Endoscopic Hemostatic Treatment Research Articles

Systematic review and meta-analysis of endoscopic versus medical management of peptic ulcers with adherent clots.

Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non-bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs)comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random-effects meta-analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8years and a mean follow up of 20days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR]=0.40, 95% confidence interval [CI] 0.16-0.95, 268 participants). However, there was no difference in mortality (RR=0.90, 95% CI 0.23-3.59, 52 participants) or need for ulcer surgery (RR=0.48, 95% CI 0.10-2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery.

Endoscopic Management of Bleeding in Altered Anatomy after Upper Gastrointestinal Surgery.

Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients-up to about 2%. Most cases of intraluminal bleeding are an indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.

Hemostatic Powder vs Standard Endoscopic Treatment for Gastrointestinal Tumor Bleeding: A Multicenter Randomized Trial

Current guidelines vary as to their recommendations addressing the role of hemostatic powders when managing patients with malignant gastrointestinal (GI) bleeding because these are based on very-low- to low-quality evidence, in large part due to a paucity of randomized trial data. This was a patient- and outcome assessor-blinded, multicenter, randomized controlled trial. Patients presenting with active bleeding from an upper or lower GI lesion suspected to be malignant at index endoscopy between June 2019 and January 2022 were randomly allocated to receive either TC-325 alone or standard endoscopic treatment (SET). The primary outcome was 30-day rebleeding, and secondary objectives included immediate hemostasis and other clinically relevant endpoints. Overall, 106 patients made up the study population (55 TC-325 and 51 SET, after 1 exclusion in the TC-325 group and 5 in the SET group). Baseline characteristics and endoscopic findings did not differ between the groups. Thirty-day rebleeding was significantly lower in the TC-325 (2.1% TC-325 vs 21.3% SET; odds ratio, 0.09; 95% confidence interval [CI], 0.01-0.80; P= .003). Immediate hemostasis rates were 100% in the TC-325 group vs 68.6% in the SET group (odds ratio, 1.45; 95% CI, 0.93-2.29; P < .001). Other secondary outcomes did not differ between the 2 groups. Independent predictors of 6-month survival included the Charlson comorbidity index (hazard ratio, 1.17; 95% CI, 1.05-1.32; P= .007) and receiving an additional nonendoscopic hemostatic or oncologic treatment during 30 days after the index endoscopy (hazard ratio, 0.16; 95% CI, 0.06-0.43; P < .001) after adjustment for functional status, Glasgow-Blatchford score, and an upper GI source of bleeding. The TC-325 hemostatic powder results in greater immediate hemostasis rates followed by lower 30-day rebleeding rates when compared to contemporary SET. (ClinicalTrials.gov, Number: NCT03855904).

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding.

Upper gastrointestinal (GI) bleeding is a common reason for emergency hospital admission. Proton pump inhibitors (PPIs) reduce gastric acid production and are used to manage upper GI bleeding. However, there is conflicting evidence regarding the clinical efficacy of proton pump inhibitors initiated before endoscopy in people with upper gastrointestinal bleeding. To assess the effects of PPI treatment initiated prior to endoscopy in people with acute upper GI bleeding. We searched the CENTRAL, MEDLINE, Embase and CINAHL databases and major conference proceedings to October 2008, for the previous versions of this review, and in April 2018, October 2019, and 3 June 2021 for this update. We also contacted experts in the field and searched trial registries and references of trials for any additional trials. We selected randomised controlled trials (RCTs) that compared treatment with a PPI (oral or intravenous) versus control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment, prior to endoscopy in hospitalised people with uninvestigated upper GI bleeding. At least two review authors independently assessed study eligibility, extracted study data and assessed risk of bias. Outcomes assessed at 30 days were: mortality (our primary outcome), rebleeding, surgery, high-risk stigmata of recent haemorrhage (active bleeding, non-bleeding visible vessel or adherent clot) at index endoscopy, endoscopic haemostatic treatment at index endoscopy, time to discharge, blood transfusion requirements and adverse effects. We used standard methodological procedures expected by Cochrane. We included six RCTs comprising 2223 participants. No new studies have been published after the literature search performed in 2008 for the previous version of this review. Of the included studies, we considered one to be at low risk of bias, two to be at unclear risk of bias, and three at high risk of bias. Our meta-analyses suggest that pre-endoscopic PPI use may not reduce mortality (OR 1.14, 95% CI 0.76 to 1.70; 5 studies; low-certainty evidence), and may reduce rebleeding (OR 0.81, 95% CI 0.62 to 1.06; 5 studies; low-certainty evidence). In addition, pre-endoscopic PPI use may not reduce the need for surgery (OR 0.91, 95% CI 0.65 to 1.26; 6 studies; low-certainty evidence), and may not reduce the proportion of participants with high-risk stigmata of recent haemorrhage at index endoscopy (OR 0.80, 95% CI 0.52 to 1.21; 4 studies; low-certainty evidence). Pre-endoscopic PPI use likely reduces the need for endoscopic haemostatic treatment at index endoscopy (OR 0.68, 95% CI 0.50 to 0.93; 3 studies; moderate-certainty evidence). There were insufficient data to determine the effect of pre-endoscopic PPI use on blood transfusions (2 studies; meta-analysis not possible; very low-certainty evidence) and time to discharge (1 study; very low-certainty evidence). There was no substantial heterogeneity amongst trials in any analysis. There is moderate-certainty evidence that PPI treatment initiated before endoscopy for upper GI bleeding likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery. Further well-designed RCTs that conform to current standards for endoscopic haemostatic treatment and appropriate co-interventions, and that ensure high-dose PPIs are only given to people who received endoscopic haemostatic treatment, regardless of initial randomisation, are warranted. However, as it may be unrealistic to achieve the optimal information size, pragmatic multicentre trials may provide valuable evidence on this topic.

Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy.

For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes.The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.

Acute upper gastrointestinal bleeding due to portal hypertension in children: What is the best timing of endoscopy?

ObjectiveTo compare initial clinical/laboratory parameters and outcomes of mortality/rebleeding of endoscopy performed <12 h(early UGIE) versus endoscopy performed after 12–24h(late UGIE) of ED admission in children with acute upper gastrointestinal bleeding(AUGIB) due to portal hypertension. MethodsThis is a retrospective cohort study. From January 2010 to July 2017, medical records of all children admitted to a tertiary care hospital with AUGIB due to portal hypertension were reviewed until 60 days after ED admission. ResultsA total of 98 ED admissions occurred from 73 patients. Rebleeding was identified in 8/98(8%) episodes, and 9 deaths were observed. UGIE was performed in 92(94%) episodes, and 53(58%) of them occurred within 12 h of ED admission. Episodes with early UGIE and late UGIE were similar in terms of history/complaints/laboratory data at admission, chronic liver disease associated, AUGIB duration, and initial management. No statistically significant associations were found between early UGIE and the outcomes of death/rebleeding and prevalence of endoscopic hemostatic treatment (band ligation or sclerotherapy) compared to late UGIE.In the multivariable logistic regression model, the endoscopic hemostatic treatment showed a negative association with early UGIE(OR=0.33;95%CI=0.1–0.9;p = 0.04). ConclusionsThis study suggests that in pediatric patients with AUGIB and portal hypertension, UGIE may be performed after 12–24 h without harm to the patient, facilitating better initial clinical stabilization/treatment and optimization of resources.

A Study of the Influence of New Generation Granulated Sorbents on the Processes Regulating the Aggregate State of the Blood with the Use of Piezoelectric Thromboelastography

Background: Gastroduodenal bleeding (GDB) and the improvement of endoscopic hemostasis (EH) remain a priority in emergency surgery. This article presents the results of an experimental study of the effects of granular sorbents (Aseptisorb, Aseptisorb-A, Aseptisorb-D) on the system regulating the aggregate state of the blood using modern capabilities of piezoelectric thromboelastography (TEG). Methods and Results: The study involved 12 healthy volunteers (9/75% men and 3/25% women) aged between 18 and 58 years, with the average age of 34.0(26.0;44.0) years. For the study, the blood of healthy volunteers with normal indicators of the system regulating the aggregate state of the blood was used. In vitro experiments: Several tests were performed with the blood of each volunteer. In the first experiment (the control stage), the blood cuvette did not contain the test material. At the second stage of the experiment, the hemostatic properties of new generation granulated sorbents (Aseptisorb, Aseptisorb-A, and Aseptisorb-D) were studied. Experimental studies have shown that the use of granular sorbents Aseptisorb, Aseptisorb-A, and Aseptisorb-D in varying degrees affects the links of platelet and coagulation hemostasis, providing acceleration of thrombosis processes while increasing the maximum density of the clot. These effects determine the effectiveness of the clinical use of these sorbents to stop various types of bleeding. Conclusion: Experimental studies of the effect of granular sorbents on the system regulating the aggregate state of the blood using piezoelectric TEG have shown that the use of Aseptisorb, Aseptisorb-A, and Aseptisorb-D can significantly reduce the time of blood clotting and increase the maximum clot density, which determines the possibility of the use of these sorbents in endoscopic hemostatic treatment for GDB.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Acute upper gastrointestinal bleeding in southern Saudi Arabia: A retrospective observational study

