Hemostasis Rate Research Articles

Efficacy of a novel hemostatic adhesive powder in patients with upper gastrointestinal tumor bleeding

BackgroundGastrointestinal tumor bleeding remains a clinical challenge because it is difficult to treat with conventional endoscopic hemostatic options. Recently, an endoscopic hemostatic powder (UI-EWD) was developed and reported to provide effective control of upper gastrointestinal bleeding. The aim of current study was to evaluate the feasibility and efficacy of this novel hemostatic powder in tumor bleeding.MethodsA total of 41 consecutive patients with upper gastrointestinal tumor bleeding were included. UI-EWD was applied in all patients as an auxiliary hemostatic method as a salvage therapy or monotherapy during endoscopic treatment. Hemostasis success rates, adverse event related to UI-EWD, and rates of re-bleeding were evaluated.ResultsIn all cases, UI-EWD application was successful at tumor bleeding sites. Immediate hemostasis occurred in 40/41 (97.5%) patients, and re-bleeding within 28 days occurred in 10 of 40 (22.5%) patients that achieved initial hemostasis. The success rate of immediate hemostasis for UI-EWD monotherapy was 100% (23/23). The re-bleeding rate at 28 days after UI-EWD monotherapy was 26.1% (6/23). No adverse events associated with UI-EWD application were encountered.ConclusionsThe success rate of UI-EWD for immediate hemostasis in cases of GI tumor bleeding was excellent and UI-EWD produced promising results with respect to the prevention of re-bleeding. Based on these results, we suggest that UI-EWD be considered an effective salvage therapy or even monotherapy for GI tumor bleeding.

Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study

Background & aimAlthough acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management. MethodsAdult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded. ResultsOverall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5–4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients. ConclusionMortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT 04364412].

Design and Preclinical Evaluation of Chitosan/Kaolin Nanocomposites with Enhanced Hemostatic Efficiency.

In the current study, hemostatic compositions including a combination of chitosan and kaolin have been developed. Chitosan is a marine polysaccharide derived from chitins, a structural component in the shells of crustaceans. Both chitosan and kaolin have the ability to mediate a quick and efficient hemostatic effect following immediate application to injury sites, and thus they have been widely exploited in manufacturing of hemostatic composites. By combining more than one hemostatic agent (i.e., chitosan and kaolin) that act via more than one mechanism, and by utilizing different nanotechnology-based approaches to enhance the surface areas, the capability of the dressing to control bleeding was improved, in terms of amount of blood loss and time to hemostasis. The nanotechnology-based approaches utilized to enhance the effective surface area of the hemostatic agents included the use of Pluronic nanoparticles, and deposition of chitosan micro- and nano-fibers onto the carrier. The developed composites effectively controlled bleeding and significantly improved hemostasis and survival rates in two animal models, rats and rabbits, compared to conventional dressings and QuikClot® Combat Gauze. The composites were well-tolerated as demonstrated by their in vivo biocompatibility and absence of clinical and biochemical changes in the laboratory animals after application of the dressings.

In Vivo Investigation of Noncontact Rapid Photothermal Hemostasis on Venous and Arterial Bleeding.

Endoscopic surgical procedures rigorously underscore the significance of rapid hemostasis for unavoidable intraoperative bleeding, requiring advancement of the immediate hemostatic interventions for favorable clinical outcomes. Here, we report the efficacy of a new optical treatment with dual-wavelengths to develop an endoscopic hemostasis method. we combine visible (20-W 532 nm at 1.1 kW/cm2) and near-infrared (40-W 980 nm at 2.2 kW/cm2) wavelengths for facilitating noncontact thermal hemostasis on venous and arterial bleeders in in vivo leporine models. Simultaneous irradiation of 60-W dual-wavelengths allows for an increased irradiance of 3.3 kW/cm2, involving both rapid light absorption by hemoglobin and deep thermal penetration. The collective thermal effects from the combined wavelengths contribute to a significant reduction in coagulation time and a high success rate of complete hemostasis for both venous and arterial bleeders. The enhanced hemostatic potential of the dual-wavelengths treatment accompanies minimal hemorrhage, reduces inflammatory responses, and facilitates re-epithelialization. The proposed dual-wavelengths method can achieve rapid and complete hemostasis for endoscopic procedures. We present the high-irradiance photothermal treatment using the dual-wavelengths as a novel method to regulate venous and arterial bleeding and potentially as a rapid noncontact hemostasis option to mitigate the risk associated with significant blood loss.

