Hemostatic Clips Research Articles

Investigating precise control pathway for haemostatic clip usage in laparoscopic cholecystectomy based on patient clinical variations: an exploratory retrospective observational study

ObjectivesTo explore a precise control pathway based on patient clinical variations for haemostatic clip usage in laparoscopic cholecystectomy (LC) through on-site research data from a teaching hospital. Specifically, the study...

Application of a New Hemostatic Clip to Prevent Delayed Bleeding After Endoscopic Sphincterotomy: A Propensity Score-matched Analysis.

Delayed bleeding after endoscopic sphincterotomy (ES) is a serious adverse event of endoscopic retrograde cholangiopancreatography. The aim of this study is to evaluate the effect of prevent delayed bleeding of hemostatic clip (Sureclip) after ES. Consecutive patients diagnosed with common bile duct stones with a high risk of delayed bleeding who received ES from January 1, 2013, to July 31, 2022, were analyzed retrospectively. A 1:1 propensity score-matching analysis and logistic regression analysis were used. The patients were allocated into the hemostatic clip and control groups. The rate of delayed bleeding, hyperamylasemia, pancreatitis, and hemostatic clip closing the bile duct or pancreatic duct by mistake were compared between the 2 groups. Overall, 161 and 232 patients were allocated to the control and hemostatic clip groups, respectively, propensity score matching created 120 matched pairs. The rate of delayed bleeding was significantly lower in the hemostatic clip group than in the control group (1.67% vs. 7.5%, P =0.031). After adjusting for confounding factors, logistic regression showed hemostatic clip was associated with decreased odds of delayed bleeding (0.134, 95% CI: 0.025-0.719). No case of hemostatic clip closing the bile duct or pancreatic duct by mistake occurred in the hemostatic clip group. No significant differences were observed in postoperative hyperamylasemia and pancreatitis between the 2 groups. This study indicated that the prophylactic application of a hemostatic clip is associated with a significantly reduced rate of delayed bleeding after ES in high-risk patients. This approach did not increase the risk of adverse event.

What is the weakest point of a secured aortic cannula in central extracorporeal membrane oxygenation?

The purpose of this study was to compare techniques for securing the aortic extracorporeal membrane oxygenation (ECMO) cannula, using in vitro models. Two models were studied: a tissue model using porcine aortas and a stand model replacing the aorta with a metal stand to study the system independent of the tissue. Interventions in each model were divided into three experimental groups: Group 1 (3-0 Prolene® + 20-French Medtronic Arterial Cannula EOPA™), Group 2 (4-0 Prolene® + 16-French Medtronic Arterial Cannula DLP Pediatric), and Group 3 (5-0 Prolene® + 8-French Medtronic Arterial Cannula DLP Pediatric). In separate experiments, both gradual and rapid forces were applied to the cannulas, starting with 9.8 Newtons and increasing exponentially if the cannula remained secured. Additionally, the method of securing the tourniquet and the number of ties securing the tourniquet to the cannula were evaluated. In the tissue model, even with a minimum force of 9.8 Newtons, the suture pulled through the aortic tissue, leaving sutures and ties intact. In the stand model, two purse-string sutures secured by two ligaclips held the cannula reliably and withstood higher total force. Dislodgement was prevented at forces close to 60 Newtons with only two hemostatic clips included in cannulation. The weakest part of the aortic ECMO cannulation system using in vitro experiments was the tissue. Assuming that these experiments translate in vivo, it is therefore critical to prevent any pull on the cannulas by securing ECMO cannulas and ECMO tubing to both the patient and the patient's bed. Sutures with a larger diameter withstand more force. Two medium hemostatic clips can secure Prolene® sutures within snares as safely as a mosquito hemostat. Two polypropylene purse-string sutures secured by two hemostatic clips were most reliable at greater forces. The rationale for publishing our experiments in this manuscript is to (1) communicate our quantification of possible contributing factors to this rare and likely catastrophic complication of unintended decannulation, (2) increase awareness about this potential complication, and (3) increase vigilance to assure prevention of this dreaded complication.

Development and evaluation of RFID-integrated endoscopic clips for laparoscopic surgery marking.

