Sprayed tissue adhesive prevents post-endoscopic submucosal dissection bleeding in massive early gastric cancer: A case report

Abstract

BACKGROUND

Endoscopic submucosal dissection (ESD) is the standard endoscopic resection technique for early gastric cancer (EGC). However, postoperative bleeding remains a frequent and clinically significant complication, especially after resection of large or extensively distributed lesions. Conventional hemostatic modalities, including titanium clips and endoloop ligation, often prove insufficient for achieving durable hemostasis and resection defect coverage across extensive mucosal defects. Sprayed tissue adhesive represents an emerging adjunctive strategy offering rapid, conformal sealing of large denuded surfaces.

CASE SUMMARY

A 59-year-old man presented with a large, diffusely infiltrating EGC lesion involving the gastric body, angulus, and antrum. ESD was performed, resulting in a 60 mm × 100 mm resection defect that could not be closed with endoscopic clips or sutures. Tissue adhesive was sprayed onto the defect surface, and the patient received postoperative proton pump inhibitor therapy. No immediate or delayed bleeding was observed during hospitalization or subsequent follow-up. A 4-month follow-up endoscopy revealed a wellhealed scar without evidence of recurrence or delayed bleeding.

CONCLUSION

Sprayed tissue adhesive safely and effectively aids prevention of post-ESD bleeding in large mucosal defects unsuitable for standard closure.

Key Words: Early gastric cancer; Endoscopic submucosal dissection; Endoscopic tissue adhesive; Butylcyanoacrylate; Hemostasis; Case report

Core Tip: Sprayed tissue adhesive effectively prevents post-endoscopic submucosal dissection bleeding in massive early gastric cancer with extensive mucosal defects, where clipping is infeasible. It is simple, covers large areas, and may be used as an adjunct or rescue therapy for refractory bleeding.

INTRODUCTION

Early gastric cancer (EGC) refers to gastric malignancies that are confined to the mucosa or submucosa, irrespective of lymph node metastasis[1,2]. Endoscopic submucosal dissection (ESD) offers the advantage of en-bloc resection and yields histological data to verify curative resection; therefore, it is currently a critical therapeutic modality for these early lesions[3]. Nevertheless, ESD is a technically demanding procedure associated with significant complications, such as hemorrhage and perforation[4]. Hemorrhage during ESD procedures is almost inevitable, particularly in large-size lesions with large mucosal defects[5], wherein conventional modalities such as titanium clips and endoloop ligation have limited efficacy for hemostasis and resection defect closure. Thus, appropriate management of hemostasis during the procedure is essential to guarantee safe ESD performance. Herein, we report a case of spraying tissue adhesive for hemostasis and prevention of delayed bleeding after gastric ESD for a large, widely involved EGC lesion.

CASE PRESENTATION

Chief complaints

A 59-year-old male patient was referred to our hospital with a 2-year history of paroxysmal dull epigastric pain and discomfort, accompanied by occasional acid regurgitation and nausea.

History of present illness

The patient first developed symptoms 2 years ago, characterized by intermittent dull epigastric discomfort, with intermittent acid regurgitation and nausea.

History of past illness

The patient’s past medical history was unremarkable.

Personal and family history

There was no family history of malignant tumors.

Physical examination

Physical examination yielded unremarkable findings.

Laboratory examinations

The laboratory findings, including complete blood count, liver function tests, electrolytes, serum creatinine, and coagulation profile, revealed no abnormalities. Additional auxiliary examinations were also performed. No abnormalities were observed on electrocardiography. Diagnostic endoscopy revealed patchy mucosal roughness and oedema on the posterior wall and lesser curvature of the lower gastric body, as well as the gastric angulus and posterior wall of the gastric antrum, with these lesions being continuous across the involved sites. Targeted biopsies were obtained from multiple sites for histopathological examination. Histopathology confirmed extensive low-grade intraepithelial neoplasia involving the gastric body, gastric angulus and gastric antrum.

Imaging examinations

Abdominal computed tomography did not reveal any abnormalities.

FINAL DIAGNOSIS

High-grade intraepithelial neoplasia of the gastric mucosa was confirmed by pathological examination of the ESD specimen, although the preoperative biopsy had suggested low-grade intraepithelial neoplasia.

TREATMENT

After written informed consent was obtained, gastric ESD was performed. Circumferential submucosal dissection was carried out along the marking incision, and the lesion was completely en-bloc resected. The procedure generated a large resection defect measuring 60 mm × 100 mm (Figure 1). Due to the large size of the resection defect, neither the traditional clamps nor nylon endoscopic sutures were suitable for stopping bleeding after heat coagulation treatment. Therefore, endoscopic tissue adhesive was sprayed widely over the defect surface (Video), and we observed effective hemostasis on the surface of the bleeding resection defect (Figure 1). After the ESD procedure was successfully completed, proton pump inhibitor therapy was administered, and no signs of bleeding were observed in the patient during postoperative monitoring.

Figure 1 Endoscopy images during endoscopic submucosal dissection. A: After spraying indigo rouge, the stain on the lesion is obvious and the edge of the lesion is clear; B: Intraoperative marking showed that the lesion extended from the posterior wall and lesser curvature of the lower gastric body to the gastric angulus and gastric antrum; C and D: Under the traction and assistance of titanium clips, the submucosal lesion was completely removed by endoscopic submucosal dissection; E: Spraying tissue adhesive onto the surface of the resection defect to prevent postoperative bleeding; F: Complete resection of the lesion, about 60 mm × 100 mm in size.

