Comparison of hemostasis using bipolar hemostatic forceps with hemostasis by endoscopic hemoclipping for nonvariceal upper gastrointestinal bleeding in a prospective non-randomized trial

Background

We previously reported on the safety and efficacy of bipolar hemostatic forceps for treating nonvariceal upper gastrointestinal (UGI) bleeding. However, no prospective or randomized studies have evaluated the efficacy of bipolar hemostatic forceps. The aim of this study was to evaluate the hemostatic efficacy of using bipolar hemostatic forceps compared with the hemostatic efficacy of the commonly used method of endoscopic hemoclipping for treating nonvariceal UGI bleeding.

Methods

A total of 50 patients who required endoscopic hemostasis for UGI bleeding were divided into two groups: those who underwent endoscopic hemostasis using bipolar hemostatic forceps (Group I) and those who underwent endoscopic hemostasis by endoscopic hemoclipping (Group II). We compared the two groups in terms of hemostasis success rate and time required to achieve hemostasis and stop recurrent bleeding.

Results

All (100 %) of 27 patients in Group I and 18 (78.2 %) of 23 patients in Group II were successfully treated using bipolar hemostatic forceps or by endoscopic hemoclipping alone, respectively, indicating a significantly higher success rate for Group I than for Group II (p < 0.05). The time required to achieve hemostasis was 6.8 ± 13.4 min for Group I and 15.4 ± 17.0 min for Group II. One patient in Group I (3.7 %) and four patients in Group II (22.2 %) experienced recurrent bleeding.

Conclusion

Bipolar hemostatic forceps was more effective than endoscopic hemoclipping for treating nonvariceal UGI bleeding.     

Use of hemostatic forceps as a preoperative rescue therapy for bleeding peptic ulcers

Standard endoscopic management of bleeding peptic ulcers includes injection, thermal coagulation, or mechanical clipping. The use of hemostatic forceps has increased with the widespread use of endoscopic submucosal dissection to control bleeding. However, there are few reports on the use of hemostatic forceps to control bleeding peptic ulcers. From January to October 2010, four hundred twenty-seven patients received endoscopic therapy at our institution for bleeding peptic ulcers. In 5 patients hemostasis was achieved with hemostatic forceps as a rescue therapy after standard endoscopic therapy had failed. In 4 patients successful hemostasis was achieved, whereas 1 patient had to undergo emergency surgery. We found that hemostatic forceps are a useful alternative for the control of bleeding peptic ulcers after standard endoscopic treatment has failed. This treatment may help in avoiding the necessity of surgery. Further large-scale studies are required to confirm our observations.     

Non-surgical approach to bleeding gastric ulcer

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest's classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001 - December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them (31.1)-1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60% male and 40% female) with a mean age of 64.3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest's classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26.34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no--steroid antinflammatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.     

Changes in surgical strategies for peptic ulcers before and after the introduction of H2-receptor antagonists and endoscopic hemostasis

A total of 902 surgical patients with peptic ulcer disease were evaluated to clarify the effects of H₂-receptor antagonists and endoscopic hemostasis on surgical treatment. Following the introduction of these treatments to our institute in 1982, the number of operations performed annually decreased by 40%, or 36 cases per year. However, a remarkable increase in the frequency of surgical emergency intervention since 1982 was concurrently observed, with the ratio of emergency procedures to the total number of operated cases increasing to 72.5% in the last 5 years of the study. Moreover, intractability as an indication for surgery decreased to 34.1%, compared with an increase in the number of patients with bleeding and perforated ulcers requiring operation. There were 13 postoperative deaths recorded (1.4%). All of the deaths were in patients who had undergone emergency surgery in poor health. Of these 13 patients, 10 had bleeding ulcers. A study of bleeding ulcers for which endoscopic hemostasis had been unsuccessful revealed that shock on admission and a concomitant medical condition had been evident in all the patients who died, and in 52.2% and 30.4% of the survivors, respectively. The current study suggests that the frequency of high-risk patients requiring surgery is increasing since the introduction of H₂-receptor antagonists and endoscopic hemostasis, and thus, prompt surgical treatment and intensive management for such patients is essential.     

