud-like quality of the hemostasis material. Video Video 1 • The known fungating, partially circumferential adenoma measuring approximately 5 × 4 cm was found in the posterior wall of the gastric antrum and prepyloric region of the stomach.• The lesion was marked at its periphery with an SB Knife Jr (Olympus America) and then lifted away from the muscularis propria with targeted submucosal injections.• The standard dissection technique was used to separate the tumor from the underlying muscle layers en bloc. The remaining stalk was resected using a snare owing to angulation of the stomach.• Persistent bleeding occurred throughout the procedure and appeared to be from tumor-driven angiogenesis pathology.• Multiple attempts were made to control bleeding, including mechanical tamponade with the SB short knife with the addition of soft coaguation current, argon photo coagulation, and scope tamponade using the endoscope cap.• However, despite use of these hemostatic agents, bleeding persisted, and a decision was made to use a single application of hemostasis spray, which was immediately effective.• Note that clips were not used because there were multiple sites of bleeding and suturing of the lesion was planned.• Subsequently, a dual channel flexible endoscope fitted with the Overstitch suturing device (Apollo Endosurgery) was advanced into position, and the resection site was progressively closed with sutures, which were cinched into place under direct visualization. However, the resection site was only 80% closed because of the adherent and mud-like quality of the hemostasis spray, which made effective suturing problematic, and the case was concluded. Video 2. • This mass lesion was located in the antrum and prepyloric region of the stomach, causing intermittent gastric outlet obstruction with ulcerations (red arrow) and thought to be causing ongoing blood loss. The hyperplastic mass involved the duodenum as well.• The decision was made to resect it using cap-band EMR.• There was continuous venous bleeding after resection. Initially, a snare tip and soft coagulation were used to treat bleeding.• The bleeding persisted, so a thermal hemostasis coagulation grasper was used next. This was initially successful, but then there was recurrent bleeding.• An attempt was made to clip the lesion, but the lesion continued to bleed through the clip.• Hemostasis spray was then used as a salvage method with successful control of the bleeding. Video link

SUBMITTER: Hartz K 

PROVIDER: S-EPMC8503932 | biostudies-literature |

REPOSITORIES: biostudies-literature