BACKGROUND Hemostatic powders have been used as primary or salvage therapy to control gastrointestinal bleeding in a number of scenarios.PuraStat®is a novel,selfassembling peptide gel that has properties that dif...BACKGROUND Hemostatic powders have been used as primary or salvage therapy to control gastrointestinal bleeding in a number of scenarios.PuraStat®is a novel,selfassembling peptide gel that has properties that differ from hemostatic powders.It is transparent,can be used in narrow spaces and combined with other modalities.Also,it is pre-filled in a syringe ready to use and easy to handle and deliver.PuraStat®has been shown to be effective and safe in treating gastrointestinal bleeding lesions.But,its role as a hemostatic agent in all bleeding indications remains to be clarified.AIM To evaluate PuraStat®efficacy and its applications,feasibility and safety in treating gastrointestinal bleeding lesions.METHODS We performed a retrospective single-centre analysis of all consecutive patients with gastrointestinal bleeding,that required endoscopic treatment and where PuraStat®was applied,from June 2020 to October 2022.Demographics,biochemical,endoscopic,endoscopist assessment and outcome data were collected.We analysed the whole cohort and the subgroup with upper gastrointestinal bleeding.The primary outcome was to evaluate the efficacy of PuraStat®at achieving initial hemostasis.The patients were followed-up for 30 days after the episode of bleeding.RESULTS In total 45 patients were included,and 17/45(37.8%)females.The mean age was 65.8 years.Charlson score was>2 in 27/45(60%)and 26/45(57.8%)required transfusion.The procedures were gastroscopy(77.8%),colonoscopy(15.5%),endoscopic retrograde cholangiopancreatography(4.4%)and enteroscopy(2.2%).The most common bleeding lesion was peptic ulcer(33.3%).PuraStat®was used alone in 36%of the cases.One hundred percent achieved initial hemostasis and no complications were documented.There were no significant differences between the use of PuraStat®alone or in combination in terms of re-bleeding(P=0.64)or mortality(P=0.69).In 46.6%of cases,the reason for applying PuraStat®was as addition to standard of care,in 35.5%as an alternative because standard of care was not possible and in 17.8%as a rescue therapy.CONCLUSION PuraStat®is an effective therapy for multiple etiologies and is considered very easy to use in the majority.Its role as front line agent should be considered in the future.展开更多
BACKGROUND Non variceal upper gastrointestinal bleeding(NVUGIB)is a life-threatening condition requiring prompt and effective hemostasis.Various endoscopic inter-ventions,including novel hemostatic powders(HP),over-th...BACKGROUND Non variceal upper gastrointestinal bleeding(NVUGIB)is a life-threatening condition requiring prompt and effective hemostasis.Various endoscopic inter-ventions,including novel hemostatic powders(HP),over-the-scope clips(OTSC),and traditional approaches,have been employed to manage upper gastroin-testinal bleeding(UGIB).Despite advancements,comparative efficacy and safety of these modalities remain uncertain.AIM To evaluate the efficacy and safety of novel hemostatic interventions compared to conventional endoscopic techniques for managing UGIB.METHODS Cochrane,MEDLINE,PubMed and Scopus libraries were searched for rando-mized controlled trials(RCTs)published up to October 2024.Only RCTs compa-ring novel interventions,such as HP or OTSC,with conventional endoscopic treatments computed tomography(CT)were included.The primary outcome was the 30-day rebleeding rate.Secondary outcomes included initial hemostasis,short-term rebleeding rates,need for salvage therapy(surgical/angiographic),30-day all-cause mortality,and bleeding-related mortality.We performed pairwise and network meta-analyses for all treatments.RESULTS Seventeen studies were included in this analysis.Regarding the 30-day rebleeding rate,OTSC and HP showed superior efficacy compared with CT[OTSC vs CT:Relative risk(RR):0.47,95%confidence interval(CI):0.33-0.65;HP vs CT:RR:0.73,95%CI:0.45-1.13],while OTSC and HP had comparable efficacy(RR:0.56,95%CI:0.30-1.05).OTSC ranked the highest in the network ranking estimate for this outcome.For the secondary outcomes,OTSC demonstrated superior efficacy for the short-term rebleeding rate(OTSC vs CT:RR:0.35,95%CI:0.14-0.74;HP vs CT:RR:0.62,95%CI:0.28-1.35;OTSC vs HP:RR:0.59,95%CI:0.17-1.67).Regarding the initial hemostasis rate,OTSC was slightly more effective than CT(OTSC vs CT:RR:1.20,95%CI:1.06-1.57)and comparable to HP(OTSC vs HP:RR:1.08,95%CI:0.89-1.40).There were no significant differences among treatments for all-cause mortality,bleeding-related mortality,or the necessity of surgical or angiographic salvage therapy.OTSC consistently ranked highest across most outcomes in the network ranking estimate.展开更多
The management of gastrointestinal(GI)bleeding patients during endoscopy remains a challenge.Hemorrhage is still one of the significant causes of morbidity and even death.Several therapeutic options have been used ove...The management of gastrointestinal(GI)bleeding patients during endoscopy remains a challenge.Hemorrhage is still one of the significant causes of morbidity and even death.Several therapeutic options have been used over the years depending on the extent,site and cause of bleeding.These include thermal therapy,injection therapy,and mechanical methods of hemostasis(e.g.,endoscopic clips and ligation bands).Patients with refractory bleeding,high-risk ulcer lesions,malignant disease,antiplatelet medications,and chronic kidney disease are at increased risk of upper and lower GI bleeding(LGIB).In this editorial,I commented on the paper by Ballester et al.Their work aimed at evaluating PuraStat^(■)(TDM-621),a novel hemostatic agent,particularly its efficacy,applications,feasibility,and safety in treating GI bleeding lesions.The authors concluded that PuraStat^(■)is an effective therapy for GI bleeding and is usually easy to use.Although the authors recommended its consideration as a frontline therapy in the future,they did not explore the clinical and GI uses of PuraStat®.This editorial focuses on the pharmacology of PuraStat®and how it differs from Hemospray®(TC-325)(hemostatic powder).It also explores the current experience of using PuraStat^(■)in upper and LGIB,its uses and safety,and the need for further research to fully understand its potential.展开更多
