Hemostatic Clips Research Articles

Ex vivo comparison of sliding knot ligatures vs. haemostatic clips for equine small intestinal mesenteric vessel occlusion

BackgroundIn equine abdominal surgery, resection and anastomosis of strangulated intestine is a commonly performed procedure. To date, ligatures, vessel sealing devices and the ligate-divide stapler have been described for this use in horses. The objective of this study was to compare the application of haemostatic clips and ligatures to occlude equine mesenteric vessels.Portions of jejunum with ten associated mesenteric vessels were collected from 12 horses at a local abattoir and divided into two groups. Portions of intestine were divided into two sections comprising five vessels each and assigned to Group A or Group B. Each vessel was occluded with a triple ligature. In Group A, vessels were ligated with three circumferential ligatures tied with a sliding knot with two overthrows. In Group B, vessels were occluded with application of three haemoclips. The procedures were performed by the same experienced surgeon. Intestinal length, construction time and vessel leaking pressure were measured and compared between groups.ResultsThe intestinal length (mean ± SD) was 3.78 ± 0.43 m in Group A and 3.04 ± 0.83 m in Group B. The difference was not significant (p = 0.297).The construction time (mean ± SD) was 7.03 ± 0.34 min in Group A and 2.40 ± 0.43 min in Group B. The difference was significant (p < 0.0001).The leaking pressure was 1000 (750–1050) mmHg (median, IQ range) in Group A and 1050 (800–1050) mmHg (median, IQ range) in Group B. The difference was not significant (p = 0.225).ConclusionsHaemoclip application is comparable in terms of leaking pressure but quicker than sliding knots to apply.

Efficacy of cyanoacrylate in the prevention of delayed bleeding after endoscopic mucosal resection of large colorectal polyps: a pilot study.

Postoperative bleeding is a common complication after endoscopic polypectomy, particularly after endoscopic mucosal resection (EMR) of large non-pedunculated polyps, despite prophylactic clipping can reduce its occurrence. Cyanoacrylate glue has recently been proposed as a useful tool in reducing bleeding in surgery because of its adhesive and haemostatic properties. The aim of this study is to evaluate the usefulness of endoscopic application of a modified cyanoacrylate glue in the prevention of early or delayed post EMR bleeding. This is a pilot study. Inclusion criteria were patients between 18 and 75years old affected by sessile or flat colonic polyps larger than 2cm. Patients enrolled in the study were randomized in two groups: group A (EMR) and group B (EMR with the application of 0.3ml of N-butyl-2-cyanoacrylate + methacryloxysulfolane-Glubran 2®). Fifteen patients in both group A and B were enrolled. There were no intraoperative complications but haemostatic clipping was necessary in 3 patients in each group because of active bleeding. Delayed (after 24h) bleeding occurred in two patients (13.3%) in group A requiring hospital readmission and re-do endoscopy with apposition of haemostatic clips. No case of bleeding was recorded in group B (p = 0.48). The results of this pilot study suggest a potential role of local spray application of Glubran®2 in reducing post-procedural bleeding.

AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.

The utility of patent ductus arteriosus closure with hemostatic clip in dogs.

This study investigated the utility of patent ductus arteriosus (PDA) closure with hemostatic clip by comparing with traditional PDA closure. Medical records of 51 dogs with surgical closure of PDA were reviewed and retrospective study was conducted. 29 dogs were treated by procedure with hemostatic clip (Group HC), and 22 dogs were treated by surgical ligation (Group SL). Data pertaining to breed, sex, age and body weight at the time of surgery, echocardiographic minimal ductal diameter, duration of surgery, hemostatic clip size, echocardiographic findings, hemor-rhage, residual ductal flow and recanalization were collected from records. The results showed that procedure with hemostatic clip had been selected in lighter dogs than traditional PDA closure. Duration of surgery performed only hemostatic clip technique was significantly shorter than that in group SL. Preoperative LVIDd, E-wave and FS were significantly lower than postoperative ones. As regard all parameters, the differences between pre- and postoperative periods were not significantly different between group HC and group SL. Hemorrhage, residual ductal flow, and recanalization were not significantly different in both groups. The present study showed that procedure with hemostatic clip is beneficial in that it is available in smaller dogs and can make shorter operation duration than traditional PDA closure. Moreover, the procedure is effective for the resolution of volume overload of the left atrium and ventricle in short-term outcome. Complications including hemorrhage, residual ductal flow and recanaliza-tion were not significantly different with both techniques.