Principles of medical care of patients with gastrointestinal ulcer hemorrhage]

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.     

Surgical management of peptic ulcer disease today – indication, technique and outcome

Aims: The current surgical management of peptic ulcer disease and its outcome have been reviewed. Results: Today, surgery for peptic ulcer disease is largely restricted to the treatment of complications. In peptic ulcer perforation, a conservative treatment trial can be given in selected cases. If laparotomy is necessary, simple closure is sufficient in the large majority of cases, and definitive ulcer surgery to reduce gastric acid secretion is no longer justified in these patients. Laparoscopic surgery for perforated peptic ulcer has failed to prove to be a significant advantage over open surgery. In bleeding peptic ulcers, definitive hemostasis can be achieved by endoscopic treatment in more than 90% of cases. In 1–2% of cases, immediate emergency surgery is necessary. Some ulcers have a high risk of re-bleeding, and early elective surgery might be advisable. Surgical bleeding control can be achieved by direct suture and extraluminal ligation of the gastroduodenal artery or by gastric resection. Benign gastric outlet obstruction can be controlled by endoscopic balloon dilatation in 70% of cases, but gastrojejunostomy or gastric resection are necessary in about 30% of cases. Conclusions: Elective surgery for peptic ulcer disease has been largely abandoned, and bleeding or obstructing ulcers can be managed safely by endoscopic treatment in most cases. However, surgeons will continue to encounter patients with peptic ulcer disease for emergency surgery. Currently, laparoscopic surgery has no proven advantage in peptic ulcer surgery. Received: 11 January 2000 Accepted: 12 January 2000     

腹腔镜治疗胃十二指肠急性大出血的体会

目的:探讨腹腔镜手术治疗胃十二指肠急性大出血的应用价值及手术技巧。方法:回顾分析2010年8月至2012年1月5例胃十二指肠急性大出血患者经胃镜确诊并初步止血后行腹腔镜手术的临床资料。其中胃窦巨大溃疡出血2例,十二指肠球后溃疡出血、胃底溃疡出血、胃间质瘤胃镜活检后出血各1例。结果:5例患者经胃镜确诊并初步止血后急诊行腹腔镜手术,疗效良好,无一例围手术期死亡,术后无手术相关并发症发生。结论:腹腔镜手术治疗胃十二指肠急性大出血术中能快速处理病灶,止血效果确切,具有较高的治疗价值。     

Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques

Background

Through-the-scope clips are commonly used for endoscopic hemostasis of gastrointestinal (GI) bleeding, but their efficacy can be suboptimal in patients with complex bleeding lesions. The over-the-scope clip (OTSC) could overcome the limitations of through-the-scope clips by allowing compression of larger amounts of tissue, allowing a more efficient hemostasis. We analyzed the use of OTSC in a consecutive case series of patients with acute GI bleeding unresponsive to conventional endoscopic treatment modalities.

Methods

In a retrospective analysis of prospectively collected data in tertiary referral centers, patients undergoing emergency endoscopy for severe acute nonvariceal GI bleeding were treated with the OTSC after failure of conventional techniques. All patients underwent repeat endoscopy 2–4 days after the procedure. Data analysis included primary hemostasis, complications, and 1-month follow-up clinical outcome.

Results

During a 10-month period, 30 patients entered the study consecutively. Bleeding lesions unresponsive to conventional endoscopic treatment (saline/adrenaline injection and through-the-scope clipping) were located in the upper and lower GI tract in 23 and 7 cases, respectively. Primary hemostasis was achieved in 29 of 30 cases (97 %). One patient with bleeding from duodenal bulb ulcer required emergent selective radiological embolization. Rebleeding occurred in two patients 12 and 24 h after the procedure; they were successfully treated with conventional saline/adrenaline endoscopic injection.

Conclusions

OTSC is an effective and safe therapeutic option for severe acute GI bleeding when conventional endoscopic treatment modalities fail.     