Gastrointestinal bleeding(GIB)presents a significant challenge for patients with hematologic malignancies,especially those with severe thrombocytopenia.Although endoscopic intervention is frequently used in managing G...Gastrointestinal bleeding(GIB)presents a significant challenge for patients with hematologic malignancies,especially those with severe thrombocytopenia.Although endoscopic intervention is frequently used in managing GIB,its safety and effectiveness in this high-risk group remain unclear.A recent study by Alhumayyd et al provided insight into this issue.However,it has notable limitations,including its retrospective nature,small sample size,and failure to adjust for important confounding factors such as disease severity,hemodynamic status,and platelet function.The study’s findings indicated that urgent endoscopy may help decrease the incidence of recurrent bleeding;however,it did not show a clear benefit in terms of mortality.Future research ought to prioritize prospective,multicenter studies that employ standardized protocols and incorporate risk stratification models to better understand the impact of endoscopic treatment for GIB in these patients.Additionally,integrating platelet function assays could improve clinical decision-making.Addressing these research gaps is essential for improving patient outcomes and developing effective guidelines for managing GIB in individuals with thrombocytopenia.展开更多
Acquired hemophilia A(AHA)is a rare blood disorder that can cause life-threatening severe bleeding because of the development of autoantibodies(inhibitors)against factor VIII.AHA is common in elderly patients,and alth...Acquired hemophilia A(AHA)is a rare blood disorder that can cause life-threatening severe bleeding because of the development of autoantibodies(inhibitors)against factor VIII.AHA is common in elderly patients,and although most cases are characterized by subcutaneous or intramuscular bleeding,rare cases of gastrointestinal bleeding have been reported.Controlling gastrointestinal bleeding in patients with AHA is difficult even after multiple endoscopic hemostasis or transcatheter arterial embolization procedures,and these patients are prone to rebleeding.CASE SUMMARY We report the case of a 76-year-old Japanese woman with AHA who presented with repeated bleeding from an esophageal ulcer as the initial symptom.A hemorrhagic ulcer was detected in the lower esophagus,and endoscopic hemostasis using radiofrequency ablation was performed seven times over a month.However,this procedure was unsuccessful,and the patient was transferred to our department.Hypertonic saline-epinephrine injection plus clipping was administered for endoscopic hemostasis,but the treatment response of the patient was poor.After the AHA diagnosis was confirmed,a single dose of a mixture of factors VIIa and X was administered as a bypass hemostatic agent,and the bleeding was successfully controlled.In addition,emicizumab,a bispecific monoclonal antibody that is a substitute for activated factor VIII,was administered,and no further rebleeding was observed.CONCLUSION Multidisciplinary interventions between endoscopists and hematologists are essential to manage rare gastrointestinal bleeding caused by coagulation disorders,such as AHA.展开更多
[Objective] The aim was to investigate the hemostatic effects of chitosan-based fibre on liver. [Method] The liver hemorrhage model of rabbit was established. Hemostasis was performed with chitosam-based fiber in expe...[Objective] The aim was to investigate the hemostatic effects of chitosan-based fibre on liver. [Method] The liver hemorrhage model of rabbit was established. Hemostasis was performed with chitosam-based fiber in experimental group, surgicel in control group and no material in blank group. The hemostatic effects were evaluated by total blood loss (TBL) and hemostatic rate. [Result] Experimental group had no bleeding in observation period, with the hemostatic rate of 100% and the blood loss of only (0.443±0.30) g/kg, better than the control group and blank group (P<0.005). [Conclusion] Chitosan-based fiber has effective hemostasis in liver wound, which will provide reliable information for the clinical trials.展开更多
TO THE EDITORWe read with interest the article entitled ＂Bleeding gastric varices： Results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital＂ by Noophun et al. They performed n-buty...TO THE EDITORWe read with interest the article entitled ＂Bleeding gastric varices： Results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital＂ by Noophun et al. They performed n-butyl-2-cyanoacrylate （CA） injection therapy for bleeding gastric varices in twentyfour patients, and hemostasis was achieved in seventeen （71%） patients. They concluded that CA injection therapy was effective and safe for bleeding gastric varices. However, we disagreed with the author＇s conclusion.展开更多
AIM: To evaluate the hemostatic effect of topical hemocoagulase spray in digestive endoscopy.METHODS: Eighty-nine patients who developed oozing bleeding during endoscopic treatment from September 2014 to October 2014 ...AIM: To evaluate the hemostatic effect of topical hemocoagulase spray in digestive endoscopy.METHODS: Eighty-nine patients who developed oozing bleeding during endoscopic treatment from September 2014 to October 2014 at Center for Digestive Endoscopy, Tianjin Medical University General Hospital were randomly divided into either a study group(n = 39) or a control group(n = 50). The study group was given topical hemocoagulase spray intraoperatively, while the control group was given traditional 8% norepinephrine spray. Hemostatic efficacy was compared between the two groups. Bleeding site, wound cleanliness and perforation were recorded, and the rates of perforation and late bleeding were compared.RESULTS: Successful hemostasis was achieved in 39(100%) patients of the study group and in 47(94.0%) patients of the control group, and there was no significant difference in the rate of successful hemostasis between the two groups. Compared with the control group, after topical hemocoagulase spray in the study group, the surgical field was clearer, the bleeding site was more easily identified, and the wound was cleaner. There was no significant difference in the rate of perforation between the study and control groups(16.7% vs 35.0%, P = 0.477), but the rates oflate bleeding(0% vs 15.8%, P = 0.048) and overall complications(P = 0.032) were significantly lower in the study group.CONCLUSION: Topical hemocoagulase spray has a definite hemostatic effect for oozing bleeding in digestive endoscopy, and this method is convenient, safe, and reliable. It is expected to become a new method for endoscopic hemostasis.展开更多