Application of Nursing Risk Management in Nursing of Severe Peptic Ulcer Bleeding

Objective: To assess and compare the clinical application value of nursing risk management in the diagnosis and treatment of severe peptic ulcer bleeding. Methods: A total of 70 patients with severe peptic ulcer bleeding were selected as the research objects, randomly divided into observation group and control group, 35 cases for each. The nursing risk management and conventional nursing management were implemented for the two groups, respectively. The success rate of hemostasis, average length of stay, cure rate, complication rate, dyspnea rate, nursing dispute rate, SAS score, and SDS score were compared between the two groups. Patients’ satisfaction with nursing quality was also compared. Results: After the implementation of two different nursing management methods, all the above-mentioned metrics were better in the observation group than in the control group, and the differences were statistically significant (P < 0.01 or P < 0.05). Conclusion: The application of nursing risk management in the nursing intervention process of patients with severe peptic ulcer bleeding can effectively reduce the probability of nursing risk events, increase the cure rate, shorten the patient’s hospital stay, but also improve the patients’ psychological state and increase the patient’s satisfaction with nursing quality, which is worth clinical promotion.

A multicenter, prospective, randomized clinical trial of marine mussel-inspired adhesive hemostatic materials, InnoSEAL Plus.

PurposeInnoSEAL Plus is an adhesive, coagulant-free hemostatic material that mimics the adhesion mechanism of marine mussels. This study reports on the safety and efficacy of InnoSEAL Plus for patients with hemorrhage after hepatectomy despite first-line hemostasis treatments.MethodsThis is a multicenter, prospective, single-blinded, randomized clinical trial involving 96 hepatectomy patients. TachoSil was used as a comparator group. Three-minute and 10-minute hemostatic success rates were monitored. Rebleeding rates were also observed. Safety was assessed by recording all novel undesirable symptoms.ResultsInnoSEAL Plus showed a 3-minute hemostasis rate of 100%, while TachoSil had a rate of 98.0% (48 of 49 patients), demonstrating that the 2 had similar hemostatic efficacies. The difference in efficacy between the test and comparator group was 2.04%, and the lower limit of the one-sided 97.5% confidence interval was −1.92%; as this is greater than the noninferiority limit of −23.9%, the 2 treatments were equivalent. Meanwhile, the 10-minute hemostatic success rate was the same in both groups (100%). No rebleeding occurred in either group. In the safety evaluation, 89 patients experienced adverse events (45 in the test group and 44 in the comparator group). The difference between the 2 groups was not significant. No death occurred after application of the test or comparator group product.ConclusionGiven that InnoSEAL Plus is a coagulation factor-free product, the hemostasis results are encouraging, especially considering that TachoSil contains a coagulation factor. InnoSEAL Plus was found to be a safe and effective hemostatic material for control of bleeding in hepatectomy patients.

