Renato Baracat

Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials.

BackgroundPeptic ulcer represents the most common cause of upper gastrointestinal bleeding. Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this review is to compare the different modalities of endoscopic therapy.MethodsStudies were identified by searching electronic databases MEDLINE, Embase, Cochrane, LILACS, DARE, and CINAHL. We selected randomized clinical trials that assessed contemporary endoscopic hemostatic techniques. The outcomes evaluated were: initial hemostasis, rebleeding rate, need for surgery, and mortality. The possibility of publication bias was evaluated by funnel plots. An additional analysis was made, including only the higher-quality trials.ResultsTwenty-eight trials involving 2988 patients were evaluated. Injection therapy alone was inferior to injection therapy with hemoclip and with thermal coagulation when evaluating rebleeding and the need for emergency surgery. Hemoclip was superior to injection therapy in terms of rebleeding; there were no statistically significant differences between hemoclip alone and hemoclip with injection therapy. There was considerable heterogeneity in the comparisons between hemoclip and thermal coagulation. There were no statistically significant differences between thermal coagulation and injection therapy, though their combination was superior, in terms of rebleeding, to thermal coagulation alone.ConclusionsInjection therapy should not be used alone. Hemoclip is superior to injection therapy, and combining hemoclip with an injectate does not improve hemostatic efficacy above hemoclip alone. Thermal coagulation has similar efficacy as injection therapy; combining these appears to be superior to thermal coagulation alone. Therefore, we recommend the application of hemoclips or the combined use of injection therapy with thermal coagulation for the treatment of peptic ulcer bleeding.

EUS-guided fistulization of postoperative colorectal stenosis in an infant with Hirschsprung's disease: a new technique

1. Abe N, Takeuchi H, Yanagida O, et al. Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor. Surg Endosc 2009;23:1908-13. 2. Nakajima K, Nishida T, Takahashi T, et al. Partial gastrectomy using natural orifice translumenal endoscopic surgery (NOTES) for gastric submucosal tumors: early experience in humans. Surg Endosc 2009;23:2650-5. 3. Cho WY, Kim YJ, Cho JY, et al. Hybrid natural orifice transluminal endoscopic surgery: endoscopic full-thickness resection of early gastric cancer and laparoscopic regional lymph node dissection—14 human cases. Endoscopy 2011;43:134-9.

Endoscopic treatment of upper-GI ulcer bleeding with hemostatic powder spray

Peptic ulcer is the most common cause of upper-GI bleeding (UGIB). Despite the advances in the management of this condition, mortality remains significant, at 10%. Hemospray (TC-325, Cook Medical, Bloomington, Ind) is a new hemostatic modality that has shown interesting results in a variety of causes, either as monotherapy or as rescue therapy, apparently with the advantage of its easy applicability, especially in difficult situations. Hemospray consists of a mineral powder that absorbs water when applied into the actively bleeding lesion, forming a mechanical barrier over the bleeding site. A 58-year-old man experienced major in-hospital UGIB. The patient did not describe previous diseases and presented to the emergency department with progressive dyspnea. A CT scan showed small nodules uniformly distributed throughout both lungs, suggestingmiliary tuberculosis asso-

Hemostatic powder: a new ally in the management of postsphincterotomy bleeding

ERCP with sphincterotomy is the criterion standard treatment for the management of choledocholithiasis because it has low morbidity and mortality rates and excellent outcomes; however, adverse events are not uncommon. Postsphincterotomy bleeding has an estimated incidence of less than 2%, but it represents a serious adverse event of ERCP. The management of postsphincterotomy bleeding is challenging, and the main therapeutic modality is endoscopic treatment. The most commonly performed hemostatic procedure is epinephrine injection, which is effective in most cases. Nevertheless, some cases demand combined therapy. It is known that endoscopic clipping with the use of a side-view endoscope is a laborious procedure; therefore, the development of new hemostatic procedures is imperative. Hemospray (Cook Medical, Winston-Salem, NC) is a new endoscopic accessory and consists of a mineral powder that absorbs water when applied to an actively bleeding lesion, forming a mechanical barrier over the bleeding site. We offer a video in which Hemospray application successfully controlled postsphincterotomy bleeding. A 69-year-old man was referred to our department with a diagnosis of choledocholithiasis. ERCP confirmed the latter, and sphincterotomy, followed by calculi extraction,