delayed bleeding
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2022 ◽  
Vol 71 (12) ◽  
pp. 2838-2838
Author(s):  
Muhammad Umer ◽  
Syed Wasif Bukhari

Endoscopy nowadays is widely used as a diagnostic and therapeutic tool for various gastrointestinal diseases due to it being less invasive and safer. However, amongst some adverse events is delayed bleeding. The definition of delayed bleeding requires endoscopic hemostasis and/or blood transfusion after at least two days of treatment. (1) Oesophageal cancer is comparatively more common in Pakistan, being 7th most common malignancy in men and 6th most common in women in Karachi. (2) Oesophageal endoscopic submucosal dissection (E-ESD) employed in the treatment of the above- mentioned cancer has an incidence of delayed bleeding of about 1.3-6.7%. (1) The prevalence of gastric cancer across Pakistan was about 2-18% (3), for which endoscopic submucosal dissection is often used has an incidence of delayed bleeding of 4.7-15.6%. (1) Endoscopic therapy for gastroesophageal varices can also result in delayed bleeding, the incidence of which easily reaches up to 10%. (1) In a retrospective cohort study of 124,422 patients conducted in Japan, it was found that vonoprazan was more effective in reducing the risk of delayed bleeding compared to omeprazole. (OR= 0.75) (1) Vonoprazan works by competitively inhibiting the potassium-acid channel resulting in strong and sustained acid inhibition. (4) It was also found to have a superior effect in the eradication of H Pylori and an equal effect in acid-related disorders. (5)  In the retrospective study mentioned above, it is also worth noting that the efficacy of vonoprazan was variable with respect to procedures and was most prominent with gastroduodenal endoscopic submucosal dissection (OR=0.70). (1) Other procedures did not elicit any significant difference. In addition, standard/high dose vonoprazan proved to be most efficacious in reducing the risk of delayed bleeding compared with standard/high-dose PPI and low-dose vonoprazan. It was also observed that patients taking anti-thrombotic medications at a higher risk of delayed bleeding also benefited from high-dose vonoprazan. (OR=0.74) (1) The findings above compel the conclusion that high dose vonoprazan should be ideal for reducing the risk of delayed bleeding in patients who have undergone gastroduodenal endoscopic submucosal dissection and/or are on anti-thrombotics. Though high-dose vonoprazan does look promising, it is imperative that more randomized controlled trials on more diverse populations be conducted to further explore its efficacy and safety as the drug might be a potential first line of therapy.


2022 ◽  
Vol 10 (01) ◽  
pp. E74-E81
Author(s):  
Saurabh Chandan ◽  
Antonio Facciorusso ◽  
Daryl Ramai ◽  
Smit Deliwala ◽  
Babu P. Mohan ◽  
...  

Abstract Background and study aims Endoscopic mucosal resection (EMR) of laterally spreading tumors (LSTs) > 20 mm in size can be challenging. Piecemeal EMR of these lesions results in high rates of adenoma recurrence at first surveillance colonoscopy (SC1). Snare tip soft coagulation (STSC) of post resection margins is a safe and effective technique to prevent adenoma recurrence. We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of this technique. Patients and methods Multiple databases were searched through April 2021 for studies that reported on outcomes of post EMR STSC for LSTs > 20 mm in size. Meta-analysis was performed to determine pooled odds of adenoma recurrence as well as pooled proportion of adverse events including intraprocedural and delayed bleeding as well as intraprocedural perforation events. Results Six studies including two randomized controlled trials (RCT) and four cohort studies with 2122 patients were included in the final analysis. Overall pooled odds of adenoma recurrence at SC1 with post EMR STSC compared to no STSC was 0.27 (95 % 0.18–0.42; I2 = 0 %), P < 0.001. Pooled rate of adenoma recurrence at SC1 in post EMR STSC cohort was 6 %. Rates of intraprocedural bleeding, delayed bleeding and intraprocedural perforation were 10.3 %, 6.5 % and 2 % respectively. Conclusions Our results show that thermal ablation of resection margins with STSC in LSTs > 20 mm is a safe and effective technique in reducing the incidence of adenoma recurrence.


2021 ◽  
pp. 159101992110669
Author(s):  
Tomoyoshi Shigematsu ◽  
Maximilian J Bazil ◽  
Stavros Matsoukas ◽  
Rene Chapot ◽  
Michelle Sorscher ◽  
...  