Postpancreatectomy hemorrhage with negative angiographic findings: outcomes of empiric embolization compared to conservative management

ObjectiveTo evaluate the efficacy of empiric embolization for postpancreatectomy hemorrhage (PPH) with negative angiographic signs of active bleeding. Materials and methodsA total of 100 patients (76 men, 24 women) who were diagnosed with PPH with angiographic findings revealing no signs of active bleeding from December 2013 to December 2019 were included in the study. The patients were divided into two groups according to whether the procedures were performed with or without empiric embolization in angiography (group of empiric embolization, N=47; group of no embolization, N=53). Data reflecting patients' characteristics, hemorrhagic details, classification of PPH grade, and postoperative complications were acquired. The rates of clinical success in hemostasis and mortality were compared between the group of empiric embolization and the group of no embolization. ResultsIn the group of empiric embolization, the rate of clinical success in hemostasis and mortality were 61.7% and 27.7%, respectively. In the group of no embolization, the rates of clinical success in hemostasis and mortality were 39.6% and 13.2%, respectively. The rate of clinical success in hemostasis in the group of empiric embolization was significantly higher than that in the group of no embolization (p = 0.028). There was no statistically significant difference in mortality between the different groups (p = 0.071). ConclusionThe clinical success rate of hemostasis in patients with empiric embolization is higher than that in patients with no embolization. Empiric embolization may be an efficacious hemostatic treatment for PPH with angiographic findings revealing no signs of active bleeding.

Hemostatic spray powder TC-325 in the primary endoscopic treatment of peptic ulcer-related bleeding: multicenter international registry.

Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % - 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy. Data were collected prospectively (January 2016 - March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist's discretion. 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P < 0.05) compared with monotherapy or rescue therapy. There were high immediate hemostasis rates across all peptic ulcer disease Forrest classifications. This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.

Efficacy of urgent colonoscopy for colonic diverticular bleeding: A propensity score-matched analysis using a nationwide database in Japan.

Although colonic diverticular bleeding (CDB) is considered to have good prognosis with conservative therapy, some cases are severe. The efficacy of urgent colonoscopy for CDB and clinical factors affecting CDB prognosis are unclear. This study aimed to evaluate the efficacy of urgent colonoscopy for CDB and identify risk factors for unfavorable events, including in-hospital death during admission, owing to CDB. We collected CDB patients' data using the Diagnosis Procedure Combination database system. We divided eligible patients into urgent and elective colonoscopy groups using propensity score matching and compared endoscopic hemostasis and in-hospital death rates and length of hospital stay. We also conducted logistic regression analysis to identify clinical factors affecting CBD clinical events, including in-hospital death, a relatively rare CDB complication. Urgent colonoscopy reduced the in-hospital death rate (0.35% vs 0.58%, P=0.033) and increased the endoscopic hemostasis rate (3.0% vs 1.7%, P<0.0001) compared with elective colonoscopy. Length of hospitalization was shorter in the urgent than in the elective colonoscopy group (8 vs 9days, P<0.0001). Multivariate analysis also revealed that urgent colonoscopy reduced in-hospital death (odds ratio=0.67, 95% confidence interval: 0.46-0.97, P=0.036) and increased endoscopic hemostasis (odds ratio=1.84, 95% confidence interval: 1.53-2.22, P< 0.0001). Urgent colonoscopy for CDB may facilitate identification of the bleeding site and reduce in-hospital death. The necessity and appropriate timing of urgent colonoscopy should be considered based on patients' condition.

Characteristics of peptic ulcer bleeding in cirrhotic patients with esophageal and gastric varices