Risk of Gastrointestinal Endoscopic Procedure-Related Bleeding in Patients With or Without Continued Antithrombotic Therapy.

Prospective studies on bleeding risk during/after gastrointestinal endoscopic procedures are rare. We investigated the risk of endoscopic procedure-related bleeding in patients with biopsy and/or cold snare polypectomy (CSP) in relation to antithrombotic therapy. This prospective, observational single-center cohort study (NCT02594813) enrolled consecutive patients who underwent diagnostic esophagogastroduodenoscopy (EGD) or colonoscopy. The primary outcome measure was delayed bleeding in patients with biopsy and/or CSP who required endoscopic treatment within 2weeks post-procedure. The secondary outcomes were immediate bleeding and the number of hemostatic clips used during the procedure. From November 2015 to October 2018 at our institution, 3069 (mean age, 66years) and 37,887 (57years) patients underwent EGD with and without antithrombotic therapy, respectively. In addition, 1116 (72years) and 11,901 (65years) patients had colonoscopy with and without antithrombotic therapy, respectively. In the 3069 EGD patients receiving antithrombotic therapy, no delayed bleeding occurred, whereas immediate bleeding occurred in 9 of 141 patients (6.4%) with biopsy. Of the 1116 colonoscopy patients receiving antithrombotic therapy, delayed bleeding occurred in three of 228 (1.3%) following CSP. Immediate bleeding occurred in nine of 225 (4%) following biopsy and in 32 of 228 (14%) following CSP. Multivariate analysis following univariate analysis identified chronic kidney disease and CSP as factors significantly associated with procedure-related bleeding in patients taking antithrombotic agents. The risk of delayed bleeding in diagnostic EGD with biopsy or in colonoscopy with biopsy and/or CSP was low despite continuation of antithrombotic therapy.

Sa1234 A THOUSAND AND A HUNDRED FORTY PERORAL ENDOSCOPIC MYOTOMY FOR ESOPHAGEAL ACHALASIA: 10 YEARS’EXPERIENCE FROM A SINGLE TERTIARY CENTER

Esophageal achalasia is most commonly treated with endoscopic dilation or laparoscopic Heller myotomy. Peroral endoscopic myotomy (POEM) has recently been described as a novel treatment for achalasia in humans. The aim of this study was to assess the clinical effectiveness and safety of POEM for treating esophageal achalasia performed in a single tertiary center within 10 years. Between June 2010 to May 2019, POEM was performed in 1140 consecutive patients with achalasia. POEM procedure consisted of the following step: firstly, submucosal tunnel was created and extended below the lower esophageal sphincter (LES) onto the gastric cardia after a mucosal incision was made; then endoscopic myotomy of circular muscle bundles was done; finally, the mucosal entry was closed by hemostatic clips. The Eckardt score and manometry were used to evaluate the outcomes. POEM was successfully performed in 1115 of 1140 cases (97.8%). Mean procedure time was 47.1 min (range 33-86) and mean myotomy length was 9.5 cm (range 7-16). Mucosal perforations occurred in 23 (2%) patients during submucosal tunnel creation, major bleeding occurred in 15 (1.3%) patients, and 29 (2.5%) patients suffered pneumothorax immediate after procedure. All the complications were managed conservatively. During a mean follow-up period of 49.3 months (range 5-89 months), treatment success was achieved in 1005/1140 patients (88.2%). Mean LES pressure was 57.5 mmHg (29.2-83.1) and 15.6 mmHg (5.2-23.1) before and after the procedure (P = 0.000), respectively. Mean Eckardt score was 6.1 (4-11, median 6) and 0.6 (0-3, median 1) before and after POEM, respectively (P = 0.000). In a multivariate analysis, no independent predictors of treatment success was found. 215 patient (18.9%) developed mild reflux symptoms and required intermittent medication with proton pump inhibitors during the follow-up. Our study demonstrated that POEM is a safe, and effective treatment for achalasia during a long-term follow-up. Further studies are warranted to compare the clinical outcomes of POEM with other treatment modalities.