In some vein of galen aneurysmal malformation (VGAM) patients, transvenous embolization (TVE) is an attractive option, but its safety is unclear. Here we report the first two VGAM patients treated using the Chapot “pressure cooker” technique (ChPC). Methods Two patients, one 5-year-old and one 7-year-old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n-BCA for choroidal VGAMs. Results We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform TVE using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils and n-BCA are used to prevent reflux of Onyx. Conclusions In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: (1) without liquid embolic, deployed coils may not occlude the fistula entirely. (2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE.


2021 ◽  
Vol Volume 14 ◽  
pp. 477-492
Author(s):  
Oliver Bendall ◽  
Joel James ◽  
Katarzyna M Pawlak ◽  
Sauid Ishaq ◽  
J Andy Tau ◽  
...  

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2105-2105
Author(s):  
Tyler W. Buckner ◽  
Shannon L Carpenter ◽  
Nabil Daoud ◽  
Nikki Hirsh ◽  
Thomas W. McLean ◽  
...  

Abstract INTRODUCTION: The recent introduction of new therapies for people with hemophilia A and B (HA and HB) mandates careful monitoring of the safety of these treatments. The primary aim of ATHN 7: A Natural History Study of the Safety, Effectiveness, and Practice of Treatment for People with Hemophilia (NCT03619863) is to monitor the safety of current hemophilia therapies. METHODS: ATHN 7 is a longitudinal, prospective cohort study being conducted at 26 American Thrombosis and Hemostasis Network (ATHN)-affiliated sites. The study is approved by central and local institutional review boards. Any person with a diagnosis of congenital hemophilia A or B (factor VIII or IX activity &lt; 50%) who receives care at a participating site is eligible for inclusion. Participants and/or a parent/guardian sign informed consent and assent prior to participation. Adverse events, including those events designated by the European Haemophilia Safety Surveillance group as well as other adverse events of special interest, are recorded and monitored. Demographic and clinical information are collected at baseline and at least quarterly through participant interview and medical record review. Descriptive statistics of medical history and demographic data as well as longitudinal data are used to characterize the study population. RESULTS: As of June 2021, a total of 391 participants had enrolled in ATHN 7. The median age of participants was 22.5 ± 17.8 years. Males represented 97.7% (382/391) of participants. Eighty-five percent (333/391) were not Hispanic. White participants comprised 82.6% (323/391) of the study population, while 7.9% (31/391) were Black/African American, 3.8% (15/391) were Asian, 1.8% (7/391) were of mixed race, and 3.8% (15/391) were of other or unknown race. The primary diagnosis of participants included 70.1% (274/391) with severe HA, 15.3% (60/391) with moderate HA, 7.2% (28/391) with mild HA, 4.1% (16/391) with severe HB, 2.0% (8/391) with moderate HB, and 1.0% (4/391) with mild HB. Nineteen percent (71/391) of participants had a documented history of an inhibitor at the time of enrollment with a mean peak inhibitor titer of 96.7 ± 214.3 Bethesda Units. Substitution therapy with a non-factor molecule was the primary medication for 43.4% (162/391) participants, while 4.3% (16/391) utilized a plasma-derived clotting factor concentrate, 28.4% (196/391) utilized a standard half-life, recombinant factor concentrate, 18.3% (126/391) utilized an extended half-life recombinant factor concentrate, 4.1% (28/391) utilized a bypassing agent, and 19.3% (133/391) utilized some other hemostatic agent. Continuous prophylaxis was the primary regimen for 79.1% (295/391) participants. The remaining 19.6% (73/391) of participants were on episodic therapy. Within the cohort of 391 participants, a total of 14 adverse events have been reported in 8 participants. No adverse events of special interest were reported. Redness or rash at injection site accounted for 64.2% (9/14) of the reported adverse events, all in participants receiving emicizumab. Two participants experienced bruising or bleeding while on emicizumab. Two participants on emicizumab were diagnosed with malignancy, neither found to be attributed to their therapy. One participant developed an allergic reaction to their standard half-life recombinant factor concentrate. DISCUSSION: Open to enrollment in January 2019, ATHN 7 has now collected 18 months of longitudinal safety data for therapies used to treat HA and HB in 391 participants, an addition of 12 months and 24 participants since our last report. As the study was designed to enhance representation of those utilizing substitution therapy, almost half of the participants were on emicizumab for prophylaxis of bleeding. Adverse events attributable to hemophilia therapy was limited to minor skin reactions. As previously reported, a single participant experienced delayed bleeding after closed head trauma (despite factor replacement and normal intracranial imaging at the time of the event), providing potentially important information on the risk of delayed bleeding from significant trauma in those receiving emicizumab. Over the coming year, participants in ATHN 7 will be transitioned to ATHN's new longitudinal natural history study, ATHN TRANSCENDS (NCT04398628). Disclosures Buckner: Pfizer: Honoraria; Takeda: Honoraria; Bayer: Honoraria; Sanofi: Honoraria; Spark: Honoraria; Genetech: Honoraria; CSL Behring: Honoraria; Novo Nordisk: Honoraria; Tremeau Pharmaceuticals: Consultancy, Honoraria; BioMarin: Consultancy, Honoraria; uniQure: Consultancy, Honoraria; American Thrombosis: Membership on an entity's Board of Directors or advisory committees; Hemostasis Network: Membership on an entity's Board of Directors or advisory committees. Carpenter: Hemophilia and Thrombosis Research Society: Membership on an entity's Board of Directors or advisory committees; Kedrion Pharmaceuticals: Honoraria; Genentech: Honoraria; Novo Nordisk: Honoraria. Raffini: Genentech: Consultancy; CSL Behring: Consultancy; HEMA Biologics: Consultancy; XaTek: Consultancy; Bayer: Consultancy. Zia: Takeda: Consultancy; Hemophilia and Thrombosis Research Society: Membership on an entity's Board of Directors or advisory committees. Recht: Hema Biologics: Consultancy; Kedrion: Consultancy; Novo Nordisk: Consultancy; Octapharma: Consultancy; Pfizer: Consultancy; Sanofi: Consultancy; Takeda: Consultancy; uniQure: Consultancy; Foundation for Women and Girls with Blood Disorders, Partners in Bleeding Disorders: Speakers Bureau; American Thrombosis and Hemostasis Network: Current Employment; Oregon Health & Science University: Current Employment; Genentech: Consultancy; CSL Behring: Consultancy; Catalyst Biosciences: Consultancy.