Upper gastrointestinal bleeding (UGIB) is common in liver cirrhosis. Although esophageal and gastric varices (EGV) is the main bleeding source, there were still a proportion of patients with peptic ulcer bleeding. Thus, this study aimed to analyze the characteristic of variceal bleeding and peptic ulcer bleeding in liver cirrhosis. Cirrhotic patients with confirmed UGIB by urgent endoscopy from July 2012 to June 2018 were enrolled, and classified into peptic ulcer bleeding group (n = 248) and variceal bleeding group (n = 402). Clinical and endoscopic characteristics, therapeutic efficacy and prognosis were evaluated, and independent risk factors for 42-day morality were determined. The mean age and gender ratio of peptic ulcer bleeding group were higher than those in variceal bleeding group (55.58 ± 11.37 vs. 52.87 ± 11.57, P < 0.01; 4.51:1 vs. 2.87:1, P = 0.023). Variceal bleeding group most commonly presented as red blood emesis and coffee grounds (67.16%), while peptic ulcer group primarily manifested as melena (62.10%). Hepatocellular carcinoma was more prevalent in peptic ulcer group (141 vs. 119, P < 0.01). Albumin level in variceal bleeding group was lower higher (P < 0.01), but serum bilirubin, creatinine and prothrombin time were significantly higher (all P < 0.01). Success rate of endoscopic hemostasis for variceal bleeding and peptic ulcer bleeding was 89.05% and 94.35% (P = 0.021). Univariate and multivariate analysis identified prothrombin time (P = 0.041, OR [95% CI] 0.884 [0.786–0.995]), MELD score (P = 0.000, OR [95% CI] 1.153 [1.073–1.240]), emergency intervention (P = 0.002, OR [95% CI] 8.656 [2.219–33.764]), hepatic encephalopathy before bleeding (P = 0.003, OR [95% CI] 8.119 [2.084–31.637]) and hepatic renal syndrome before bleeding (P = 0.029, OR [95% CI] 3.877 [1.152–13.045]) as the independent predictors for 42-day mortality. Peptic ulcer bleeding should be distinguished from variceal bleeding by clinical and endoscopic characteristics.

Outcomes Associated With 4-Factor Prothrombin Complex Concentrate Administration to Reverse Oral Factor Xa Inhibitors in Bleeding Patients.

Compared with vitamin K antagonists (VKAs), oral factor Xa inhibitors are associated with at least equivalent efficacy and a lower incidence of major bleeding. Despite this benefit, bleeding remains the most common adverse event. Prior to the approval of andexanet alfa, alternative agents such as 4-factor prothrombin complex concentrate (4F-PCC) were utilized for reversal. This was a retrospective, descriptive study conducted on patients 18 years of age or older who received 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Patients were excluded if they received a VKA or dabigatran in the previous 48 hours. A subgroup analysis comparing 4F-PCC with andexanet alfa was conducted on patients who met the inclusion and exclusion criteria of the ANNEXA-4 trial. The primary end point of this study was to evaluate the incidence of hemostasis and associated dosing strategies in patients receiving 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Thirty-eight patients were included, and 28 patients (74%) achieved hemostasis. The median dose of 4F-PCC was 50units/kg. In patients who achieved hemostasis, the median dose was 50units/kg, and in those who failed to reach hemostasis, a median dose of 30units/kg was seen. Within the subgroup analysis, there was no difference in overall rates of hemostasis between the 4F-PCC and andexanet alfa groups. Remaining a reasonable option to utilize for reversal of oral factor Xa inhibitors is 4F-PCC, especially when andexanet alfa is unavailable, with 50units/kg appearing to be the most effective dose to achieve hemostasis. Further studies are needed to determine a preferential agent.

Current status and future challenges in the endoscopic management of non-variceal upper gastrointestinal bleeding in children.

This study aimed to elucidate the characteristics of non-variceal upper gastrointestinal bleeding (NVUGIB) in children and the outcomes of endoscopic hemostasis (EH) performed by pediatric surgeons. We retrospectively reviewed the medical records of pediatric patients with NVUGIB who had undergone esophagogastroduodenoscopy (EGD) at our hospital, between December 2006 and March 2020. Thirty-six patients were included. The most common endoscopic diagnosis was gastritis (28%), followed by gastric ulcer (25%) and duodenal ulcer (25%). Thirty patients (83%) had underlying diseases, including a recent viral infection (39%), followed by Helicobacter pylori infection (14%). Fourteen patients (39%) underwent EH, exhibiting a high initial rate of hemostasis (100%). This was achieved in 12/14 patients by clipping. One patient was treated using a combination of a hypersaline and epinephrine (HSE) injection and coagulation therapy, as the ulcer exceeded the width of the hemoclips. Rebleeding occurred in one patient (7.1%) initially treated with pure ethanol injections. The partial view of the pediatric duodenum prevented the placement of hemoclips; hence, the patient was treated using a combination of HSE and coagulation therapy. Clipping, injection, and/or coagulation therapy can lead to high success rates for hemostasis, considering the anatomical characteristics in a pediatric population.