In order to prepare a novel hemostatic dressing for uncontrolled hemorrhage, a porous chitosan sponge was coated with self-assembled（thrombin/tannic acid）n films, which were based on hydrogen bonding interactions be...In order to prepare a novel hemostatic dressing for uncontrolled hemorrhage, a porous chitosan sponge was coated with self-assembled（thrombin/tannic acid）n films, which were based on hydrogen bonding interactions between thrombin and tannic acid at physiologic p H. According to the whole blood clotting test, the coated chitosan sponges showed a significantly high rate of blood clotting due to the addition of thrombin. On the other hand, the storable half-life of immobilized thrombin is extended to 66.9 days at room temperature, which is 8.5 times longer than unfixed thrombin. It is because of the immobilization effect of, not only the porous structure of chitosan sponge but also the interactions between thrombin and tannic acid. In addition, the tannic acid has similar antibacterial effect to chitosan. Therefore, it is an excellent combination of chitosan, thrombin and tannic acid. Besides, all of materials in this research have been approved by the United States Food and Drug Administration（FDA）. So the chitosan-based sponge is a promising candidate dressing for uncontrolled hemorrhage due to its storable, bio-safe and highly effective hemostatic properties.展开更多
Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enab...Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharma-cotherapy during the healing process are essential.展开更多
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma.A significant number of deaths due to hemorrhage occur before and in the first hour after hospi...Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma.A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival.A literature search was performed through PubMed,Scopus,and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents,prehospital,battlefield or combat dressings,and prehospital hemostatic resuscitation,followed by cross-reference searching.Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted.Based on these findings,this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings.These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action.Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.展开更多
Objective: Transradial coronary catheterization has proved to be safe and effective in clinical practice. Various hemostatic compressive devices have been used in subsequent procedures. The objective of this study was...Objective: Transradial coronary catheterization has proved to be safe and effective in clinical practice. Various hemostatic compressive devices have been used in subsequent procedures. The objective of this study was to compare the efficacy and safety of a new hemostatic compression device and the widely used TR Band. Methods: A total of 118 patients were divided randomly into two groups: TR Band and the new hemostatic compression device. Efficacy of hemostasis, patient comfort, local vascular dysfunction, and radial artery occlusion(RAO) were evaluated and compared between groups. Results: Occurrence of errhysis or hematoma did not significantly differ between groups(13.6% vs. 11.9%, P = 0.782). Fewer patients had moderate to severe pain or moderate to severe numbness in the new hemostatic compression device group(1.7% vs. 22.0%; 1.7% vs. 18.6%, respectively). Pulse loss between distal artery and device was lower in the new hemostatic compression device group(5.1% vs. 22.0%, P = 0.007), and fewer patients experienced obstruction of venous reflux compared with the TR Band group(6.8% vs. 25.4%, P = 0.006). Combined incidence of RAO at discharge was 7.6%, and was lower in the new hemostatic compression device group(1.7% vs. 13.6%, P = 0.015). In contrast to the TR Band, application of the new hemostatic compression device was independently associated with lower incidence of RAO at discharge(odds ratio: 0.062, 95% confidence interval: 0.006–0.675, P = 0.022). Conclusions: Both the new hemostatic compression device and the TR Band can efficiently achieve hemostasis following transradial coronary catheterization. However, fewer patients felt discomfort with application of the new hemostatic compression device. Pulse loss in the artery distal to the compression device, obstruction of venous reflux, and RAO occurred significantly less often with application of the new device.展开更多
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse differen...Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurologicalneurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it's important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.展开更多