Endoscopic flushing electrocoagulation for upper gastrointestinal bleeding--an alternative to surgery

Twenty-three patients, mean age of 65 years, planned for emergency surgery because of upper gastrointestinal bleeding, were electrocoagulated with an endoscopic Storz monopolar flushing electrode. Nineteen patients were managed successfully. Two out of twelve patients with gastric ulcer and both patients with gastrojejunal ulcer bleeding needed an operation. The overall success rate was 82% and the mortality was 9%. According to this study endoscopic monopolar flushing liquid electrocoagulation is a good alternative to surgery in upper gastrointestinal bleedings except gastrojejunal ulceration.     

Treatment of gastroduodenal ulcer bleedings in a general hospital of emergency care

Treatment of patients with gastroduodenal ulcer bleedings in a general hospital of emergency care is a complex of measures including of endoscopic diagnosis and stopping of bleeding, use of effective antisecretory drugs with obligatory laboratory control of acid-producing function of the stomach, surgical treatment and eradication of H. pylori. Up-to-date methods of endoscopic hemostasis - spirituous infiltration, argon-plasma coagulation, clipping of vessels in ulcer and also their combination in difficult cases - provide reliable hemostasis and allow to avoid urgent surgery. Recently we succeeded in reducing the rate of urgent surgeries performed at the height of bleedings from 70 to 40%. These methods can be recommended for clinical practice because they reduce significantly lethality rates in patients with severe conditions.     

不同内镜止血方法治疗老年消化性溃疡出血的效果比较

目的：评价不同内镜止血方法治疗老年消化性溃疡出血的效果。方法回顾性分析2008年1月～2013年12月在北京大学首钢医院住院并接受内镜治疗的80例老年消化性溃疡出血患者的临床及内镜检查资料,病变出血征象采用Forrest分级。内镜止血治疗方法包括内镜下肾上腺素注射（54例）和金属钛夹治疗（26例）。结果进行内镜治疗的病变均为Forrest Ⅰa～Ⅱb级。与内镜下肾上腺素注射组相比,金属钛夹治疗组的内镜治疗成功率更高（96.2％与87.0％）,再出血发生率更低（7.7％与14.8％）,临床症状消失时间更短[（2.3±0.6）d与（3.4±1.1）d],住院天数更短[（7.8±0.9）d与（11.5±2.4）d],差异均有统计学意义。结论内镜下金属钛夹止血治疗老年消化性溃疡出血的有效性和安全性均优于肾上腺素注射治疗。     

Laser photocoagulation of bleeding gastric and duodenal ulcer

Laser photocoagulation of bleeding ulcer is one of the effective methods of endoscopic hemostasis. Experimental studies were carried out on resected stomach preparation. The preparations were studied histologically. Clinical trial was conducted in 43 patients with gastric and duodenal ulcer for hemostasis and prophylaxis of recurrent bleeding. Initial endoscopic hemostasis was successful in all the patients. Relapse of bleeding was seen in 4 patients. Overall efficacy of laser hemostasis was 90.7%. It is concluded that laser photocoagulation is one of effective and convenient methods of endoscopic hemostasis.     

Hemorrhagic gastro-duodenal ulcers. In which cases should emergency surgery be performed?]

From January 1983 to December 1987, 127 patients with bleeding peptic ulcer were admitted to hospital. The mean age of the 85 males was 57 years and 72 years for 42 females. All but four of the patients were managed medically after emergency endoscopy. Twenty-seven patients required surgical operations (21.2%): seven for cataclysmic haemorrhage, eight for persistent haemorrhage, twelve for recurrent bleeding. An analysis of factors leading to the necessity of surgical haemostasis was undertaken by considering the clinical status, endoscopic findings and laboratory results. The size of the ulcer (greater than 2 cm) was the most significant parameter (less than 0.01). Five other criteria (rectal bleeding) shock, endoscopic signs of recent haemorrhage, gastric or duodenal posterior ulcer) were also significant (p less than 0.05). Considering the gravity of these patients (six deaths among twenty-seven), clinical trials in bleeding peptic ulcer disease should only include patients in the high risk group.     