As advancements in surgical instruments and techniques continue to evolve, minimally invasive surgery has become increasingly preferred as a means of reducing patient pain and recovery time. However, one major challenge in performing minimally invasive surgery for early gastrointestinal cancer is accurately identifying the location of the lesion. This is particularly difficult when the lesion is confined to the lumen of the intestine and cannot be visually confirmed from the outside during surgery. In such cases, surgeons must rely on CT or endoscopic imaging to locate the lesion. However, if the lesion is difficult to identify with these images or if the surgeon has less experience, it can be challenging to determine its precise location. This can result in an excessive resection margin, deviating from the goal of minimally invasive surgery. To address this challenge, researchers have been studying the development of a marker for identifying the lesion using a radio-frequency identification (RFID) system. One proposed method for clinical application of this detection system is to attach an RFID tag to an endoscopic hemostatic clip and fix it to the intended position, providing a stable marker for the inner wall of the organ. This approach has the potential to improve the accuracy and effectiveness of minimally invasive surgery for early gastrointestinal cancer. In the development of a marker for identifying gastrointestinal lesions using a radio-frequency identification (RFID) system, the shape of the clip and suitable materials for attaching the RFID tag were determined through finite element method (FEM) analysis. A prototype of the clip was then fabricated and ex-vivo experiments were conducted using porcine intestine to evaluate the stability of the clip in relation to its position. To further evaluate the performance of the RFID-integrated clip in vivo, the clip was placed in the gastric wall of the stomach of anesthetized porcine using an endoscopic instrument. The clip was then detected using a RFID detector designed for laparoscopic approach. And later, the accuracy of detection was confirmed by incising the lesion. The design and fabrication of a clip with varying thicknesses using STS316 and STS304 stainless steel were accomplished using the results of finite element method analysis. The stability of the clip was evaluated through ex-vivo experiments, showing it to be a viable option. In-vivo experiments were performed on anesthetized porcine, in which the RFID-integrated clip was placed in the gastric wall and detected using a custom-made RFID detector. The resection margin, measured at about 30 mm from the detector position, was accomplished with low error. These findings indicate the feasibility and efficacy of using an RFID-integrated clip as a marker in minimally invasive surgery for the identification of gastrointestinal lesions. The study evaluated the feasibility of using stainless steel clips for lesion detection in endoscopic surgery using computer-aided engineering analysis and ex-vivo experimentation. Results showed that STS304 was suitable for use while STS316L was not. The ex-vivo experiments revealed that the clip holding force and tissue retention length varied depending on the location of attachment. In-vivo experiments confirmed the accuracy and usefulness of the RFID lesion detection system. However, challenges remain for its use in clinical field, such as ensuring the stability of the clip and the safe attachment of the RFID tag, which requires further research for commercialization.

Effectiveness and economic outcomes in patients undergoing laparoscopic radical prostatectomy with a new surgical shear with an integrated energy system: A retrospective study based on a tertiary hospital database in China

ObjectiveThis study aimed to demonstrate a new surgical shear with an integrated energy system (Harmonic ACE®+7) value by determining its effectiveness and economic outcomes compared with conventional ultrasonic shears (CUSs) in a real-world setting. MethodsThis was a retrospective study of adults with prostate cancer undergoing laparoscopic radical prostatectomy with the ACE®+7 shear or CUSs between August 2019 and April 2021 at Shanghai Ruijin Hospital (the headquarters and Luwan Center in China). Demographic and diagnosis information, intraoperative and postoperative clinical outcomes, and total and categorical costs were collected. Propensity score matching was performed to form the study population for each clinical group. Data were compared between the two groups using t-test and Chi-squared test. ResultsThe ACE®+7 was associated with a lower mean number of hemostatic clips used per surgery compared with CUSs (12.8 vs. 19.8, p<0.001), a moderate but not significant difference in mean postoperative drainage duration (6.6 [standard deviation, SD 2.2] days vs. 7.9 [SD 4.1] days, p=0.082), a reduction on mean total drainage volume (275.5 [SD 374.3 mL vs. 492.9 [SD 1495.0] mL, p=0.321), and a lower average rate of postoperative hemostatic drug usage (16.0% vs. 52.0%, p<0.001). There was no significant difference in total costs between the ACE®+7 and CUS groups. ConclusionThis study provides real-world data demonstrating that the ACE®+7 shear with an integrated energy system improves clinical outcomes compared with CUSs and can offer cost savings for hospitals and health systems. Using the ACE®+7 during laparoscopic radical prostatectomy allows physicians to help their patients achieve better outcomes and not spend additional money.

