Yen-I Chen

Use of the endoscopically applied hemostatic powder TC-325 in cancer-related upper GI hemorrhage: preliminary experience (with video)

o p h a p 4 Upper GI hemorrhage is a common complication of gastroduodenal tumors. Bleeding from these neoplasms s generally difficult to control and is associated with high ebleeding rates. Current modalities for management inlude endoscopy, radiotherapy, interventional angiograhy, and surgery. Hemospray (Cook Medical, Winston-Salem, NC) is an merging endoscopic hemostatic technology that was reently introduced in the management of upper GI bleedng.2 It is composed of a proprietary inorganic powder that, when put in contact with moisture in the GI tract, becomes coherent and adhesive, thus serving as a mechanical barrier for hemostasis. Given its malleable nature, its ability to cover large areas, and especially the lack of direct contact with target tissue as it is sprayed onto the lesion, its use in bleeding gastroduodenal tumors has been suggested.2 Animal studies have demonstrated its safety nd its lack of absorption by the GI tract; it is also elimiated within 48 hours of application with no reported owel obstruction.3 Recently, a prospective, pilot study involving 20 patients with nonmalignant upper GI bleeding showed that the application of Hemospray was associated with a 95% initial hemostasis with no active bleeding seen on repeat EGD at 72 hours, followed by total elimination of the inorganic substance without complications such as intestinal obstruction or embolization.2 To our knowledge, the following describes the first 5 reported cases of upper GI hemorrhage secondary to gas-

Hemostatic powder TC-325 in the management of upper and lower gastrointestinal bleeding: a two-year experience at a single institution

BACKGROUND AND STUDY AIMS TC-325 is a novel endoscopic hemostatic powder. Our aim was to describe a single-center experience with the use of TC-325 in the upper and lower gastrointestinal tract, while for the first time attempting to determine how long the powder remains on a lesion. PATIENTS AND METHODS The charts of consecutive patients receiving TC-325 therapy between July 2011 and July 2013 were reviewed retrospectively. Primary endpoints included immediate hemostasis and early rebleeding (≤ 72 hours). RESULTS Overall, 60 patients received 67 treatments with TC-325: 21 for nonmalignant nonvariceal upper gastrointestinal bleeding, 19 for malignant upper gastrointestinal bleeding, 11 for lower gastrointestinal bleeding, and 16 for intra-procedural bleeding. Immediate hemostasis was achieved in 66 cases (98.5 %), with 6 cases (9.5 %) of early rebleeding. No serious adverse events were noted. No TC-325 powder was identified in the 11 patients who underwent second-look endoscopy, performed within 24 hours in 4 patients. CONCLUSIONS TC-325 appears safe and effective for managing bleeding in the upper and lower gastrointestinal tract with a variety of causes. The time during which the powder remains in the gastrointestinal tract is short, with complete elimination from the gastrointestinal tract as early as within 24 hours after use.

Hemostatic Powders in Gastrointestinal Bleeding: A Systematic Review.

Topical hemostatic agents and powders are an emerging modality in the endoscopic management of upper and lower gastrointestinal bleeding. This systematic review demonstrates the effectiveness and safety of these agents with special emphasis on TC-325 and Ankaferd Blood Stopper. The unique noncontact/nontraumatic application, ability to cover large areas of bleed, and ease of use make these hemostatic agents an attractive option in certain clinical situations, such as massive bleeding with poor visualization, salvage therapy, and diffuse bleeding from luminal malignancies.

Celiac plexus neurolysis in the management of unresectable pancreatic cancer: When and how?