982 USE OF A ANAL/RECTOVAGINAL FISTULA PLUG SET TO REPAIR A TRACHEOESOPHAGEAL FISTULA

Tracheoesophageal fistulas (TEFs) are communications between the trachea and esophagus. These pathologic communications can result in significant morbidity and even mortality for patients due to airway compromise and infection. Standard treatment options include either surgical repair or endoscopic remediation using stents, clips or endoscopic suturing. Our patient was a 76 year old man with a history of T3N0 esophageal adenocarcinoma. He initially underwent treatment with neoadjuvant chemoradiation followed by transhiatal esophagectomy. This surgery was complicated by a recurrent esophagogastric stricture. Treatment for the stricture was performed with serial dilation and stenting. Following stent placement, the patient developed symptoms consistent with the development of a TEF. Subsequent endoscopic treatment with over-the-scope clipping, esophageal stenting, tracheal stenting and endoscopic suturing were unsuccessful. Given the patient’s persistent symptoms and desire to avoid revisional surgery, we planned to perform a combined procedure with interventional pulmonology to place a biologic fistula plug in the TEF tract. The plug was 7 mm in diameter with a larger cap at one end. The plug was shortened given the shallow tissue plane between the trachea and esophagus. A suture was also added to the end of the plug to aid in endoscopic manipulation. Under direct visualization with both endoscopy and bronchoscopy the fistula plug was placed in the TEF. Hemostatic clips followed by esophageal stenting was used to anchor the plug in the esophagus. Dural sealant was used in the trachea to assist with sealing the defect. No complications developed following the procedure. The patient had immediate symptomatic improvement with decreased cough. A follow up esophagram one month after the procedure did not redemonstrate the TEF. Tracheoesophageal fistulas are often difficult to treat. Here we demonstrate the use of a biologic plug to aid in fistula closure for a recalcitrant TEF. Development of biologic plugs or grafts specifically for use in TEFs may be useful in the future.

Tu1512 ASSESSING THE UTILIZATION AND EFFICACY OF HEMOSTATIC POWDER IN TREATING NON-VARICEAL GASTROINTESTINAL HEMORRHAGES

In 2018, the FDA approved hemostatic powder as a therapeutic instrument to treat non-variceal gastrointestinal bleeding. Since this treatment modality has now been in use for approximately 12 months in the US we evaluated several aspects of its application, such as pattern of utilization, efficacy, trends in hemostasis techniques and patient outcomes. To assess the last 12 months of hemostatic powder utilization, and determine its efficacy of treating non-variceal gastrointestinal hemorrhages as compared to the current hemostatic modalities used in endoscopic procedures at a tertiary medical center. In a retrospective review of our endoscopic procedural database we identified 251 cases of suspected upper gastro-intestinal bleeding (UGIB) between 11/2018 and 11/2019. Cases with confirmed malignancies and those with low risk lesions that did not require endoscopic intervention were excluded. We collected data on immediate cessation of bleeding, as well as re-bleed rates at 24 hours and 7 days after procedure. Etiology was also noted, with Forrest classifications being attributed to peptic ulcers. We identified 74 patients with UGIB requiring endotherapy. Of those cases, hemostatic powder was applied in 23 (31%); in 17 (73%) as an upfront intervention prior to other therapies or as a single modality, and 6 (27%) in combination following other hemostatic interventions (epinephrine injection, hemostatic clips, thermal probe, and over-the-scope clips). Cases in which hemostatic powder was used had a 95.6% success rate of immediate hemostasis. This was not significantly different then in those when hemostatic powder was not used (95% success rate; N.S). There was a significant decrease in 7 day rebleed rates in the hemostatic powder group (26 vs 33%; p<0.05). Peptic ulcers accounted for 52.7% of the UGIB cases seen with intervention. Within that group, hemostatic powder application carried an immediate success rate of 90.9%, and a within 7-day rebleed rate of 18.1%; whereas UGIB cases without hemostatic powder intervention carried rates of 96.4% and 28.5% respectively (p<0.05). Our study shows that hemostatic powder is being used in close to 1/3 of high risk GI bleeding cases. Although in cases when hemostatic powder was used the immediate hemostasis was not different than in other cases, we did demonstrate a lower rebleed rate in benign non-variceal upper GI bleeds.