Characteristics of Bleeding Peptic Ulcers and the Outcome after Endoscopic Therapy at a Tertiary Care Centre of Pakistan

Peptic ulcers are a global health concern. Bleeding episodes, a common complication require urgent intervention. Endoscopic therapy for managing bleeding peptic ulcers offering both diagnostic and therapeutic benefits. Objective: To analyze the characteristics of bleeding peptic ulcers and assess the outcomes following endoscopic therapy. Methods: A descriptive case series was conducted at Lahore General Hospital (LGH) between June 2021 and January 2022. Patients aged 18-80 with upper GI bleeding due to peptic ulcers or undergoing endoscopy with bleeding peptic ulcers were included. An 80mg bolus of omeprazole was given, followed by infusion at 8mg per hour and an urgent endoscopy was planned. Patients were observed for re-bleeding for 72 hours post-endoscopy. Results: Out of total 100 patients with upper GI bleeding, 70% of patients were male and 30% were female. The most common diagnosis was duodenal ulcers (75%), with the anterior wall being the most common site (86.67%). Dual therapy was administered in all patients, with hemostatic clips being applied in 68% of patients and electrocoagulation heat therapy being used in 32% of patients. Initial hemostasis was successful in 88% of patients treated endoscopically. But, 12% of patients experienced heavy bleeding during endotherapy and out of these, 8 patients required urgent laparotomy. Patients needed a second look endoscopy, 4 patients requiring angiographic embolization and 6 being managed with endotherapy. Conclusion: Dual therapy, hemostatic clips and electrocoagulation heat therapy are effective in achieving initial hemostasis in most cases

Perforation of a peptic ulcer with migration of hemostatic clips: a rare complication in the treatment of upper gastrointestinal haemorrhage

Abstract Hemostatic clips are one of the most common treatment options for upper gastrointestinal haemorrhage, allowing for monotherapy in Forrest IIa or higher-grade bleeding. Complications associated with them are infrequent, limited to erosions and minor bleeding related to their deployment. We present the case of a patient with upper gastrointestinal haemorrhage secondary to a duodenal peptic ulcer. The patient was treated using a combination of various hemostatic methods, which resulted in perforation of the ulcer and migration of a hemostatic clip into the duodeno-pancreatic groove.

Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit.

Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.

A137 BALLOON-ASSISTED ENDOSCOPY FOR SMALL BOWEL BLEEDING – A REVIEW

Abstract Background Gastrointestinal (GI) bleeding is a potentially life-threatening medical emergency requiring immediate medical attention. Obscure GI bleeding (OGIB) Is defined as GI bleeding with no obvious culprit lesion found on initial upper or lower endoscopy. Further investigations are needed as 75% of those cases originate in the small bowel. The advent of small bowel endoscopy, consisting of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE) has allowed clinicians to endoscopically visualize the entire GI tract and perform therapeutic interventions. These devices include balloon assisted endoscopy (BAE) and Spiral Endoscopy (SPE). Aims The objectives of this review are to analyze the definitions, etiologies, and risk factors of OGIB. Furthermore, we reviewed the diagnostic and therapeutic yields of DAE and its safety profile. Due to the adverse effects and recall of SPE, we only report here on BAE. Methods A literature review was conducted using PubMed and OvidSP (Medline) to identify articles on the use of VCE and DAE for OGIB. Keywords included a combination of gastrointestinal bleeding with occult, obscure, active and inactive, small bowel bleed, diagnostic yield, therapeutic yield, and rebleeding rate. The information was obtained via systematic review and meta-analysis, retrospective studies, and case reports. Results A total of 32 papers were reviewed. The most common causes of OGIB reported were vascular lesions (23-47%), inflammatory lesions (12-16%), and tumors (5-16%). The risk factors associated with OGIB include age, cardiac disease, liver cirrhosis, chronic kidney disease, and hereditary vascular diseases. The overall diagnostic and therapeutic yields of BAE in OGIB were 76.3% and 49.5%, respectively. Factors that increased the yield included performing an initial VCE (increase by 7%) and performing the procedure within the first 10 days after the initial bleeding episode (87.5%) as compared to after 10 days (11.1%). Recurrent bleeding can occur in up to 46% of patients. Risk factors for rebleeding include cirrhosis, overt bleeding symptoms, and presence of multiple vascular lesions. Associated adverse effects in DAE were minor in 9.1% of patients and severe in less than 2%. These include bleeding (0.8%), perforation (0.3%), and pancreatitis (0.3%). Conclusions OGIB is a challenging clinical entity. BAE now allows clinicians to diagnose and treat culprit lesions in the small bowel with reasonable success and a strong safety profile, however timing and prior VCE can further optimize this. Clinical decisions and follow up should be made based around existing risk stratification tools and scores. Further prospective research is needed to determine optimal timing of DAE from presentation of OGIB that would increase diagnostic and therapeutic yields. Figure 1. A and B) Endoscopic images of small bowel vascular lesion. C) Bleeding vascular lesion treated with hemostatic clips. Funding Agencies None