S0634 Gastric Variceal Bleeding Carries Worse Prognosis Than Other Causes of Upper Gastrointestinal Bleeding in Cirrhosis

INTRODUCTION: Gastric varices (GV) are present in approximately 20% of patients with cirrhosis and have been previously associated with poor outcomes. In part, this is because they are often not amenable to standard endoscopic band ligation. However endoscopic and endovascular interventions have been studied for GV management. Our single center study describes the characteristics and outcomes associated with GV bleeding (GVB) as well as the utilization of various therapies. METHODS: Adults admitted at an academic medical center between 2012 and 2018 with cirrhosis and upper gastrointestinal bleed (GIB) were included; those with lower GIB, malignancy as primary cause of liver disease, or previous liver transplant were excluded. The primary outcome was 6-week mortality from GVB. Secondary outcomes included endoscopic findings, endoscopic hemostasis rates, and 5-day survival. Logistic and linear regression analyzed outcomes. RESULTS: Of 208 included patients, 31 (14.9%) had GV and 75 (36.1%) had esophageal varices (EV) without GV. The identified source of bleeding was GV in 17 patients, 8 GV were actively bleeding on index endoscopy. Baseline characteristics between EV and GV bleeds were similar (Table 1). The primary type of GV identified was GOV1, and a variety of endoscopic therapies were utilized (Table 2). When controlling for age, gender, admission hemoglobin, INR, and Child Class, patients with active GVB had much lower rates of endoscopic hemostasis than those with EV bleed (25 vs 83.7%, OR 0.03, 95% CI 0.002-0.36, P < 0.01). While 13 (76.5%) GV bleed patients were eligible for transjugular intrahepatic portosystemic shunt (TIPS), only 3 received TIPS during hospitalization, 3 received TIPS post-discharge and 4 were transplanted. Six-week mortality for GV was 31.3% and 5-day mortality was 25%. In addition, overall clinical outcomes were much worse for those with GVB than other GIB causes (Table 3). When GV was identified as the source of bleed, mortality was numerically higher at 6 weeks (50 vs 12.5%, P = 0.10) as well as 5 days (37.5 vs 12.5%, P = 0.24) among patients who did not receive either endoscopic or endovascular therapies. CONCLUSION: Our single center case series correlates with previous findings that GVB is highly morbid, despite use of therapeutic options. GV patients had less hemostasis on endoscopy than EV and despite advanced therapies, mortality was higher than other upper GIB causes. Overall, advanced therapies trended towards improved outcomes but may have been underutilized.Table 1.: Patient Baseline CharacteristicsTable 2.: Types of gastric varices seen and clinical managementTable 3.: Outcomes of gastric variceal bleed

Multicenter analysis of endoclot as hemostatic powder in different endoscopic settings of the upper gastrointestinal tract.

Gastrointestinal bleeding (GIB) still presents a demanding situation with high morbidity and mortality rates; thus hemostatic powders such as EndoClot (EC) have been developed to improve endoscopic armament. The aim of the present study was to determine which indications triggered the application of EC and to assess resulting hemostasis rates. Forty three patients undergoing endoscopical procedures in three hospitals; two tertiary care and one university hospital, were included. EC was applied in 48 endoscopies in 43 patients (27 male, age 65.5 years, range 28 - 92 years) following four different indications. EC was used in active GIB as rescue or first-line therapy giving a short-term and long-term hemostasis in 13/17 patients (76.5%). In the setting of non-active GIB, following conventionally achieved hemostasis or endoscopic interventions, EC was found to prevent bleeding in 19/21 patients (90.4%). EC induced hemostasis in 8/10 patients (80%) with impaired coagulation. EC failures resulted from tumor bleeding, Forrest I lesions or perforated duodenal ulcers. No major adverse events were recorded and one technical failure (2.1%) occurred. EC was applied as first line or salvage treatment in ongoing bleedings with promising results. Furthermore, EC was used after successful hemostasis or following endoscopic interventions to further reduce re-bleeding rates. We saw promising results in all indications, albeit lacking a control group.