透明帽用于消化内镜止血治疗的护理配合

目的探讨透明帽在消化内镜止血治疗中的作用及护理配合方法。方法对86例消化道出血患者实施内镜止血治疗,均于内镜下找到出血点后安装透明帽,其中32例消化道溃疡底部动脉或Dieulafoy病出血者选用带侧孔的透明帽电凝止血,21例贲门黏膜撕裂综合征出血者选用不带侧孔的透明帽以金属夹止血,33例食管胃静脉曲张者选用带侧孔的透明帽注射硬化剂止血,同时加强术前准备、术中配合及术后观察护理。结果 86例均顺利完成内镜治疗并取得较好的止血效果,无相关并发症发生;术后3~6个月内镜复查,出血部位瘢痕形成,2例食管胃静脉曲张患者再出血,第2次给予硬化剂注射联合套扎治疗止血成功;余84例无复发出血。结论透明帽用于消化内镜止血治疗效果好,并发症少,护理人员熟练掌握其性能和操作,能缩短操作时间,提高治疗效果。     

How evidence-based are current guidelines for managing patients with peptic ulcer bleeding?

Current guidelines for managing ulcer bleeding state that patients with major stigmata should be managed by dual endoscopic therapy (injection with epinephrine plus a thermal or mechanical modality) followed by a high dose intravenous infusion of proton pump inhibitors (PPIs). This paper aims to review and critically evaluate evidence supporting the purported superiority of a continuous infusion over less intensive regimens of PPIs administration and the need for adding a second hemostatic endoscopic procedure to epinephrine injection. Systematic searches of PubMed, EMBASE and the Cochrane library were performed. There is strong evidence for an incremental benefit of PPIs over H2-receptor antagonists or placebo for the outcome of patients with peptic ulcer bleeding following endoscopic hemostasis. However, the benefit of PPIs is unrelated to either the dosage (intensive vs standard regimen) or the route of administration (intravenous vs oral). There is significant heterogeneity among the 15 studies that compared epinephrine with epinephrine plus a second modality, which might preclude the validity of reported summary estimates. Studies without second look endoscopy plus re-treatment of re-bleeding lesions showed a significant benefit of adding a second endoscopic modality for hemostasis, while studies with second-look and re-treatment showed equal efficacy between endoscopic mono and dual therapy. Inconclusive experimental evidence supports the current recommendation of the use of dual endoscopic hemostatic means and infusion of high-dose PPIs as standard therapy for patients with bleeding peptic ulcers. Presently, the combination of epinephrine monotherapy with standard doses of PPIs constitutes an appropriate treatment for the majority of patients.     

Recurrence of acute gastroduodenal ulcer bleedings

Multifactor analysis of 818 cases of acute gastroduodenal ulcer bleedings (clinical and laboratory examination, gastroscopy, morphological studies) was carried out, 97 of these patients had recurrence of bleeding. It is demonstrated that recurrence of gastroduodenal ulcer bleeding is cause by progressed ischemic necrosis in periulcerous zone in condition of local hypoperfusion as a result of systemic hemodynamic disorders due to acute blood loss syndrome and chronic ischemia dueto ulcerous process. Systemic hemostatic therapy, antisecretory drugs, methods of endoscopic hemostasis don't guarantee absence of bleeding recurrence. Prognosis of the recurrence must be based on assessment of significant clinical and gastroscopic data. Dynamical determination of pO2 in periulcerous zone is an additional prognostic criterion. Recurrence of gastroduodenal ulcer bleeding increases general and postoperative lethality 2 times as minimum. Active surgical policy based on prognosis of bleeding recurrence probability permitted us to reduce total lethality in acute gastroduodenal ulcer bleedings to 6.2%, postoperative lethality to 8.5%.     