Turn over the new leaf of the treatment in peptic ulcer bleeding: a review of the literature.

Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%-90%. However, 10%-20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments.

Tulip-bundle technique for suture dehiscence in a Boerhaave syndrome.

A 55-year-old-woman was admitted to the emergency department with hematemesis and abdominal pain. Her physical examination was unremarkable. Laboratory results without anemia. The upper gastrointestinal endoscopy revealed a deep large tear between 36 and 39 cm with transmural perforation. A diagnosis of Boerhaave syndrome was made. Thoraco-abdominal CT-scan revealed a laceration in the left posterolateral side of the esophagus, measuring 6.5 cm proximal to the esophagogastric junction (GEJ), associated with a pneumomediastinum, pneumoperitoneum and a mediastinal air fluid collection anteriorly to the GEJ. The patient was submitted to laparoscopic surgery with closure of the perforation, Graham patch confection. Nine days after, the esophago-gastric transit showed luminal contrast leakage to the posterior mediastinum. An endoscopic evaluation showed a 2 cm suture dehiscence. We applied a hemostatic clip in the distal end of the tear to bring the edges closer, but it was impossible to put additional ones. It was decided to perform a tulip-bundle technique with a single-channel endoscope in a sequential two-step maneuver and another two clips were placed in the borders of the tear with an endoloop applied over the clips with success. One month later, an endoscopic revaluation was performed, revealing the clips involved by the endoloop and no signs of leakage. After that, she started oral diet without any complications.

Uterine tubal ligation via mini-laparotomy in South American coatis (Nasua nasua)

Population management is becoming critically important for species that inhabit urban areas, particularly due to the public health risks they pose. The South American coatis (Nasua nasua), recognized as synanthropic species in Brazil, have raised increasing concerns due to their cohabitation with humans, especially in recreational settings such as parks, where the potential for zoonotic disease transmission is heightened. This study aimed to assess the effectiveness of a minimally invasive sterilization method for female South American coatis, employing tubal ligation via mini-laparotomy. A total of nine females were selected for this procedure, which was performed in both an ecological park and a zoo setting. The techniques employed involved either the application of titanium hemostatic clips (n = 2) or a nylon suture (n = 7). The results demonstrated that the nylon suture technique was not only quicker (12.7 ± 1.7 vs. 47.5 ± 2.5 min) and more cost-effective but also maintained effective contraception. There were no recorded instances of pregnancy among the sterilized females, whether they were later exposed to males in captivity or recaptured in the wild. Furthermore, the procedure did not alter the social dynamics or sexual behaviors of the coatis upon their return to their natural habitat. The methods used in this study were proven to be safe, enabling quick recovery and showing no post-surgical complications, highlighting their viability for managing populations of synanthropic species in urban environments.

Prevention of Migration of Esophageal Self-Expandable Metallic Stents Using Endoscopic Clips.

