Published online Apr 7, 2019. doi: 10.3748/wjg.v25.i13.1592
Peer-review started: December 25, 2018
First decision: February 21, 2019
Revised: March 6, 2019
Accepted: March 11, 2019
Article in press: March 12, 2019
Published online: April 7, 2019
Gastrointestinal (GI) bleeding frequently leads to hospital admission and is associated with relevant morbidity and mortality, particularly in the elderly. Due to the increasing administration of direct oral anticoagulants in the last years and the emerging role of antiplatelet agents, sufficient and effective treatment of GI bleeding is mandatory while at the same time can be clinically challenging. In the last years, endoscopists increasingly face emergency bleeding in a clinical scenario in which coagulation parameters cannot always be corrected to normal range. Further, with increasing development of advanced endoscopic therapeutic procedures, iatrogenic bleeding after endoscopic resections represents another emerging problem. For refractory cases, hemostatic powders (HP) represent “touch-free” agents.
Although data on the efficacy of Endoclot (EC) are still limited, first clinical evidences suggest that both Hemospray (HS) and EC allow for effective bleeding control. Further, no direct comparison of the efficacy of these two HP is available to date.
Against this background we set off: (1) To analyze the short and long term success in achieving hemostasis with HP; and (2) to directly compare the two agents HS and EC in their efficacy for achieving hemostasis in a large cohort of patients treated for emergency GI bleeding in our center.
Data were prospectively collected on patients who were treated with HS and EC for endoscopic hemostasis during emergency endoscopy between September 2013 and September 2017 in our center. Patients were followed-up for at least one month after index endoscopy and data analysis was performed after follow-up was completed
HP was applied in 154 consecutive patients (mean age 67 years) with GI bleeding in our center. Patients were followed up for at least 1 month (mean follow up: 3.2 mo). The majority of HP applications were in the upper GI tract (89%) with the following bleeding sources: Peptic ulcer disease (35%), esophageal varices (7%), tumor bleeding (11.7%), reflux esophagitis (8.7%), diffuse oozing bleeding and erosions (15.3%). Overall short term (ST) success with HP was achieved in 125 patients (81%) and long term (LT) success in 81 patients (67%). Re-bleeding occurred in 27% of all patients treated with HP. In 72 patients (47%), HP was applied as a salvage hemostatic therapy, here ST and LT success were 81% and 64%, respectively, with re-bleeding in 32% of patients. As a primary hemostatic therapy, ST and LT success were 82% and 69%, respectively, with re-bleeding occurring in 22%. Subgroup analysis showed a ST and LT efficacy for cancer bleeding of 83% and 87%, for peptic ulcer disease of 81% and 56% and in patients under therapeutic anticoagulation of 80% and 60.5%. There was no statistical difference in the ST or LT efficacy between EC and HS for the various indications; however, HS was more frequently applied for upper GI bleeding (P = 0.04)
Within this study, we retrospectively analyzed the hemostatic efficacy of HPs HS and EC as first line or salvage therapy in several clinical scenarios in a large cohort of prospectively included patients. As shown in our report, both HPs allow for excellent ST bleeding control when applied as primary or salvage therapy. At the same time, LT efficacy over a period of 4 weeks is maintained in a considerable amount of patients.
Both EC and HS exhibit high efficacy for achieving hemostasis in impaired coagulation status or friable tissues. With these properties, HPs represent powerful and effective additions to the armentarium of the endoscopist for treatment of GI bleeding.