Su1305 A SAFE AND COST EFFECTIVE STRATEGY FOR THE MANAGEMENT OF SMALL ASYMPTOMATIC GASTRIC SUBEPITHELIAL TUMORS: A CASE SERIES

Gastric subepithelial tumors (SETs) are relatively common incidental findings encountered on endoscopy. Current ASGE guidelines for small SETs (<2cm) arising from the second and third echolayers recommend tissue acquisition for diagnosis or endoscopic mucosal resection (EMR) for lesions that are symptomatic or increase in size over time. If tissue acquisition is non-diagnostic, it is recommended that these patients have endoscopic ultrasound (EUS) surveillance at poorly defined intervals. In addition to the cumulative risk of anesthesia and significant cost of repeated endoscopy, diagnosis may be challenging because of the low diagnostic yield of tissue acquisition methods currently available for these SETs and the limited accuracy of EUS with endosonographic imaging alone. We propose that routine EMR of asymptomatic gastric SETs <2cm arising from the second and third echolayers is a safe and more cost effective strategy for management than current surveillance recommendations. Provation was queried to identify patients undergoing EUS with a coded diagnosis of “gastric nodule” or “intramural lesion” from September 2017 through September 2019 at our institution. Inclusion criteria for analysis were gastric SETs <2cm arising from the second and third echolayers and removed with EMR. These cases were reviewed for EMR-related complications and pathology of removed specimens. Of the 96 cases identified, 13 patients with 14 distinct lesions met inclusion criteria. All lesions were removed via endoscopic cap band mucosectomy. The mean age of patients was 58.6 years with a female predominance (69.2%). The mean size of these gastric SETs was 7.4 mm. Lesions were most commonly located in the gastric antrum (64%). Pancreatic heterotopia (29%), gastric mucosa (29%), and inflammatory fibroid polyps (23%) were most the most commonly reported pathologic findings. Notably, no carcinoid or other neoplastic lesions were identified. Hemostatic clips were used in 50% of removed lesions. No procedural complications such as perforation were identified. Currently available tissue acquisition methods for small gastric SETs are not always diagnostic, obligating many patients to the EUS surveillance pathway. This results in repeated procedures with a cumulative risk of adverse events. Our results are consistent with published literature showing that asymptomatic SETs <2 cm originating from the second and third echolayers are often benign and can be safely removed by EMR. The more universal use of EMR in this context would increase diagnostic yield, reduce procedural risks, and provide substantial cost savings by eliminating the need for surveillance. As evidence mounts for the safe and efficacious use of EMR in this context, updated guidelines to include this as a viable option need to be considered.

Duodenal perforations secondary to a migrated biliary plastic stent successfully treated by endoscope: case-report and review of the literature

BackgroundEndoscopic retrograde biliary drainage (ERBD) is the most frequently performed procedure for treating benign or malignant biliary obstruction. Although duodenal perforations secondary to the biliary plastic stent are quite rare, they can be life-threatening. The treatment strategies for such perforations are diverse and continue to be debated.Case presentationWe report three cases of duodenal perforation due to the migration of biliary plastic stents that were successfully managed using an endoscope. The three patients were admitted on complaints of abdominal pain after they underwent ERBD. Abdominal computerized tomography (CT) revealed migration of the biliary plastic stents and perforation of the duodenum. Endoscopy was immediately performed, and perforation was confirmed. All migrated stents were successfully extracted endoscopically by using snares. In two of the three cases, the duodenal defects were successfully closed with haemostatic clips after stent retrieval, and subsequently, endoscopic nasobiliary drainage tubes were inserted. After the endoscopy and medical treatment, all three patients recovered completely.ConclusionsDuodenal perforations due to the migration of biliary stents are rare, and the treatment strategies remain controversial. Our cases and cases in the literature demonstrate that abdominal CT is the preferred method of examination for such perforations, and endoscopic management is appropriate as a first-line treatment approach.

In vitro and in vivo studies on the degradation and biosafety of Mg-Zn-Ca-Y alloy hemostatic clip with the carotid artery of SD rat model.