AIM:To evaluate a new hemostatic method using hemostatic forceps to prevent perforation and perioperative hemorrhage during colonic endoscopic submucosal dissection(ESD).METHODS:We studied 250 cases,in which ESD for c...AIM:To evaluate a new hemostatic method using hemostatic forceps to prevent perforation and perioperative hemorrhage during colonic endoscopic submucosal dissection(ESD).METHODS:We studied 250 cases,in which ESD for colorectal tumors was performed at the Kyoto Prefectural University of Medicine or Nara City Hospital between 2005 and 2010.We developed a new hemostatic method using hemostatic forceps in December 2008 for the efficient treatment of submucosal thick vessels.ESD was performed on 126 cases after adoption of the new method(the adopted group)and the new method was performed on 102 of these cases.ESD was performed on 124 cases before the adoption of the new method (the unadopted group).The details of the new method are as follows:firstly,a vessel was coagulated using the hemostatic forceps in the soft coagulation mode according to the standard procedure,and the coagulated vessel was removed using the forceps in the"endocut" mode without perioperative hemorrhage.Secondly,the partial surrounding submucosa was dissected using the forceps in the endocut mode.In the current study,we evaluated the efficacy of this method.RESULTS:Coagulated vessels were successfully removed using the hemostatic forceps in all 102 cases without severe perioperative hemorrhage.Moderate perioperative hemorrhage occurred in five cases(4.9%);however,it was stopped by immediately reuse of the hemostatic forceps.The partial surrounding submucosa was dissected using the forceps in all 102 cases.In the adopted group,the median operation time was 105 min.The proportion of endoscopic en bloc resection was 92.8%(P<0.01)compared to 80.6%in the unadopted group.The postoperative hemorrhage and perforation rates were 2.3%and 2.3%.The rate of perforation was significantly lower than that in the unadopted group (9.6%,P<0.01).We evaluated the ease of use of this method by allowing our three trainees to performed ESD on 46 cases,which were accomplished without any severe hemorrhage.CONCLUSION:The new method effectively treated submucosal thick vessels and shows promise for the prevention of perforation and perioperative hemorrhage in colonic ESD.展开更多
New endoscopic techniques for hemostasis in nonvariceal bleeding were introduced and known methods further improved. Hemospray and Endoclot are two new compounds for topical treatment of bleeding. Initial studies in t...New endoscopic techniques for hemostasis in nonvariceal bleeding were introduced and known methods further improved. Hemospray and Endoclot are two new compounds for topical treatment of bleeding. Initial studies in this area have shown a good hemostatic effect, especially in active large scale oozing bleeding, e.g., tumor bleedings. For further evaluation larger prospective studies comparing the substanced with other methods of endoscopic hemostasis are needed. For localized active arterial bleeding primary injection therapy in the area of bleeding as well as in the four adjacent quadrants offers a good method to reduce bleeding activity. The injection is technically easy to learn and practicable. After bleeding activity is reduced the bleeding source can be localized more clearly for clip application. Today many different through-thescope(TTS) clips are available. The ability to close and reopen a clip can aid towards good positioning at the bleeding site. Even more important is the rotatability of a clip before application. Often multiple TTS clips are required for secure closure of a bleeding vessel. One model has the ability to use three clips in series without changing the applicator. Severe arterial bleeding from vessels larger than 2 mm is often unmanageable with these conventional methods. Here is the over-the-scopeclip system another newly available method. It is similar to the ligation of esophageal varices and involves aspiration of tissue into a transparent cap before closure of the clip. Thus a greater vascular occlusion pressure can be achieved and larger vessels can be treated endoscopically. Patients with severe arterial bleeding from the upper gastrointestinal tract have a very high rate of recurrence after initial endoscopic treatment. These patients should always be managed in an interdisciplinary team of interventional radiologist and surgeons.展开更多
BACKGROUND Dieulafoy's lesion is a rare vascular abnormality characterized by a small abnormally dilated artery that runs a tortuous course in the submucosa.There is usually no ulcer present in Dieulafoy's les...BACKGROUND Dieulafoy's lesion is a rare vascular abnormality characterized by a small abnormally dilated artery that runs a tortuous course in the submucosa.There is usually no ulcer present in Dieulafoy's lesions and the overlying mucosa is most often normal.Bleeding caused by a Dieulafoy's lesion is usually urgent,massive,life-threatening and prone to recurrence.Dieulafoy's lesions have been reported throughout the digestive tract although the majority of them have been found in the upper digestive tract especially the stomach and duodenum.However,a Dieulafoy's lesion occurring inside a duodenal diverticulum is very rare.CASE SUMMARY A 74-year-old Asian male with epigastric pain,hematemesis and melena was admitted to our clinic.Before admission,the patient had vomited 500 m L of dark red blood,and passed 200 g of black tarry stool.Conservative management was first undertaken as the patient had not been fasting.However,hemorrhage recurred and the patient went into shock.Urgent endoscopy was performed and a diverticulum of 1.8 cm×1.2 cm×0.8 cm was found on the anterior wall of the descending duodenum.The diverticulum was covered with a blood clot.After the clot was removed,an artery stump was observed in the diverticulum with a diameter of 2-3 mm.Two titanium hemostatic clips were inserted to clamp the vessel stump.The patient was discharged 7 d post-endoscopy and followed for 6 mo with no recurrence.CONCLUSION This case was diagnosed with a Dieulafoy's lesion inside a duodenal diverticulum which has rarely been reported.Hematemesis was stopped by clamping the vessel stump with titanium clips.No complications occurred.展开更多