Pancreatic cancer is the second most common abdominal cancer in North America with an estimated 20% resectability at diagnosis, and overall 5-year survival of 5%. Pain is common in pancreatic cancer patients with 70%-80% suffering substantial pain. Celiac plexus neurolysis (CPN) is a technique that can potentially improve pain control in pancreatic cancer while preventing further escalation of opioid consumption. CPN is performed by injecting absolute alcohol into the celiac plexus neural network of ganglia. This review sets out to explore the current status of CPN in non-resectable pancreatic cancer. We will examine: (1) the efficacy and safety of percutaneous-CPN and endoscopic ultrasound guided-CPN; (2) specific technique modifications including bilateral (vs central) injections and celiac ganglia neurolysis; and (3) the issue of CPN timing, early at pancreatic cancer diagnosis vs traditional late use as salvage therapy.

Prevention and Management of Gastroesophageal Varices in Cirrhosis

Variceal hemorrhage is one of the major complications of liver cirrhosis associated with significant mortality and morbidity. Its management has evolved over the past decade and has substantially reduced the rate of first and recurrent bleeding while decreasing mortality. In general, treatment of esophageal varices can be divided into three categories: primary prophylaxis (prevention of first episode of bleeding), management of acute bleeding, and secondary prophylaxis (prevention of recurrent hemorrhage). The goal of this paper is to describe the current evidence behind the management of esophageal varices. We will discuss indications for primary prophylaxis and the different modes of therapy, pharmacological and interventional treatment in acute bleeding, and therapeutic options in preventing recurrent bleeding. The indications for TIPS will also be reviewed including its possible benefits in acute variceal hemorrhage.

Endoscopic Management of Acute Peptic Ulcer Bleeding

This review discusses the indications, technical aspects, and comparative effectiveness of the endoscopic treatment of upper gastrointestinal bleeding caused by peptic ulcer. Pre-endoscopic considerations, such as the use of prokinetics and timing of endoscopy, are reviewed. In addition, this article examines aspects of postendoscopic care such as the effectiveness, dosing, and duration of postendoscopic proton-pump inhibitors, Helicobacter pylori testing, and benefits of treatment in terms of preventing rebleeding; and the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, and oral anticoagulants, including direct thrombin and Xa inhibitors, following acute peptic ulcer bleeding.

Can the presence of endoscopic high-risk stigmata be predicted before endoscopy? a multivariable analysis using the RUgBe database

BACKGROUND Many aspects in the management of acute upper gastrointestinal bleeding rely on pre-esophagogastroduodenoscopy (EGD) stratification of patients likely to exhibit high-risk stigmata (HRS); however, data predicting the presence of HRS are lacking. OBJECTIVE To determine clinical and laboratory predictors of HRS at the index EGD in patients presenting with acute upper gastrointestinal bleeding using retrospective data from a validated national database - the Canadian Registry in Upper Gastrointestinal Bleeding and Endoscopy registry. methods: Relevant clinical and laboratory parameters were evaluated. HRS was defined as spurting, oozing, nonbleeding visible vessel or adherent clot after vigorous irrigation. Multivariable modelling was used to identify predictors of HRS including age, sex, hematemesis, use of antiplatelet agents, American Society of Anesthesiologists (ASA) classification, nasogastric tube aspirate, hemoglobin level and elapsed time from the onset of bleeding to EGD. RESULTS Of the 1677 patients (mean [± SD] age 66.2 ± 16.8 years; 38.3% female), 28.7% had hematemesis, 57.8% had an ASA score of 3 to 5, and the mean hemoglobin level was 96.8 ± 27.3 g⁄L. The mean time from presentation to endoscopy was 22.2 ± 37.5 h. The best fitting multivariable model included the following significant predictors: ASA score 3 to 5 (OR 2.16 [95% CI 1.71 to 2.74]), a shorter time to endoscopy (OR 0.99 [95% CI 0.98 to 0.99]) and a lower initial hemoglobin level (OR 0.99 [95% CI 0.99 to 0.99]). CONCLUSION A higher ASA score, a shorter time to endoscopy and lower initial hemoglobin level all significantly predicted the presence of endoscopic HRS. These criteria could be used to improve the optimal selection of patients requiring more urgent endoscopy.