An Mg-Zn-Ca-Y alloy operative clip was developed to overcome the drawbacks of the Ti clips such as ion dissolution inflammation, interference imaging diagnosis, and the potential harm that permanent retention brings to the patient. The structure optimization design of the hemostatic clip was carried out by the finite element numerical simulation method to realize the matching between the structure design and the material properties. Hot extrusion and wire cutting process was used to prepare the Mg-Zn-Ca-Y alloy operative clip. Corrosion degradation behavior of Mg-Zn-Ca-Y alloy in vitro was investigated using electrochemical noise (EN) and immersion test in Simulated body fluid (SBF). The carotid artery of SD rats was clipped using the Mg-Zn-Ca-Y operative clip to evaluate occlusion safety and the complete corrosion degradation behavior and biocompatibility of Mg-Zn-Ca-Y alloy clip in vivo were investigated using micro-computed tomography, histological analysis, and blood biochemical indicators. It was found that the newly designed Mg-Zn-Ca-Y clip can successfully ligate the carotid artery, and no blood leakage occurred after surgery. After eight months, the Mg-Zn-Ca-Y clip degraded utterly. Histological analysis and various blood biochemical parameters in SD rat serum samples collected at different time periods showed no tissue inflammation around the clips.

Role of Hemostatic Clips as Guidance during Transcatheter Arterial Embolization in Patients with Peptic Ulcer Bleeding after Endoscopic Treatment Failure

To investigate the feasibility and clinical efficacy of transcatheter arterial embolization using hemostatic clips as the guidance in the patients with peptic ulcer bleeding after endoscopic treatment failure. From February 2009 to October 2018, 33 patients with peptic ulcer bleeding who were treated with transcatheter arterial embolization after endoscopic treatment failure were included in the study. Clinical success rate, 30-d mortality rate and complication rate were observed. According to Forrest grading of ulcer bleeding on endoscopy, 8 patients (24.2%) were defined as Ⅰa, 14 patients (42.5%) Ⅰb, 4 patients (12.1%) Ⅱa, and 7 patients (21.2%) Ⅱb. There were 8 patients not given endoscopic treatment due to poor vision. In 25 patients who received endoscopic treatment, 7 patients did not achieve primary endoscopic hemostasis and 18 patients had re-bleeding despite successful primary hemostasis. The mean interval time from endoscopic treatment failure to transcatheter arterial embolization was (35.42±67.54) h. All patients underwent arterial angiography, and 18 patients with positive angiographic findings were treated with embolization. Among the 15 patients with negative angiographic findings, hemostatic clip could be observed fluoroscopically in 8 patients and used as guidance for embolization. Prophylactic embolization was performed in 4 out of 7 patients without visualization of clip fluoroscopically. The clinical success rates in negative angiographic findings patients with and without clip guidance were 75.0% and 28.6% respectively. The clinical success rate with positive angiographic findings was 66.7%. The overall clinical success rate and 30-d mortality rate were 60.0% and 20.0% respectively. No complication related to embolization was observed. The preliminary clinical study demonstrates that transcatheter arterial embolization with the guidance of clips is effective and safe for patients with peptic ulcer bleeding after endoscopic treatment failure.

Dieulafoy lesion: two pediatric case reports

BackgroundMassive gastrointestinal bleeding in children is uncommon. Dieulafoy lesion is an uncommon disease which may lead to massive and repeated upper gastrointestinal hemorrhage. We report two cases of gastric Dieulafoy lesion successfully treated with either band ligation or endoscopic hemoclipping.Case presentationFirst case report: A previously healthy 18-month-old female infant with E. coli sepsis, pneumonia and respiratory failure with bilateral pneumothorax requiring chest drainage. Over a few days, the patient presented hematemesis and melena with progressively worsening anemia. The esophagogastroduodenoscopy revealed an arterial vessel with eroded apex located between the body and the fundus of the stomach. Two elastic bands were applied which resulted in resolution of hematemesis and melena and improvement of the anemia.Second case report: A 8-year-old male was admitted to our department with sudden massive hematemesis and melena. Clinical examination revealed anemia (hemoglobin, 6.8 g/dl). Esophagogastroduodenoscopy revealed a mucosal erosion with visible vessel located along the small curvature, close to the antrum. Three hemostatic clips were placed on the Dieulafoy lesion and hemostasis was obtained.Conclusionswe showed that, similar to gastric DL in adult patients,, gastric DL in pediatric patients can be successfully treated with endoscopic therapy, and both hemoclipping and band ligation are suitable techniques.