BACKGROUND Gastrointestinal(GI) bleeding is a common indication for endoscopy. For refractory cases, hemostatic powders(HP) represent "touch-free" agents.AIM To analyze short term(ST-within 72 h-) and long-t...BACKGROUND Gastrointestinal(GI) bleeding is a common indication for endoscopy. For refractory cases, hemostatic powders(HP) represent "touch-free" agents.AIM To analyze short term(ST-within 72 h-) and long-term(LT-within 30 d-) success for achieving hemostasis with HP and to directly compare the two agents Hemospray(HS) and Endoclot(EC).METHODS HP was applied in 154 consecutive patients(mean age 67 years) with GI bleeding.Patients were followed up for 1 mo(mean follow-up: 3.2 mo).RESULTS Majority of applications were in upper GI tract(89%) with following bleeding sources: peptic ulcer disease(35%), esophageal varices(7%), tumor bleeding(11.7%), reflux esophagitis(8.7%), diffuse bleeding and erosions(15.3%). Overall ST success was achieved in 125 patients(81%) and LT success in 81 patients(67%). Re-bleeding occurred in 27% of all patients. In 72 patients(47%), HP was applied as a salvage hemostatic therapy, here ST and LT success were 81% and64%, with re-bleeding in 32%. As a primary hemostatic therapy, ST and LT success were 82% and 69%, with re-bleeding occurring in 22%. HS was more frequently applied for upper GI bleeding(P = 0.04)CONCLUSION Both HP allow for effective hemostasis with no differences in ST, LT success and re-bleeding.展开更多
Due to concomitant changes in pro-and anti-coagulant mechanisms,patients with liver dysfunction have a“rebalanced hemostasis”,which can easily be tipped toward either a hypo-or a hypercoagulable phenotype.Clinicians...Due to concomitant changes in pro-and anti-coagulant mechanisms,patients with liver dysfunction have a“rebalanced hemostasis”,which can easily be tipped toward either a hypo-or a hypercoagulable phenotype.Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities.Conventional coagulation screening tests,such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures.The introduction of global coagulation assays,such as viscoelastic testing(VET),has been an important step forward in the assessment of the overall hemostasis profile.A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings.The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.展开更多
文摘BACKGROUND Hemostatic powders have been used as primary or salvage therapy to control gastrointestinal bleeding in a number of scenarios.PuraStat®is a novel,selfassembling peptide gel that has properties that differ from hemostatic powders.It is transparent,can be used in narrow spaces and combined with other modalities.Also,it is pre-filled in a syringe ready to use and easy to handle and deliver.PuraStat®has been shown to be effective and safe in treating gastrointestinal bleeding lesions.But,its role as a hemostatic agent in all bleeding indications remains to be clarified.AIM To evaluate PuraStat®efficacy and its applications,feasibility and safety in treating gastrointestinal bleeding lesions.METHODS We performed a retrospective single-centre analysis of all consecutive patients with gastrointestinal bleeding,that required endoscopic treatment and where PuraStat®was applied,from June 2020 to October 2022.Demographics,biochemical,endoscopic,endoscopist assessment and outcome data were collected.We analysed the whole cohort and the subgroup with upper gastrointestinal bleeding.The primary outcome was to evaluate the efficacy of PuraStat®at achieving initial hemostasis.The patients were followed-up for 30 days after the episode of bleeding.RESULTS In total 45 patients were included,and 17/45(37.8%)females.The mean age was 65.8 years.Charlson score was>2 in 27/45(60%)and 26/45(57.8%)required transfusion.The procedures were gastroscopy(77.8%),colonoscopy(15.5%),endoscopic retrograde cholangiopancreatography(4.4%)and enteroscopy(2.2%).The most common bleeding lesion was peptic ulcer(33.3%).PuraStat®was used alone in 36%of the cases.One hundred percent achieved initial hemostasis and no complications were documented.There were no significant differences between the use of PuraStat®alone or in combination in terms of re-bleeding(P=0.64)or mortality(P=0.69).In 46.6%of cases,the reason for applying PuraStat®was as addition to standard of care,in 35.5%as an alternative because standard of care was not possible and in 17.8%as a rescue therapy.CONCLUSION PuraStat®is an effective therapy for multiple etiologies and is considered very easy to use in the majority.Its role as front line agent should be considered in the future.
文摘BACKGROUND Non variceal upper gastrointestinal bleeding(NVUGIB)is a life-threatening condition requiring prompt and effective hemostasis.Various endoscopic inter-ventions,including novel hemostatic powders(HP),over-the-scope clips(OTSC),and traditional approaches,have been employed to manage upper gastroin-testinal bleeding(UGIB).Despite advancements,comparative efficacy and safety of these modalities remain uncertain.AIM To evaluate the efficacy and safety of novel hemostatic interventions compared to conventional endoscopic techniques for managing UGIB.METHODS Cochrane,MEDLINE,PubMed and Scopus libraries were searched for rando-mized controlled trials(RCTs)published up to October 2024.Only RCTs compa-ring novel interventions,such as HP or OTSC,with conventional endoscopic treatments computed tomography(CT)were included.The primary outcome was the 30-day rebleeding rate.Secondary outcomes included initial hemostasis,short-term rebleeding rates,need for salvage therapy(surgical/angiographic),30-day all-cause mortality,and bleeding-related mortality.We performed pairwise and network meta-analyses for all treatments.RESULTS Seventeen studies were included in this analysis.Regarding the 30-day rebleeding rate,OTSC and HP showed superior efficacy compared with CT[OTSC vs CT:Relative risk(RR):0.47,95%confidence interval(CI):0.33-0.65;HP vs CT:RR:0.73,95%CI:0.45-1.13],while OTSC and HP had comparable efficacy(RR:0.56,95%CI:0.30-1.05).OTSC ranked the highest in the network ranking estimate for this outcome.For the secondary outcomes,OTSC demonstrated superior efficacy for the short-term rebleeding rate(OTSC vs CT:RR:0.35,95%CI:0.14-0.74;HP vs CT:RR:0.62,95%CI:0.28-1.35;OTSC vs HP:RR:0.59,95%CI:0.17-1.67).Regarding the initial hemostasis rate,OTSC was slightly more effective than CT(OTSC vs CT:RR:1.20,95%CI:1.06-1.57)and comparable to HP(OTSC vs HP:RR:1.08,95%CI:0.89-1.40).There were no significant differences among treatments for all-cause mortality,bleeding-related mortality,or the necessity of surgical or angiographic salvage therapy.OTSC consistently ranked highest across most outcomes in the network ranking estimate.