Background and Objectives: Esophageal stenting with self-expandable metallic stents (SEMS), for both benign and malignant reasons, has been widely practiced for decades, but migration still remains the most common complication of the procedure. In this report we aim to review our experience and results in stent fixation with clips. Materials and Methods: We present 18 patients who underwent esophageal stenting for both benign and malignant reasons. The SEMSs used were partially covered and were fixated with two to four through the scope hemostatic clips in the proximal end of the prothesis. The procedure was performed only on patients with a high risk of migration of the stent. Results: Migration occurred in only one of the above-mentioned patients and was treated with stent repositioning. The other adverse events that occurred were related to tumor growth in patients with malignant diseases. Conclusions: Clip fixation of an esophageal self-expandable metallic stent in cases considered high-risk for migration is a safe procedure. It reduces the migration rate significantly for both benign and malignant indications.

Submucosal tunneling endoscopic full-thickness resection for management of a rare case of esophageal GI stromal tumor

Video 1The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.

Adaption of novel clip-closure technique for large mucosal defects after EMR of a colon laterally spreading tumor using standard hemostatic clips

Video 1EMR of a large colonic polyp with defect closure using Resolution 360 ULTRA Clips (Boston Scientific, Boston, Mass, USA) and the Anchor, Mobilize, and Close approach.

Endoscopic Resection Techniques for Duodenal and Ampullary Adenomas.

Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary adenomas are even less common. Nonetheless, the incidence continues to rise because of widespread endoscopy use. Duodenal polyps with villous features or those that are larger than 10mm may raise concern for malignancy and require removal. We demonstrate endoscopic resection of SNDAs and ampullary adenomas using some of our preferred techniques. The duodenum has several components that can make EMR of duodenal polyps technically challenging. Not only does the duodenum have a thin muscle layer, but it is also highly mobile and vascular, which may explain higher rates of perforation and bleeding of duodenal EMR reported in the literature compared with colon EMR. A standard adult gastroscope with a distal cap is commonly used for duodenal EMRs. Based on the location, however, side-viewing duodenoscopes or pediatric colonoscopes may be used. To prepare for EMR, a submucosal injection is performed for an adequate lift. The polyp is then resected via stiff monofilament snares and subsequently closed with hemostatic clips if feasible. The ampullectomy technique differs slightly from duodenal EMRs and carries the additional risk of pancreatitis. Submucosal injection in the ampulla may not lift well; thus, its utility is debatable. Biliary sphincterotomy should be performed, and based on endoscopist preference, the pancreatic duct (PD) guidewire can be left during resection to maintain access. After resection, a PD stent is placed to minimize pancreatitis risk. The video shows the aforementioned duodenal EMR techniques. Two clips of ampullectomy are also shown in the video. A few common techniques used to perform duodenal EMR and ampullectomy are highlighted in the video. It is important to understand and manage adverse events associated with these procedures and to have established surveillance plans.

Evaluation of a single-use gastroscope in patients presenting with suspected upper gastrointestinal hemorrhage: a pilot feasibility study (One-Scope I).

BACKGROUND : Outbreaks of multidrug-resistant bacteria due to contaminated duodenoscopes and infection risks during the COVID-19 pandemic have driven the development of single-use endoscopes. The first single-use gastroscope is now available in Europe. Besides waste disposal and cost issues, the infection risk and performance remain unclear. We aimed to evaluate a single-use gastroscope in patients with signs of upper gastrointestinal bleeding. METHODS : 20 consecutive patients presenting with clinical signs of upper gastrointestinal bleeding between October and November 2022 were included in this case series. The primary aim was technical success, defined as access to the descending duodenum and adequate assessment of the upper gastrointestinal tract for the presence of a bleeding site. RESULTS : The primary aim was achieved in 19/20 patients (95 %). The bleeding site was identified in 18 patients. A therapeutic intervention was performed in six patients (two cap-mounted clips, one standard hemostatic clip, two variceal band ligations, one hemostatic powder, two adrenaline injections); technical and clinical success were achieved in all six patients. Two crossovers to a standard gastroscope occurred. CONCLUSIONS : Use of single-use gastroscopes may be feasible for patients presenting for urgent endoscopic evaluation and treatment of upper gastrointestinal bleeding.