Author(s):  
Maximilian J Bazil ◽  
Tomoyoshi Shigematsu ◽  
Maximilian J Bazil ◽  
Stavros Matsoukas ◽  
Johanna T Fifi ◽  
...  

Introduction : There are various procedural techniques described in the literature to treat VGAM: 1) transarterial embolization (TAE) via a transfemoral or transumbilical approach, 2) transfemoral or transtorcular venous coiling, and 3) the combined transarterial and transvenous “trapping” of the fistula. The transarterial technique has permitted our team to obtain total or near‐total obliteration in approximately 80% of cases; however, there is a patient population in whom the residual arterial supply is comprised of small perforators. In these patients, transvenous embolization (TVE) is an attractive option, but its safety is unclear. Here we report the first two VGAM patients treated using the Chapot “pressure cooker” technique (ChPC). Methods : Two patients, one 5‐year‐old and one 7‐year‐old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n‐BCA for choroidal VGAMs. We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform transvenous embolization using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils, and n‐BCA if necessary, are used to prevent reflux of Onyx. This forces the Onyx to occlude the vein and the most distal arterial segment. Results : Both patients had complete occlusion of the VGAM after ChPC. Conclusions : This is the first report to describe TVE to cure VGAM after multiple sessions of TAE. This is also the first report to apply ChPC to VGAM treatment. In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: 1) without liquid embolic, deployed coils may not occlude the fistula entirely. 2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE. Not only is the residual vein blocked, but also the incoming arterial supply which prevents delayed bleeding. In endovascular treatment of VGAM, TVE is feasible option once the dilated vein of Galen becomes small enough. To prevent incomplete occlusion or post‐procedural hemorrhagic complications, the use of the ChPC using DMSO liquid embolic material is a promising and necessary introduction to the neurointerventionalist’s treatment arsenal.


2021 ◽  
Vol 19 (Sup8) ◽  
pp. s22-S31
Author(s):  
Kate O’Neill ◽  
Alan R Williams

Background: Delayed bleeding is a recognised complicationf ollowing colonic endoscopic resection. Prophylactic clip application is often used to reduce this. However, there is a lack of guidelines to support this. Aims: This article aims to review the most recent evidence on the question: 'In patients undergoing endoscopic resection of colonic polyps, does prophylactic clipping of the resection, compared with not clipping, reduce the incidence of delayed bleeding?'. Methods: A rapid assessment was undertaken regarding prophylactic clipping efficacy to reduce delayed bleeding. A search of three databases (Medline, the University of Derby Library Plus and the Cochrane Library) was undertaken to identify articles from the past 4 years. Findings: Eight publications were reviewed: three meta-analyses and five randomised control trials. Five publications recommended against prophylactic clipping following colonic endoscopic resection and three, the most recent publications, strongly recommended it, specifically for those at high risk of delayed bleeding. Conclusion: Prophylactic clip application to reduce delayed bleeding is not effective across all colonic resections. However, there is evidence in favour of clipping for patients with high risk of delayed bleeding.