文摘The management of gastrointestinal(GI)bleeding patients during endoscopy remains a challenge.Hemorrhage is still one of the significant causes of morbidity and even death.Several therapeutic options have been used over the years depending on the extent,site and cause of bleeding.These include thermal therapy,injection therapy,and mechanical methods of hemostasis(e.g.,endoscopic clips and ligation bands).Patients with refractory bleeding,high-risk ulcer lesions,malignant disease,antiplatelet medications,and chronic kidney disease are at increased risk of upper and lower GI bleeding(LGIB).In this editorial,I commented on the paper by Ballester et al.Their work aimed at evaluating PuraStat^(■)(TDM-621),a novel hemostatic agent,particularly its efficacy,applications,feasibility,and safety in treating GI bleeding lesions.The authors concluded that PuraStat^(■)is an effective therapy for GI bleeding and is usually easy to use.Although the authors recommended its consideration as a frontline therapy in the future,they did not explore the clinical and GI uses of PuraStat®.This editorial focuses on the pharmacology of PuraStat®and how it differs from Hemospray®(TC-325)(hemostatic powder).It also explores the current experience of using PuraStat^(■)in upper and LGIB,its uses and safety,and the need for further research to fully understand its potential.
文摘Gastrointestinal bleeding(GIB)presents a significant challenge for patients with hematologic malignancies,especially those with severe thrombocytopenia.Although endoscopic intervention is frequently used in managing GIB,its safety and effectiveness in this high-risk group remain unclear.A recent study by Alhumayyd et al provided insight into this issue.However,it has notable limitations,including its retrospective nature,small sample size,and failure to adjust for important confounding factors such as disease severity,hemodynamic status,and platelet function.The study’s findings indicated that urgent endoscopy may help decrease the incidence of recurrent bleeding;however,it did not show a clear benefit in terms of mortality.Future research ought to prioritize prospective,multicenter studies that employ standardized protocols and incorporate risk stratification models to better understand the impact of endoscopic treatment for GIB in these patients.Additionally,integrating platelet function assays could improve clinical decision-making.Addressing these research gaps is essential for improving patient outcomes and developing effective guidelines for managing GIB in individuals with thrombocytopenia.
文摘Acquired hemophilia A(AHA)is a rare blood disorder that can cause life-threatening severe bleeding because of the development of autoantibodies(inhibitors)against factor VIII.AHA is common in elderly patients,and although most cases are characterized by subcutaneous or intramuscular bleeding,rare cases of gastrointestinal bleeding have been reported.Controlling gastrointestinal bleeding in patients with AHA is difficult even after multiple endoscopic hemostasis or transcatheter arterial embolization procedures,and these patients are prone to rebleeding.CASE SUMMARY We report the case of a 76-year-old Japanese woman with AHA who presented with repeated bleeding from an esophageal ulcer as the initial symptom.A hemorrhagic ulcer was detected in the lower esophagus,and endoscopic hemostasis using radiofrequency ablation was performed seven times over a month.However,this procedure was unsuccessful,and the patient was transferred to our department.Hypertonic saline-epinephrine injection plus clipping was administered for endoscopic hemostasis,but the treatment response of the patient was poor.After the AHA diagnosis was confirmed,a single dose of a mixture of factors VIIa and X was administered as a bypass hemostatic agent,and the bleeding was successfully controlled.In addition,emicizumab,a bispecific monoclonal antibody that is a substitute for activated factor VIII,was administered,and no further rebleeding was observed.CONCLUSION Multidisciplinary interventions between endoscopists and hematologists are essential to manage rare gastrointestinal bleeding caused by coagulation disorders,such as AHA.
文摘[Objective] The aim was to investigate the hemostatic effects of chitosan-based fibre on liver. [Method] The liver hemorrhage model of rabbit was established. Hemostasis was performed with chitosam-based fiber in experimental group, surgicel in control group and no material in blank group. The hemostatic effects were evaluated by total blood loss (TBL) and hemostatic rate. [Result] Experimental group had no bleeding in observation period, with the hemostatic rate of 100% and the blood loss of only (0.443±0.30) g/kg, better than the control group and blank group (P<0.005). [Conclusion] Chitosan-based fiber has effective hemostasis in liver wound, which will provide reliable information for the clinical trials.
文摘TO THE EDITORWe read with interest the article entitled ＂Bleeding gastric varices： Results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital＂ by Noophun et al. They performed n-butyl-2-cyanoacrylate （CA） injection therapy for bleeding gastric varices in twentyfour patients, and hemostasis was achieved in seventeen （71%） patients. They concluded that CA injection therapy was effective and safe for bleeding gastric varices. However, we disagreed with the author＇s conclusion.
文摘AIM: To evaluate the hemostatic effect of topical hemocoagulase spray in digestive endoscopy.METHODS: Eighty-nine patients who developed oozing bleeding during endoscopic treatment from September 2014 to October 2014 at Center for Digestive Endoscopy, Tianjin Medical University General Hospital were randomly divided into either a study group(n = 39) or a control group(n = 50). The study group was given topical hemocoagulase spray intraoperatively, while the control group was given traditional 8% norepinephrine spray. Hemostatic efficacy was compared between the two groups. Bleeding site, wound cleanliness and perforation were recorded, and the rates of perforation and late bleeding were compared.RESULTS: Successful hemostasis was achieved in 39(100%) patients of the study group and in 47(94.0%) patients of the control group, and there was no significant difference in the rate of successful hemostasis between the two groups. Compared with the control group, after topical hemocoagulase spray in the study group, the surgical field was clearer, the bleeding site was more easily identified, and the wound was cleaner. There was no significant difference in the rate of perforation between the study and control groups(16.7% vs 35.0%, P = 0.477), but the rates oflate bleeding(0% vs 15.8%, P = 0.048) and overall complications(P = 0.032) were significantly lower in the study group.CONCLUSION: Topical hemocoagulase spray has a definite hemostatic effect for oozing bleeding in digestive endoscopy, and this method is convenient, safe, and reliable. It is expected to become a new method for endoscopic hemostasis.