Effect of the Leaf Extract of Bidens pilosa on Haemostasis

Aims: To determine the effect of the leaf extract of Bidens pilosa on the rate of haemostasis and validate its traditional use application to fresh wounds.&#x0D; Study Design: Experimental&#x0D; Place and Duration of Study: The study was conducted at the Biology Department, Faculty of Science and Education, Busitema University and Nagongera Health Center IV laboratory between April and May 2019.&#x0D; Methodology: Different concentrations of the extract were applied to blood samples. Whole venous blood was collected by vein puncture in heparin tubes. The rate of clotting in presence and absence of the extract was determined. The experiment was replicated.&#x0D; Results: Increase in the concentration of the extract decreased the rate of haemostasis. Statistical analysis with a two-way ANOVA was significant, P = 0.02 at a 95% CI.&#x0D; Conclusion: High concentration Bidens pilosa leaf extract decreases the rate of haemostasis but may have other healing activities attributed to its historical and traditional use and application to fresh wounds.

Effectiveness and safety of endoscopic treatment for duodenal variceal bleeding: a systematic review.

Duodenal varix is a rare condition that involves massive bleeding, diagnostic difficulties, and a high rate of rebleeding and mortality. The purpose of this study was to systematically review endoscopic treatment for duodenal variceal bleeding to evaluate its effectiveness and safety. We searched PubMed, Embase, Web of Science, and the Cochrane Library up to 21 November 2019. Ninety-two studies containing 156 patients were finally included, and individual data from 101 patients (mean age: 52.67 ± 13.82 years, male: 64.4%) were collected and further analyzed. We used an analysis of variance and χ2 or Fisher's exact tests to analyze individual data from 101 patients. The cause of duodenal variceal bleeding was cirrhosis-related intrahepatic portal hypertension (IPH) in 76.2% of patients. The overall rates of initial hemostasis and treatment success of endoscopic treatment for duodenal variceal bleeding were 89.1 and 81.2%, respectively. The median duration of follow-up was 4.5 (1.0, 12.0) months. The overall rates of rebleeding and mortality were 8.9 and 13.9%, respectively. Among a variety of endoscopic treatments available, only the initial hemostasis rate was significantly different between the endoscopic injection sclerotherapy and endoscopic tissue adhesive (ETA) groups (72.7 vs. 94.7%, P = 0.023); differences in treatment success, rebleeding, mortality, and adverse events were not statistically significant among the four groups. Endoscopic intervention is a feasible, well tolerated, and effective modality for the treatment of duodenal variceal bleeding. Among the variety of endoscopic treatments available, ETA with cyanoacrylate may be preferable for duodenal variceal bleeding.

Haemostatic Efficacy of Topical Agents During Liver Resection: A Network Meta-Analysis of Randomised Trials.

Hepatic resection carries a high risk of parenchymal bleeding both intra- and post-operatively. Topical haemostatic agents are frequently used to control bleeding during hepatectomy, with multiple products currently available. However, it remains unknown which of these is most effective for achieving haemostasis and improving peri-operative outcomes. A systematic review and random-effects Bayesian network meta-analysis of randomised trials investigating topical haemostatic agents in hepatic resection was performed. Interventions were analysed by grouping into similar products; fibrin patch, fibrin glue, collagen products, and control. Primary outcomes were the rate of haemostasis at 4 and 10min. Twenty randomized controlled trials were included in the network meta-analysis, including a total of 3267 patients and 7 different interventions. Fibrin glue and fibrin patch were the most effective interventions for achieving haemostasis at both 4 and 10min. There were no significant differences between haemostatic agents with respect to blood loss, transfusion requirements, bile leak, post-operative complications, reoperation, or mortality. Amongst the haemostatic agents currently available, fibrin patch and fibrin glue are the most effective methods for reducing time to haemostasis during liver resection, but have no effect on other peri-operative outcomes. Topical haemostatic agents should not be used routinely, but may be a useful adjunct to achieve haemostasis when needed.