Context: Upper gastrointestinal bleeding (UGIB) is a common life-threatening emergency that carries considerable mortality and morbidity; it remains a common cause for admission to hospitals worldwide. UGIB is classified as variceal bleeding and non-variceal bleeding because of distinct etiologies and management. Aims: To describe present clinical manifestations in southern Saudi Arabian UGIB patients, including both endoscopic and basic laboratory parameters, to assess the risk factors, and compare the predictive power and clinical usefulness of three risk scoring systems (AIMS65 score, Glasgow-Blatchford score, Rockall risk score) for the management of patients presenting with UGIB. Methods: This was a retrospective observational study. We included 283 patients admitted to the gastrointestinal unit at Abha city, southern Saudi Arabia, from November 2017 to October 2019. The study findings were the etiology of UGI bleeding, the endoscopic findings and clinical outcome of UGI bleeding. Results: Ages ranged from 18 to 97 years old with mean age of 54.5 ± 18.5 years. The majority of patients were males (72%; 203). Melina was the most common presenting symptom, in 66 (49.3%) patients. Diabetes mellitus was the most frequently recorded risk factor for UGIB (53.9%) followed by hypertension (44.9%), and aspirin use (35.7%). Endoscopic hemostatic treatment was applied in 70 patients (24.7%); 4.9% of patients re-bled, and 21 patients (7.4%) died during the study period. Conclusions: Comorbidities such as hypertension and diabetes, in addition to some medicines including ASA, steroids and NSAIDs were identified as risk factors of upper GIT bleeding among this study casesa list of risk factors for severe UGIB, leading to hospitalization and even death.

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding

BackgroundIt is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined.MethodsTo evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow–Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization.ResultsA total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], −2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, −1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group.ConclusionsIn patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.)

Rare case of upper gastrointestinal bleeding: Dieulafoy' s lesion of duodenum. A case report.

Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report a case of haemorrhagic shock due to delafoy ulcer of the duodenum. After the failure of endoscopic haemostatic treatment, and due to the hemodynamic instability, the patient was not a candidate for transarterial embolization, the emergency surgery was needed to stop the bleeding. Using minimally invasive technique, we were able to avoid radical surgery, in critical patient would have high mortality rate. Aggressive endoscopic examinations combined with the accurate treatment endoscopic, or after the failure of this, in cases of severe hemorrhagic shock, surgical approach should be adopted when Dieulafoy-like lesion is suspected as a possible cause of upper GI haemorrhage.

Prognostic factors in patients with active non-variceal upper gastrointestinal bleeding

Background and study aimsAcute upper gastrointestinal bleeding is one of the main causes of hospitalisation. The purpose of this study was to determine the prognostic factors in non-variceal upper gastrointestinal bleeding. Patients and methodsClinical outcomes, demographic and laboratory variables of the subjects were collected from the HIS software and national code with the SQL format from three hospitals in Qazvin. The data were linked to the database software designed by the author. Clinical and upper endoscopic findings of patients’ records were collected through a questionnaire form in the designed software database. ResultsIn this study, 29.2% of patients with favourable outcome and 64.2% of patients with unfavourable clinical outcomes had a history of anticoagulant drug use before hospitalisation (p < 0.001). The prevalence of chronic cardiovascular disease, chronic liver disease, chronic lung disease, diabetes and dialysis was higher in subjects with poor clinical outcomes than those with a favourable clinical outcome.53.1% of subjects with favourable clinical outcome and 90.5% of subjects with undesirable clinical outcomes received packed red blood cell transfusion (p < 0.001). 16.1% of subjects with desirable clinical outcome and 86.3% of subjects with undesirable clinical outcomes received endoscopic haemostatic treatment which was statistically significant (p < 0.001). ConclusionUndesirable clinical outcome in patients with acute non-variceal upper gastrointestinal bleeding has a significant statistical association with longer hospitalisation, chronic underlying disease, anticoagulant administration, packed red blood cell infusion, higher Forrest stage, low systolic blood pressure, higher age, low haemoglobin, low platelet count, high INR and high BUN at the onset of diagnosis.