Diagnosis and therapy of gastrointestinal hemorrhage

In the upper gastrointestinal tract endoscopic hemostasis has not replaced surgery, but reduced it to a necessary minimum. Active bleeding can be stanched by the injection method during emergency endoscopy. For bleeding esophageal varices we use polidocanol, in other lesions in the upper gastrointestinal tract we apply thrombin and in the lower intestinal tract adrenalin. If endoscopic hemostasis is successful in small bleeding vessels, the efficiency of hemostatic injections can be trusted. Large visible vessels need to be operated early electively. After the introduction of this therapeutic concept, for example the operation frequency in bleeding gastroduodenal ulcers could be reduced from 51% in 1982 to 28% in 1988. Mortality was improved from 22.1% to 4.7%. In gastrointestinal bleeding diagnostic problems occur especially with angio dysplasia in the small intestine and colon. This is due to impaired accessibility in the small intestine and problematic cleaning of the colon. In the intestine surgical therapy of bleeding lesions has very few alternatives, for example palliative embolization of infusion of vasoconstrictiva.     

Differential treatment of gastroduodenal ulcerous bleedings

Results of treatment of 827 patients with bleedings from chronic gastric and duodenal ulcers are analyzed. Potentialities of various methods of endoscopic hemostasis were studied. Diathermocoagulation was the least effective method of hemostasis (59%). Irrigation of the bleeding source provided hemostasis in 88.7% patients, combined methods - in 94.1%. Methods of irrigation are appropriate in diffuse bleeding from ulcer (Forrest 1B). Stream bleeding (Forrest 1A) is indication for combined methods of hemostasis. It is demonstrated that type of endoscopic procedure does not influence rate of bleeding recurrences. The main element of conservative treatment of gastroduodenal ulcerous bleedings is antisecretory therapy. Proton pump blockers are more effective than H2-blockers; the rate of recurrences was 5.0 and 28.9%, respectively. Prediction of bleeding recurrences and preventive operations are the main way to treatment results improvement.     

原发性肝癌自发性破裂出血的急诊处治体会

目的 总结原发性肝癌自发性破裂出血急诊处治的经验,提高对该病的认识、诊断及治疗水平.方法 回顾分析资阳市第一人民医院2008年10月-2012年12月共收治11例原发性肝癌自发性破裂病例的临床资料.结果 3例患者给予内科保守治疗,其中1例死亡,2例患者出血停止,后行肝动脉化疗栓塞术;8例患者行急诊手术.手术仍是急诊处治的主要方法,术后效果明确,1例肝肿瘤切除术后1d死亡,1例术后3d出现大量腹水转入上级医院进一步治疗,余6例术后顺利出院,随访生存期在3个月以上.结论 原发性肝癌自发性破裂出血在急诊诊治过程中要注意减少误诊、漏诊,诊断明确后,在纠正休克的同时,可根据病情积极选择手术探查,手术方式可选择肿瘤切除术、单纯止血纱布填塞缝合止血术,以最短的时间挽救患者的生命.     

Endoscopic electrohemostasis of active upper gastrointestinal bleeding.

Emergency esophagogastroduodenoscopy for active upper gastrointestinal bleeding was performed in 160 patients. Endoscopic electrocautery for control of bleeding was considered in the last ninety patients and performed in seventy-one patients. All lesions except esophageal varices were candidates for electrohemostasis. The indications for endoscopic electrocautery were active hemorrhage and precise identification of the bleeding point. The preendoscopic blood loss ranged from 1,500 to 6,000 ml. All seventy-one patients had initial hemostasis and sixty-five (92 per cent) had permanent hemostasis after one treatment. Six patients rebled, and four of these had permanent hemostasis after a second endoscopic electrocauterization. Only two of seventy-one patients had emergency operations for bleeding. There were no complications. Endoscopic electrohemostasis is still an experimental technic which requires further laboratory study and testing before broad general clinical application. This clinical trial suggests that endoscopic electrocautery is an attractive method of controlling active upper gastrointestinal bleeding because it can be safe, effective, and rapid, and is available in most medical communities.