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.

964 HEMOSPRAY IN THE TREATMENT OF VARICEAL BLEEDS: OUTCOMES FROM THE INTERNATIONAL HEMOSPRAY REGISTRY

Early treatment for variceal bleeding is recommended within 12 hours to improve outcomes. Endoscopic therapy in acute variceal bleeding can be technically difficult and is not always successful and therefore a bridge is sometimes required towards definitive endoscopic therapy or Trans jugular intrahepatic portosystemic shunt (TIPS). Hemospray (Cook Medical, North Carolina, USA) is an endoscopic haemostatic powder for Gastrointestinal (GI) bleeding. The aim of this study was to look at outcomes in patients with upper gastrointestinal bleeds (UGIB’s) secondary to varices. Data was collected prospectively (January 2016- November 2019) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during emergency endoscopy for a variceal UGIB as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods have failed. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Rebleeding was defined as a sustained drop in Hb (>2g/l), haematemesis or melaena with haemodynamic instability following index endoscopy. 12 patients had Hemospray treatment following a variceal upper GI bleed (10 males, 2 female). 10 were oesophageal varices and 2 gastric varices. The median Rockall score was 8 (IQR, 7-8). The median Blatchford score was 15 (IQR, 13-17). There was an immediate haemostasis rate of 75%. There were no re-bleeds following treatment with Hemospray. 4 patients were treated with Hemospray monotherapy, 3 with combination therapy and 5 with rescue therapy (table 1). Hemospray was always given after oesophageal banding or injection sclerotherapy in the combination/rescue therapy cohorts. 4/9 patients died within 7 days, 3 out of these 4 patients did not achieve initial haemostasis with Hemospray. The outcomes from the registry showed an immediate haemostasis rate of 75% in variceal UGIBs following treatment with Hemospray. In those cohort of patients there is no re-bleeding. This suggests that Hemospray may play a potential role as a bridging therapy in variceal bleeds which are difficult to control, towards repeat definitive endoscopic therapy or TIPS. Larger trials are required to validate these results.

Endoscopic management of postoperative anastomotic bleeding in patients with colorectal cancer.

Postoperative anastomotic bleeding is considered a rare but life-threatening complication. There is no standard treatment strategy for this emergency condition. The aim of this study was to report our experiences in the management of postoperative anastomotic bleeding in patients with colorectal cancer. We analyzed the general characteristics, treatments, and outcomes of patients with anastomotic bleeding after surgery for colorectal carcinoma at the Sixth Affiliated Hospital of Sun Yat-Sen University between July 2013 and September 2019 retrospectively. A univariate and multivariate analysis was performed to find protective factors for endoscopic hemostasis. Risk factors for anastomotic leakage after colonoscopy were also analyzed. A total of 9870 patients underwent surgeries for colorectal carcinoma between July 2013 and September 2019. Colonoscopies were performed in 78 cases with postoperative anastomotic bleeding. The effective rate of initial endoscopic hemostasis was 81% (63/78). In univariate and multivariate analysis, hemoclip therapy (odds ratio = 4.572; 95%CI 1.305-16.017; P = 0.017) and postoperative anastomotic bleeding within 5days (odds ratio = 3.639; 95%CI 1.045-12.675; P = 0.042) are protective factors for endoscopic hemostasis. Comorbidity was associated with an increased risk for anastomotic leakage. Colonoscopy seems to be an effective way to achieve hemostasis for patients with anastomotic bleeding after surgery for colorectal carcinoma. It may be more effective in the early postoperative period, and hemoclip appears to be the first choice to control postoperative anastomotic bleeding.