基金financially supported by the National Natural Science Foundation of China(Nos.21104067,21274127 and 21374099 and 51473144)Key Basic Research Development Plan(973 Program)of China(Nos.2009CB930104 and 2011CB606203)+1 种基金Fundamental Research Funds for the Central Universities(No.2013QNA4048)Technology Foundation for Selected Overseas Scholar of Zhejiang Province
文摘In order to prepare a novel hemostatic dressing for uncontrolled hemorrhage, a porous chitosan sponge was coated with self-assembled（thrombin/tannic acid）n films, which were based on hydrogen bonding interactions between thrombin and tannic acid at physiologic p H. According to the whole blood clotting test, the coated chitosan sponges showed a significantly high rate of blood clotting due to the addition of thrombin. On the other hand, the storable half-life of immobilized thrombin is extended to 66.9 days at room temperature, which is 8.5 times longer than unfixed thrombin. It is because of the immobilization effect of, not only the porous structure of chitosan sponge but also the interactions between thrombin and tannic acid. In addition, the tannic acid has similar antibacterial effect to chitosan. Therefore, it is an excellent combination of chitosan, thrombin and tannic acid. Besides, all of materials in this research have been approved by the United States Food and Drug Administration（FDA）. So the chitosan-based sponge is a promising candidate dressing for uncontrolled hemorrhage due to its storable, bio-safe and highly effective hemostatic properties.
基金Supported by A Grant-in-Aid for Cancer Research from the Ministry of Health, Labor and Welfare of Japan, in part
文摘Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharma-cotherapy during the healing process are essential.
基金Canadian Forces Health Services and Defence Research and Development Canada for their support
文摘Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma.A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival.A literature search was performed through PubMed,Scopus,and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents,prehospital,battlefield or combat dressings,and prehospital hemostatic resuscitation,followed by cross-reference searching.Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted.Based on these findings,this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings.These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action.Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
基金provided by the National Natural Science Foundation of China(81500335)
文摘Objective: Transradial coronary catheterization has proved to be safe and effective in clinical practice. Various hemostatic compressive devices have been used in subsequent procedures. The objective of this study was to compare the efficacy and safety of a new hemostatic compression device and the widely used TR Band. Methods: A total of 118 patients were divided randomly into two groups: TR Band and the new hemostatic compression device. Efficacy of hemostasis, patient comfort, local vascular dysfunction, and radial artery occlusion(RAO) were evaluated and compared between groups. Results: Occurrence of errhysis or hematoma did not significantly differ between groups(13.6% vs. 11.9%, P = 0.782). Fewer patients had moderate to severe pain or moderate to severe numbness in the new hemostatic compression device group(1.7% vs. 22.0%; 1.7% vs. 18.6%, respectively). Pulse loss between distal artery and device was lower in the new hemostatic compression device group(5.1% vs. 22.0%, P = 0.007), and fewer patients experienced obstruction of venous reflux compared with the TR Band group(6.8% vs. 25.4%, P = 0.006). Combined incidence of RAO at discharge was 7.6%, and was lower in the new hemostatic compression device group(1.7% vs. 13.6%, P = 0.015). In contrast to the TR Band, application of the new hemostatic compression device was independently associated with lower incidence of RAO at discharge(odds ratio: 0.062, 95% confidence interval: 0.006–0.675, P = 0.022). Conclusions: Both the new hemostatic compression device and the TR Band can efficiently achieve hemostasis following transradial coronary catheterization. However, fewer patients felt discomfort with application of the new hemostatic compression device. Pulse loss in the artery distal to the compression device, obstruction of venous reflux, and RAO occurred significantly less often with application of the new device.
文摘Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurologicalneurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it's important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
文摘AIM:To evaluate a new hemostatic method using hemostatic forceps to prevent perforation and perioperative hemorrhage during colonic endoscopic submucosal dissection(ESD).METHODS:We studied 250 cases,in which ESD for colorectal tumors was performed at the Kyoto Prefectural University of Medicine or Nara City Hospital between 2005 and 2010.We developed a new hemostatic method using hemostatic forceps in December 2008 for the efficient treatment of submucosal thick vessels.ESD was performed on 126 cases after adoption of the new method(the adopted group)and the new method was performed on 102 of these cases.ESD was performed on 124 cases before the adoption of the new method (the unadopted group).The details of the new method are as follows:firstly,a vessel was coagulated using the hemostatic forceps in the soft coagulation mode according to the standard procedure,and the coagulated vessel was removed using the forceps in the"endocut" mode without perioperative hemorrhage.Secondly,the partial surrounding submucosa was dissected using the forceps in the endocut mode.In the current study,we evaluated the efficacy of this method.RESULTS:Coagulated vessels were successfully removed using the hemostatic forceps in all 102 cases without severe perioperative hemorrhage.Moderate perioperative hemorrhage occurred in five cases(4.9%);however,it was stopped by immediately reuse of the hemostatic forceps.The partial surrounding submucosa was dissected using the forceps in all 102 cases.In the adopted group,the median operation time was 105 min.The proportion of endoscopic en bloc resection was 92.8%(P<0.01)compared to 80.6%in the unadopted group.The postoperative hemorrhage and perforation rates were 2.3%and 2.3%.The rate of perforation was significantly lower than that in the unadopted group (9.6%,P<0.01).We evaluated the ease of use of this method by allowing our three trainees to performed ESD on 46 cases,which were accomplished without any severe hemorrhage.CONCLUSION:The new method effectively treated submucosal thick vessels and shows promise for the prevention of perforation and perioperative hemorrhage in colonic ESD.