A195 THE CANADIAN POEM EXPERIENCE. THE FIRST 50 PATIENTS

Abstract Background Achalasia is a disorder of esophageal motility characterized by a loss of enteric neurons resulting in impaired relaxation of the lower esophageal sphincter and absence of esophageal peristalsis. There are no current treatments that allow for regeneration of the enteric neurons. Interventions focus primarily on lowering the LES pressure to provide symptom relief and improve quality of life. Peroral endoscopic myotomy (POEM) has emerged as a less invasive technique for performing myotomy in patients with achalasia. Aims This study aims to assess the safety and efficacy of POEM in a Canadian tertiary care center. Methods All consecutive patients who underwent POEM between March 2016 and May 2018 at a tertiary center were included. The primary outcome of the study was clinical success rate of POEM defined as a post-POEM Eckardt score ≤ 3 at ≥ 3 months. Adverse events were recorded according to the Clavien-Dindo grading system. Results A total of 50 consecutive patients underwent 51 POEM procedures with a mean procedure length of 85.6±29.6 minutes. Post-POEM Eckardt scores of ≤ 3 at ≥ 3 months was achieved in 98% of patients. The incidence of pathologic reflux post-poem was 23%. The median length of hospital stay was 1 day (range 1–2 days). No major adverse events occurred. Conclusions POEM is a safe and effective procedure for the treatment of achalasia. At a median follow up of 19.5 months, 98% of patients had sustained clinical response (Eckardt score ≤ 3). Stages of POEM. a) Injection and mucosal incision, b) submucosal tunneling c) completed tunnel, view from just above the lower esophageal sphincter (main), gastric side (right upper) and esophageal side (right lower) d) myotomy e[i]) completed myotomy f) closure with hemostatic clips. Funding Agencies None

Putting a Price on Endoscopic Hemostatic Clips

Endoscopic clip placement after resection of large (≥20 mm) nonpedunculated colorectal polyps, particularly right-sided ones, can decrease the rate of

Trial protocol: preoperative administration of tranexamic acid in sleeve gastrectomy (PATAS) to reduce haemorrhage rates. A randomised controlled trial

IntroductionFast-track protocols often include short-term thromboprophylaxis and short length of hospital stay. These treatment strategies may negatively affect the occurrence and diagnosis of postoperative haemorrhage. Over the years, the rates...

Emergent Double Balloon Enteroscopy in Overt Suspected Small Bowel Bleeding: Diagnosis and Therapy.

BackgroundDouble balloon enteroscopy (DBE) is a diagnosis and therapy method for suspected small bowel bleeding (SSBB). The data for emergent DBE is limited in overt SSBB cases. The aim of this study was to investigate the role of diagnosis and therapy of emergent DBE in patients with overt SSBB.Material/MethodsThe clinical and endoscopic data for patients with overt SSBB undergoing DBE in a single center from January 2010 to December 2017 were collected and analyzed. Emergent DBE was defined as DBE performed less than 3 days of last bleeding onset.ResultsA total of 265 DBEs in 265 patients with overt SSBB were enrolled (mean age, 44.7±17.3 years; 66.8% males). The patients were divided into 3 groups according to the timing of DBE: less than 3 days (n=32), more than 3 days and less than 7 days (n=146), and more than 7 days (n=87) (first group was the emergent group, the latter 2 groups were the non-emergent groups). The diagnosis yield for the emergent group was significantly higher than the non-emergent groups (84.4% versus 65.1% or 59.8%, respectively, P<0.05), but was not different between the 2 non-emergent groups (P>0.05). The top 3 diagnoses were angioectasias (19.6%), diverticulum (16.2%), and tumor (12.1%). For therapy yield, there was a remarkable reducing trend in the emergent group (<3 days), and the 2 non-emergent groups (3 to 7 days group and >7 days group: 78.1%, 58.2% and 39.1%, respectively, P<0.05. The top 3 endoscopic treatments were hemostatic clips (21.9%), argon plasma coagulation (15.8%), and epinephrine injection (14.0%).ConclusionsThe emergent DBE had the highest yields for diagnosis and therapy. The study finding showed a pivotal role of emergent DBE in overt SSBB.