A novel collaborative approach to endoscopic double bypass in concomitant gastric outlet and biliary obstruction

Endoscopic ultrasound (EUS)-guided double bypass (EUS-DB) is a novel technique in the management of concomitant biliary and gastric outlet obstruction [1–3]. It involves the creation of both an EUS-guided gastroenterostomy and a hepatogastrostomy. We describe the first reported case in the literature (with video) of EUS-DB performed in collaboration with interventional radiology. A 54-year-old man with known locally advanced pancreatic cancer was referred for recurrent cholangitis and gastric outlet obstruction despite previous duodenal stenting and transhepatic percutaneous biliary drainage (PTBD). Endoscopy confirmed complete obstruction of the duodenal stent as a result of tumor tissue ingrowth. A decision was made to proceed to EUS-DB to optimize nutritional status, biliary drainage, and patient comfort (▶Video1). A guidewire was introduced through the PTBD, traversing the enteral stent, and advanced to the jejunum. A 20-mm dilating balloon with an overlapping snare attached was then introduced over the PTBDwire and advanced across the enteral stent to the ligament of Treitz, where the balloon was inflated under fluoroscopy (▶Fig. 1 a). Overall, 500mL of both saline and contrast was then injected percutaneously to dilate the small-bowel segment proximally to the balloon. EUS-guided puncture of the balloon was performed transgastrically with a 19-gauge needle (▶Fig. 1 b). Bursting of the balloon confirmed successful puncture in the desired jejunal segment. A 0.035-inch guidewire was then advanced through the needle, grasped with the snare, and pulled through the percutaneous access, thereby creating wire tension on both ends of the wire. Track dilation was performed with a 4mm dilating balloon. A lumen-apposing metal stent (15×10mm) was then deployed under EUS guidance (▶Fig. 1 c). Contrast injection confirmed a patent gastroenterostomy. Attention was then shifted to the hepatogastrostomy. Under EUS guidance, a dilated hepatic segment III left intrahepatic bile duct was visualized. A transgastric E-Videos

Endosonography-guided hepatogastrostomy post-percutaneous biliary drainage in collaboration with interventional radiology

Endoscopic ultrasonography-guided hepatogastrostomy (EUS-HGS) is an effective endoscopic modality for biliary drainage in the setting of concomitant gastric outlet obstruction [1, 2]. EUSHGS however requires a dilated biliary system for technical success. This case report describes the first conversion of a percutaneous transhepatic biliary drain (PTBD) into an HGS in a non-dilated biliary system using EUS and interventional radiology techniques. A 43-year-old man underwent hepatic resection for metastatic colon cancer with full surgical transection of the common bile duct (▶Fig. 1 a); PTBDs were placed. Definitive stable drainage was needed to start adjuvant chemotherapy. Therefore, a decision was taken to perform HGS. Under EUS guidance, a non-dilated left intrahepatic bile duct was punctured with a 19-gauge needle but, given the small ductal caliber, wire passage was not possible. Two occlusive balloons were inserted via the PTBD, with one central and one peripheral to the puncture target (▶Video1). Saline was infused between the balloons, dilating the isolated duct segment. This allowed passage of a 0.035-inch guidewire (▶Fig. 1b); however, the wire traveled peripherally in the bile ducts, but was then successfully grasped with a snare and pulled out of the PTBD track. With control of both ends of the wire achieved, the HGS tract was easily dilated to 6mm with a balloon inserted through the PTBD. During tract dilation, a 10×80-mm partially covered self-expandable metal stent was simultaneously loaded through the endoscope and was advanced through the HGS tract immediately following deflation of the balloon, thereby minimizing the time between dilation and stent insertion and reducing leakage of bile. The stent was deployed, resulting in excellent drainage (▶Fig. 2). The patient was discharged 4 days later after normalization of his bilirubin and removal of the PTBD. We report the first successful conversion of a PTBD to an HGS using EUS and interventional radiology techniques in a nondilated biliary system. This multidisciplinary approach may enhance the safety of HGS.