Peroperative administration of tranexamic acid in sleeve gastrectomy to reduce hemorrhage: a double-blind randomized controlled trial

IntroductionIn metabolic surgery, hemorrhage is the most common major complication. This study investigated whether peroperative administration of tranexamic acid (TXA) reduced the risk of hemorrhage in patients undergoing laparoscopic sleeve gastrectomy (SG).MethodsIn this double-blind randomized controlled trial, patients undergoing primary SG in a high-volume bariatric hospital were randomized (1:1) to receive 1500-mg TXA or placebo peroperatively. Primary outcome measure was peroperative staple line reinforcement using hemostatic clips. Secondary outcome measures were peroperative fibrin sealant use and blood loss, postoperative hemoglobin, heart rate, pain, major and minor complications, length of hospital stay (LOS), side effects of TXA (i.e., venous thrombotic event (VTE)) and mortality.ResultsIn total, 101 patients were analyzed and received TXA (n = 49) or placebo (n = 52). There was no statistically significant difference in hemostatic clip devices used in both groups (69% versus 83%, p = 0.161). TXA administration showed significant positive changes in hemoglobin levels (millimoles per Liter; 0.55 versus 0.80, p = 0.013), in heart rate (beats per minute; -4.6 versus 2.5; p = 0.013), in minor complications (Clavien–Dindo ≤ 2, 2.0% versus 17.3%, p = 0.016), and in mean LOS (hours; 30.8 versus 36.7, p = 0.013). One patient in the placebo-group underwent radiological intervention for postoperative hemorrhage. No VTE or mortality was reported.ConclusionThis study did not demonstrate a statistically significant difference in use of hemostatic clip devices and major complications after peroperative administration of TXA. However, TXA seems to have positive effects on clinical parameters, minor complications, and LOS in patients undergoing SG, without increasing the risk of VTE. Larger studies are needed to investigate the effect of TXA on postoperative major complications.Graphical abstract

Bleeding After Endoscopic Resection of Colonic Adenomatous Polyps Sized 4-10 mm.

Introduction: Colonoscopy with polypectomy is an efficacious procedure in reducing the risk of colorectal cancer development, the precursor are adenomatous polyps. The most common method for resection of polyps measuring 4-10 mm are cold (CSP) and hot snare polypectomy (HSP). CSP has a lower incidence of adverse events, especially delayed post-polypectomy bleeding. Aim: To evaluate the presence of immediate and delayed bleeding in the cold snare polypectomy of sub-centimeter polyps of the colon compared with hot snare polypectomy. Materials and Methods: This prospective clinical study is comprised all patients who were incidentally detected to have adenomatous colonic polyps measuring 4-10 mm during a colonoscopy screening. Polypectomy was done with (hot snare) or without electrocautery (cold snare). After removal of polyps, immediate bleeding, delayed bleeding, and methods for were analyzed. Results: The CSP and HSP groups included 116 patients, 113 (54.4%) polyps in 61 (52.6%) patients with CSP while 95 (45.6%) polyps in 55 (47.4%) patients with HSP. 25 (22.1%) polyps after CSP had immediate bleeding. In 5 patients (20.0%), five hemostatic clips were inserted after CSP for bleeding longer than 150 sek. The average percentage difference between immediate bleeding versus total number of resected polyps using the cold snare method is not statistically significant (p<0.05) (Difference test, p=0.0000). Delayed bleeding was not registered using this method. In the second investigated group (HSP), one patient had delayed bleeding. This was stopped with 2 clips. Immediate bleeding was not registered. Conclusion: CSP is safer than HSP in resecting colon polyps sized 4-10 mm, without risk of delayed bleeding.

Usefulness of texture- and color-enhancement imaging for identifying the bleeding point in a patient with post-endoscopic sphincterotomy bleeding.

Video 1Upon reaching the papilla, fresh blood was observed. However, the bleeding point could not be detected on white-light imaging. Therefore, we switched to texture- and color-enhancement imaging to identify the bleeding point. A visible vessel was identified on texture- and color-enhancement imaging. Endoscopic hemostasis was successfully achieved using a hemostatic clip.