Endoscopic Hemostatic Treatment of Peptic Ulcer Bleeding

Endoscopic Hemostatic Treatment of Peptic Ulcer Bleeding

Endoscopic Therapy for Variceal Bleeding: from Patient Preparation to Available Techniques and Rescue Therapies

Gastrointestinal variceal bleeding (VB) is a frequent and severe complication in cirrhosis. Despite improvement in the last decades in the management of VB, the 6-week mortality after bleeding still ranges from 10 to 20%. Here, we review an up-to-date in the global management of VB. The endoscopic hemostatic treatment relies on band ligation for esophageal variceal bleeding and tissue adhesive injection for gastric variceal bleeding. In case of refractory bleeding, self-expanding metal stents or balloon tamponade can both be used as bridge to specific treatment. The use of covered TIPS provided a new step in the management of VB in severe patients, so-called “early-TIPS” in the setting of secondary prophylaxis or in all patients with refractory bleeding. The global management of patients with VB should include volume resuscitation, blood transfusion, and prevention of complications such as renal failure+/-sepsis+/-liver encephalopathy, as they drive the prognosis. Therefore, the rapid control of gastrointestinal bleeding and subsequent organ complications should be performed in specific intensive care units.

Recurrent bleeding of colonic diverticular hemorrhage after endoscopic treatment: Clinical experience of an endoscopic center

SummaryAimsDiverticular bleeding is one of the most common etiologies of lower GI bleeding. Endoscopy is a useful tool in both diagnosis and therapeutic management. The endoscopic hemostatic methods included epinephrine injection, thermal coagulation, clipping or combination of them. The aim of this study was to evaluate the outcome of different type of hemostasis.Patients and methodsWe reviewed the medical record of all patients who underwent endoscopic therapy for diverticular bleeding from December 2000 to December 2011. We measured hemoglobulin before procedure, early rebleeding (&lt; 30 days), late rebleeding (&gt; 30 days), blood transfusion requirement, hospital stay and complication.ResultsIn our hospital, acute lower GI bleeding leads to almost 600 patients in the past 10 years. We identified 21 patients who underwent endoscopic hemostatic treatment for the diverticular hemorrhage. Patients with epinephrine injection alone had one of thirteen with early rebleeding (&lt; 30 days) and one of thirteen with late rebleeding (&gt; 30 days). Patients with combination therapy (epinephrine injection combined with coagulation or clipping) had one of eight with early bleeding and two of eight patients had late bleeding. There was no significant difference between these two groups on early rebleeding and late rebleeding.ConclusionsIn our series, epinephrine injection alone for diverticular hemorrhage seems to be non‐inferior to the combination therapy for providing good initial hemostasis and preventing recurrent bleeding.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Intravenous Esomeprazole for Prevention of Peptic Ulcer Rebleeding: A Randomized Trial in Chinese Patients

High-dose intravenous esomeprazole is the only approved pharmacological treatment for the prevention of peptic ulcer rebleeding (currently approved in over 100 countries worldwide), but has not yet been approved in China. This study aimed to evaluate a high-dose esomeprazole intravenous regimen vs. an active control (cimetidine) for the prevention of rebleeding in Chinese patients with a high risk of peptic ulcer rebleeding who had undergone primary endoscopic hemostatic treatment. This was a parallel-group study conducted at 20 centers in China. The study comprised a randomized, double-blind, intravenous treatment phase of 72h in which 215patients received either high-dose esomeprazole (80mg+8mg/h) or cimetidine (200mg+60mg/h), followed by an open-label oral treatment phase in which all patients received esomeprazole 40mg tablets once daily for 27days. The primary outcome was the rate of clinically significant rebleeding within the first 72h after initial endoscopic hemostatic therapy. Secondary outcomes included the rates of clinically significant rebleeding within 7 and 30days; proportions of patients who had endoscopic retreatment and other surgery due to rebleeding; and number of blood units transfused. The rate of clinically significant rebleeding within 72h was low overall (3.3%) and numerically lower in patients treated with esomeprazole compared with cimetidine (0.9% vs. 5.6%). Overall, the results of the secondary outcomes also showed a numerical trend towards superiority of esomeprazole over cimetidine. All treatments were well tolerated. In this phase 3, multicenter, randomized trial conducted in China, esomeprazole showed a numerical trend towards superior clinical benefit over cimetidine in the prevention of rebleeding in patients who had successfully undergone initial hemostatic therapy of a bleeding peptic ulcer, with a similar safety and tolerability profile. These findings suggest that esomeprazole may be an alternative treatment option to cimetidine for this indication in China. AstraZeneca. ClinicalTrials.gov identifier, NCT01757275.

Endoscopic Submucosal Dissection for Early Gastric Cancer using the Clutch Cutter: a large single-center experience.