Use of craniotomy hemostatic clips in the excision of large scalp tumors

Slow Mohs micrographic surgery (MMS) is used for margin evaluation of skin tumors that are difficult to assess histologically on frozen sections. It is performed mainly for dermatofibrosarcoma protuberans, sebaceous carcinoma, and large lentigo maligna. Unlike conventional MMS, which can be performed intraoperatively, in slow MMS, the margins are processed as rush permanent sections on formalin-fixed, paraffin-embedded tissue. After tumor excision, the defect is left open until margin assessment is completed by the dermatopathologist, which may take several days.

P608 Endoscopic treatment of enterocutaneous fistulas in Crohn’s disease patient

Abstract Background The management of enterocutaneous fistulas (ECF) in Crohn’s disease (CD) patients is complex and requires a multidisciplinary approach. Despite the advent of anti-TNF, the majority of patients still need surgical management. The aim of this study was to report the feasibility of endoscopic treatment of ECF in CD patient. Methods We prospectively identified CD patients with an ECF who failed to conventional medical therapies. Demographic and clinical data were collected retrospectively. Under general anaesthesia, a colonoscopy was performed to identify the fistula. At the discretion of the operator, an Ovesco® clip under or hemostatic clip were placed on the top of the fistula, with radiological opacification control. Technical success was defined by the clip placement on the EFC. The clinical success was defined by the closure of the fistula (defined by the absence of emission of stool or gas by the cutaneous orifice). Results Eight patients (female, 75 %, median age 45 years (interquartile range (IQR), 33–51)) were identified. Regarding the EFC, they evolved from a median of 3 months (IQR, 1.75–5.5) before the endoscopic management. The fistulas were localised on the ileocolonic anastomosis for 7 patients, and on the stomach in one. Two patients had an endoscopic activity, as defined by the presence of ulcer(s). Seven patients were treated with an OVESCO clip and one with Boston® resolution 360 hemostatic clips. Thirteen endoscopic procedures were performed, with a median number of 1 procedure/patient (IQR, 1–2). Technical success was observed in 100% of cases. Clinical success at 3 months was observed in 75% of cases (6/8 patients). After a median follow-up of 8 months (IQR, 5–12), 2/6 patients in clinical success underwent a new procedure due to EFC recurrence at respectively 4 and 7 months due to a clip migration. Among the 2 failures, one patient underwent a second colonoscopy with a new Ovesco® placement and the other was treated with fibrin glue. In both cases the procedure was ineffective. No complication related to the clip insertion was observed. Conclusion This demonstrates |, for the first time, the feasibility and short-term effectiveness of endoscopic clips for the treatment of EFC in CD patients. New prospective studies should confirm these results.

Managing Potentially Fatal Bleeding During Laparoscopic Hepatectomy: Intracorporeal Suturing

Presenter: Jaime Kruger MD | Hospital das Clinicas - University of Sao Paulo Background: Laparoscopic liver surgery has evolved substantially along last years and has gained progressive acceptance among liver surgeons. Despite minimally invasive, hepatic resection remains a complex procedure associated with operative complications frequently related to blood loss. Operative hemorrhage is the most common cause to conversion during laparoscopic operations. In instances of massive bleeding conversion may not be the solution since it takes time to open the cavity, place retractors and finally manage the bleeding spot. Another risk during conversion for venous defects is air embolism with non diffusible gases. Methods: Three cases of intraoperative hemorrhage are shown. The first case is a laparoscopic right hepatectomy and bleeding occurred during liver mobilization, when transecting the right coronary ligament an inadvertent lesion occurred to the wall of the right hepatic vein. In this case the surgeon was experienced in both open and laparoscopic liver surgery. Case two depicts a surgeon during the course of his learning curve on liver resection performing a left lateral sectionectomy in which during final phase of liver transection an inadvertent lesion is inflicted to the root of the left hepatic vein. Third case describes another planned right hepatectomy in which a hemostatic clip slips from the inferior vena cava, while dissection is carried out by an experienced conventional liver surgeon, but still climbing the learning curve for minimally invasive operations. Results: All three cases were managed with intracorporeal suturing avoiding conversion. The first two cases did not require blood transfusion and the third patient received two units of packed red blood cells. Conclusion: Potentially fatal hemorrhage can occur at any point of a surgeon's learning curve and at any point of a liver operation. This video shows hemorrhagic events during mobilization, transection and vascular control. Liver surgeons dealing with laparoscopic resections must be trained in both advanced liver and laparoscopic surgery in order to manage operative complications in which the conversion may be riskier than laparoscopic management.