Author(s):  
Zhongsheng Cao ◽  
Weili Jin ◽  
Xueping Wu ◽  
Wensheng PAN

Background: Little is known about the efficacy and safety of single balloon enteroscopy (SBE) in patients with Peutz-Jeghers syndrome (PJS). The aim of this study was to assess the efficacy and safety of SBE for treatment of small bowel polyps in patients with PJS. Methods: We conducted a single center observational study, which included all patients diagnosed with PJS who underwent SBE for polypectomy between January 2018 and March 2021. Complete treatment was defined as the absence of polyps≥20mm after SBE resection. The clinical records were retrospectively reviewed. Results: 102 patients (including 40 men and 62 women) with a mean age of 28.7 years (range 13-55y), were enrolled in our study. The intubation depth via oral approach of patients with history of laparotomy was significantly shorter than that of the patients without history of laparotomy ([241.6±64.2] cm vs [280.9±40.2] cm, P = 0.008). The maximum size of the resected polyps via anus during the second hospitalization was significantly smaller than that during the first hospitalization ([2.25±1.29] cm vs [4.26±3.51] cm, P = 0.032). Complications occurred in 10/129 of hospitalizations (4 delayed bleeding, 3 perforation, and 3 acute pancreatitis). Conclusions: SBE is effective and safe for resection of small bowel polyps in patients with PJS.


Digestion ◽  
2021 ◽  
pp. 1-7
Author(s):  
Osamu Goto ◽  
Mitsuru Kaise ◽  
Katsuhiko Iwakiri

<b><i>Background:</i></b> Endoscopic treatments for gastric cancers have still been progressing even after the great success of endoscopic submucosal dissection (ESD). <b><i>Summary:</i></b> In further advancements of ESD, safe and less-invasive procedures are challenged by managing postoperative bleeding, one of the major adverse events in ESD. Covering the mucosal defect after removal of lesions appears reasonable and effective for preventing delayed bleeding from the post-ESD ulcers. Shielding with biodegradable sheets is attempted on clinical trials, which show equivocal results. Although suturing of the mucosal rims is technically challenging, pilot studies demonstrate favorable outcomes for avoiding post-ESD bleeding even in cases at high risk. In cases after noncurative resection of ESD, the selection of patients who truly require additional gastrectomy with lymph node dissection is important to provide necessary surgery. Risk stratification of lymph node metastases and surgery has been developed, which offers tailor-made management to each patient considering the risks and benefits. In surgery, function-preserving gastrectomy to minimize the resection area in both lymphadenectomy and the primary site is clinically introduced. The sentinel node navigation surgery is promising to realize the minimally invasive gastrectomy, and it should strongly fit ESD as well as laparoscopic endoscopic cooperative surgery or endoscopic full-thickness resection, although nonexposure approaches are desirable. <b><i>Key Message:</i></b> Development for less-invasive managements on gastric cancer will be continued in step with the advancement of endoscopic treatments.


Endoscopy ◽  
2021 ◽  
Author(s):  
Motohiko Kato ◽  
Yoji Takeuchi ◽  
Shu Hoteya ◽  
Tsuneo Oyama ◽  
Satoru Nonaka ◽  
...  

Background and study aim: There is no enough data for endoscopic resection (ER) of superficial duodenal epithelial tumors (SDETs) due to its rarity. There are two main kinds of ER techniques for SDETs: EMR and ESD. In addition, modified EMR techniques, underwater EMR (UEMR) and cold polypectomy (CP), are getting popular. We conducted a large-scale retrospective multicenter study to clarify detailed outcomes of duodenal ER. Patients and methods : Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs) (defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using Kaplan-Meier method. Results: In total, 3107 patients (including 1017 receiving ESD) were included. En bloc resection rates were 79.1%, 78.6%, 86.8%, and 94.8%, and delayed AE rates were 0.5%, 2.2%, 2.8%, and 7.3% for CP, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher for ESD group than non-ESD group among lesions less than 19 mm (7.4% vs 1.9%, p<0.0001), but not among lesions larger than 20 mm (6.1% vs 7.1%, p=0.6432). The local recurrence rate was significantly lower in ESD group than non-ESD group (p<0.001). Furthermore, for lesions larger than 30 mm, the cumulative local recurrence rate at 2 years was 22.6% in non-ESD group compared to only 1.6% in ESD group (p<0.0001). Conclusions: ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.


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