Background and study aims: The Clutch Cutter (CC) was developed to reduce the risk of complications related to endoscopic submucosal dissection (ESD) using knives. The CC is able to grasp and coagulate and/or incise the targeted tissue using electrosurgical current, like a biopsy technique. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early gastric cancer (EGC). Patients and methods: From June 2007 to March 2014, 325 consecutive patients with a diagnosis of EGC were enrolled in this prospective study. They had all satisfied the Japanese gastric cancer treatment guidelines for ESD indication, namely confirmation by preliminary endoscopy, endoscopic ultrasound, and endoscopic biopsies. The CC was used for all steps of ESD (marking, circumferential marginal incision, submucosal dissection, and hemostatic treatment). The therapeutic efficacy and safety were assessed. Results: The en-bloc resection rate was 99.7 % (324/325) and the R0 resection rate was 95.3 % (310/325). The mean operating time was 97.2 minutes. Perforation during ESD-CC occurred in one case (0.3 %), which was managed with conservative medical treatment after endoscopic closure of the perforation. Post-ESD-CC bleeding occurred in 11 cases (3.4 %), which were successfully treated by endoscopic hemostatic treatment. The R0 resection rate was significantly low in tumors > 20 mm (88.9 %), and in the exclusion indication group (73.7 %). Significant differences were seen in the mean operating time, depending upon tumor size, histologic type, location, and indication criteria. Conclusions: ESD-CC is a technically efficient, safe, and easy method for resecting EGC.

Clinical analysis of 18 cases of children refractory nasal bleeding by electric coagulation filling endoscopic hemostatic treatment

目的 研究鼻内窥镜电凝填塞止血术在治疗儿童难治性鼻出血中的疗效，并与传统填塞方法比较。 方法 选取2010年1月至2013年12月应用鼻内窥镜电凝填塞止血术治疗难治性鼻出血患儿18例进行回顾性分析，就病因、手术方法、疗效及并发症等与传统方法比较。 结果 18例中外伤、异物与血液系统疾病占主要比例(72.2%)，术后2例于术后1周再次出血，再次手术后未再出血，治愈率88.9%，与同期门诊鼻出血行常规鼻腔填塞患儿(90.1%)比较，差异无统计学意义(P>0.05)。术后随访1个月，并发鼻窦炎、鼻腔黏连、中耳炎比例均显著低于常规鼻腔填塞患儿，无严重并发症发生。 结论 应用鼻内窥镜电凝填塞止血术治疗儿童难治性鼻出血有利于查找出血部位，止血准确迅速，治愈率高，值得临床推广。

Endoscopic Hemostatic Treatment of Gastric Varices during Pregnancy by Injection of Histoacryl

The occurrence of pregnancy is relatively rare in patients with portal hypertension, and has been reported as clinical cases. However, few studies have evaluated the effectiveness of injecting histoacryl during pregnancy. The choice of treatment for varicose bleeding during pregnancy has been described in the literature based on the elastic ligature. We report the second case, to our knowledge, of treatment of bleeding gastric varices by injection of histoacryl with good maternal and fetal development.

“First look” unsedated transnasal esogastroduodenoscopy in patients with upper gastrointestinal bleeding? A prospective evaluation

With small diameter endoscopes, transnasal esophagogastroduodenoscopy (t-EGD) is routinely performed. The aim of this prospective observational study was to evaluate the role of t-EGD for upper gastrointestinal bleeding (UGIB). One hundred and forty-five consecutive patients (mean age, 66±18.4 years) with suspicion of UGIB were classified a priori into 3 groups according to initial clinical presentation: (1) intensive care unit with EGD under sedation, (2) endoscopy unit with EGD under transient sedation and (3) unsedated t-EGD as "first look". Demographic, clinical and biological parameters, Rockall and Blatchford scores, endoscopic diagnosis and treatment, and outcome were analysed. Unsedated t-EGD was attempted in 89 patients, performed in 52 (5 failures, 28 contraindications) and the procedure was converted under sedation for 2 patients. Based on ASA classification, clinical (blood pressure, hemodynamical failure) and biological variables (hemoglobin, platelets, creatinine), these patients were less severe than in the other groups. Pre-endoscopic Rockall and Blatchford scores were significantly lower in this group. More patients in this group presented significant cardiovascular co-morbidity (47.2%), taking aspirin, clopidogrel and/or anticoagulant. Our results strongly support that "first look" unsedated t-EGD can avoid unnecessary sedation in selected patients with UGIB, presenting a low probability for endoscopic haemostatic treatment and high sedation risks.