OUTCOME AND FOLLOW-UP

No early adverse events including bleeding, perforation or infection were observed after endoscopic resection. Histopathological examination of the resected specimen confirmed high-grade intraepithelial neoplasia (Figure 2). The patient was arranged for gastroscopic surveillance at 4 months. An ESD scar in the gastric body and gastric angulus was observed by the gastroscopy at the end of the fourth month, indicating a well- recovered resection defect without postoperative bleeding (Figure 3).

Figure 2 Findings of histopathology examination of the endoscopically resected specimen. A and B: There were no lesions at the lateral and basal incisal margins of the lesion. High-grade intraepithelial neoplasia presented a multifocal and scattered distribution, some of which showed adenocarcinoma in situ-like changes without invading the stroma and muscularis mucosa. The surrounding mucosa presented low-grade intraepithelial neoplasia, showing intestinal metaplasia and atrophy.

Figure 3 Endoscopy images of the reexamination 4 months after endoscopic submucosal dissection. A-C: An endoscopic submucosal dissection scar in the gastric body and gastric angulus was observed by the gastroscopy four months after the operation, indicating a well-recovered resection defect without postoperative bleeding (arrows).

DISCUSSION

ESD provides a minimally invasive yet curative treatment for patients with EGC. Previously, many of these patients were treated surgically at substantial cost and with significant risk of gastrointestinal function impairment. En-bloc resection of these early cancers allowed complete diagnosis of the tumor, stratification of the subsequent therapeutic approach, and potential cure[6], making it a preferred treatment option for EGC and promoting innovations in this field. However, ESD procedures are technically demanding, especially for large and deeply invasive lesions[7], and bleeding is one of the most frequent adverse events in ESD, potentially life-threatening. The size of the resection defect positively correlates with the incidence of postoperative bleeding[8,9]. Commonly, consumables such as titanium clips, nylon endoscopic sutures, and hot biopsy forceps are used to prevent postoperative bleeding. However, these methods are only suitable for small resection defects, and not feasible for large-size resection defects. In our case, the tumor lesion invaded the gastric body, angulus, and antrum. And it was impossible to seal the resection defects with titanium clips or nylon endoscopic sutures due to the large size of the resection defect, yet the method of spraying tissue adhesive onto the resection defect surface demonstrated promising results.

Topical hemostatic agents, such as tissue adhesives, hemostatic powders and polyglycolic acid (PGA) sheets, complement conventional endoscopic hemostatic strategies (injection, mechanical clipping and thermal coagulation).In comparison with traditional hemostatic and closure techniques, topical agents are simple to administer, require no direct contact with bleeding foci, and provide wide-area coverage. Consequently, they are often effective for managing lesions that are refractory to conventional hemostatic methods, as well as for diffuse or extensive bleeding[10-15].

In theory, the main component of tissue adhesive, butylcyanoacrylate (NBCA), undergoes rapid polymerization and solidifies into a protective membrane upon contact with anions present in blood and tissue fluid covering the resection defect. The meshlike architecture of this membrane impedes the transit of red blood cells and platelets, seals disrupted vasculature, and thus exerts hemostatic action. At the same time, it isolates the resection defect surface from direct contact with digestive fluids such as bile and gastric acid, thereby promoting resection defect healing. NBCA has been widely used for hemostasis in various settings, with previous reports covering portal vein embolization, cerebral vessel embolization, hemorrhagic trauma, and gastrointestinal bleeding. Accumulated data demonstrate that the hemostatic efficacy of NBCA is non-inferior to conventional interventions such as endoscopic clipping[16].

Hemostatic powders are administered using gas-driven delivery. Their application carries risks of barotrauma, catheter looping, and compromised endoscopic visualization. Moreover, contact with mucus often causes powder agglutination and catheter obstruction, disrupting the procedure. In comparison, sprayed tissue adhesive offers simpler handling, eliminates barotrauma risk, and preserves adequate visualization during management[13]. Nonetheless, caution is required to avoid occlusion of the endoscope working channel by tissue adhesive.

PGA sheets are flexible, mesh-forming high-molecular-weight polymers with robust tensile strength. Fibrin glue, a mixture of fibrinogen and thrombin, generates strongly adherent gel upon component mixing, which securely attaches PGA sheets to the mucosal defect. The combination of PGA sheets and fibrin glue provides an important adjunctive measure for preventing postESD perforation and bleeding[14]. From the perspective of procedural convenience, sprayed tissue adhesive is easier to implement than PGA sheet fixation with fibrin glue.

CONCLUSION

We consider that sprayed tissue adhesive is particularly appropriate for extensive yet superficial mucosal defects where conventional clipping is technically challenging or ineffective, for diffuse oozing over large postESD ulcers, for bleeding originating from irregular mucosal defects, and for hemorrhage refractory to standard hemostatic approaches such as injection therapy, mechanical clipping, or thermal coagulation. However, sprayed tissue adhesive should not be applied as monotherapy in high-risk scenarios: Deep defects with exposed large vessels (visible vessel or spurting bleeding); muscular injury or suspected perforation, which may require additional closure methods such as endoscopic clipping, overthescope clips, or surgical consultation. Overall, we recommend sprayed tissue adhesive as an adjunct or rescue therapy when conventional hemostatic methods are unsuitable or unsuccessful.