文摘New endoscopic techniques for hemostasis in nonvariceal bleeding were introduced and known methods further improved. Hemospray and Endoclot are two new compounds for topical treatment of bleeding. Initial studies in this area have shown a good hemostatic effect, especially in active large scale oozing bleeding, e.g., tumor bleedings. For further evaluation larger prospective studies comparing the substanced with other methods of endoscopic hemostasis are needed. For localized active arterial bleeding primary injection therapy in the area of bleeding as well as in the four adjacent quadrants offers a good method to reduce bleeding activity. The injection is technically easy to learn and practicable. After bleeding activity is reduced the bleeding source can be localized more clearly for clip application. Today many different through-thescope(TTS) clips are available. The ability to close and reopen a clip can aid towards good positioning at the bleeding site. Even more important is the rotatability of a clip before application. Often multiple TTS clips are required for secure closure of a bleeding vessel. One model has the ability to use three clips in series without changing the applicator. Severe arterial bleeding from vessels larger than 2 mm is often unmanageable with these conventional methods. Here is the over-the-scopeclip system another newly available method. It is similar to the ligation of esophageal varices and involves aspiration of tissue into a transparent cap before closure of the clip. Thus a greater vascular occlusion pressure can be achieved and larger vessels can be treated endoscopically. Patients with severe arterial bleeding from the upper gastrointestinal tract have a very high rate of recurrence after initial endoscopic treatment. These patients should always be managed in an interdisciplinary team of interventional radiologist and surgeons.
文摘BACKGROUND Dieulafoy's lesion is a rare vascular abnormality characterized by a small abnormally dilated artery that runs a tortuous course in the submucosa.There is usually no ulcer present in Dieulafoy's lesions and the overlying mucosa is most often normal.Bleeding caused by a Dieulafoy's lesion is usually urgent,massive,life-threatening and prone to recurrence.Dieulafoy's lesions have been reported throughout the digestive tract although the majority of them have been found in the upper digestive tract especially the stomach and duodenum.However,a Dieulafoy's lesion occurring inside a duodenal diverticulum is very rare.CASE SUMMARY A 74-year-old Asian male with epigastric pain,hematemesis and melena was admitted to our clinic.Before admission,the patient had vomited 500 m L of dark red blood,and passed 200 g of black tarry stool.Conservative management was first undertaken as the patient had not been fasting.However,hemorrhage recurred and the patient went into shock.Urgent endoscopy was performed and a diverticulum of 1.8 cm×1.2 cm×0.8 cm was found on the anterior wall of the descending duodenum.The diverticulum was covered with a blood clot.After the clot was removed,an artery stump was observed in the diverticulum with a diameter of 2-3 mm.Two titanium hemostatic clips were inserted to clamp the vessel stump.The patient was discharged 7 d post-endoscopy and followed for 6 mo with no recurrence.CONCLUSION This case was diagnosed with a Dieulafoy's lesion inside a duodenal diverticulum which has rarely been reported.Hematemesis was stopped by clamping the vessel stump with titanium clips.No complications occurred.
文摘BACKGROUND Gastrointestinal(GI) bleeding is a common indication for endoscopy. For refractory cases, hemostatic powders(HP) represent "touch-free" agents.AIM To analyze short term(ST-within 72 h-) and long-term(LT-within 30 d-) success for achieving hemostasis with HP and to directly compare the two agents Hemospray(HS) and Endoclot(EC).METHODS HP was applied in 154 consecutive patients(mean age 67 years) with GI bleeding.Patients were followed up for 1 mo(mean follow-up: 3.2 mo).RESULTS Majority of applications were in upper GI tract(89%) with following bleeding sources: peptic ulcer disease(35%), esophageal varices(7%), tumor bleeding(11.7%), reflux esophagitis(8.7%), diffuse bleeding and erosions(15.3%). Overall ST success was achieved in 125 patients(81%) and LT success in 81 patients(67%). Re-bleeding occurred in 27% of all patients. In 72 patients(47%), HP was applied as a salvage hemostatic therapy, here ST and LT success were 81% and64%, with re-bleeding in 32%. As a primary hemostatic therapy, ST and LT success were 82% and 69%, with re-bleeding occurring in 22%. HS was more frequently applied for upper GI bleeding(P = 0.04)CONCLUSION Both HP allow for effective hemostasis with no differences in ST, LT success and re-bleeding.
文摘Due to concomitant changes in pro-and anti-coagulant mechanisms,patients with liver dysfunction have a“rebalanced hemostasis”,which can easily be tipped toward either a hypo-or a hypercoagulable phenotype.Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities.Conventional coagulation screening tests,such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures.The introduction of global coagulation assays,such as viscoelastic testing(VET),has been an important step forward in the assessment of the overall hemostasis profile.A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings.The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.
