Over-the-scope clipping and detachable snare ligation as a novel combination hemostatic therapy for diverticular bleeding

Ligation therapy, such as endoscopic band ligation and detachable snare ligation, is an effective treatment for colonic diverticular hemorrhage [1] [2]. However, delayed perforation has been reported in patients undergoing steroid therapy and endoscopic ligation [3]. As an alternative, over-the-scope (OTS) clipping enables full-thickness resection at the central tissue mound of the inverted diverticulum while preventing perforation ([Fig. 1]) [4]. Recent reports have described that OTS clipping is effective for hemostasis of diverticular bleeding; however, early rebleeding was observed in 33 % of patients treated with OTS clips alone ([Fig. 2 a], [Fig. 3]) [5].

Fig. 1 An over-the-scope clip.

Fig. 2 Schema of over-the-scope (OTS) clipping and snare ligation combination method. a Early rebleeding after OTS clip placement for hemostasis of colonic diverticular hemorrhage. b–d The OTS clip was released onto the diverticulum, allowing primary hemostasis. A detachable snare was then applied to ligate the central tissue mound of the inverted and bulged diverticulum to prevent rebleeding.

Fig. 3 Early rebleeding after over-the-scope clip (*) placement for hemostasis of colonic diverticular hemorrhage (arrow).

We developed a combination method of OTS clipping and detachable snare ligation as a novel treatment for diverticular bleeding to reduce the occurrence of rebleeding and delayed perforation ([Fig. 2 b–d], [Video 1]).

Video 1 The combination method of over-the-scope clipping and detachable snare ligation as a novel hemostatic treatment for colonic diverticular bleeding and prevention of rebleeding and perforation.

A 79-year-old man taking 15 mg prednisolone daily for remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome and low-dose aspirin for angina pectoris presented with hematochezia. Colonoscopy revealed diverticular bleeding in the ascending colon ([Fig. 4]). Standard marking clips were placed near the diverticulum. The scope, mounted with the OTS clipping system, was then inserted and the clip was released onto the diverticulum, allowing primary hemostasis. The resulting central tissue mound of the inverted and bulged diverticulum was further ligated using a detachable snare to prevent rebleeding ([Fig. 5]). The patient was discharged 6 days after endoscopic treatment without any adverse events or early rebleeding.

Fig. 4 a, b Active bleeding (arrow) from a diverticulum at the ascending colon.

Fig. 5 In addition to the primary hemostasis by over-the-scope clip (a), a detachable snare was applied to ligate the central tissue mound of the inverted and bulged diverticulum to prevent rebleeding (b–d).

We believe that the novel combination method described here is a safe and effective standard therapy for hemostasis of colonic diverticular hemorrhage, especially in patients with increased risk for perforation and rebleeding.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Setoyama T, Ishii N, Fujita Y. Endoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25: 3574-3578
• 2 Akutsu D, Narasaka T, Wakayama M. et al. Endoscopic detachable snare ligation: a new treatment method for colonic diverticular hemorrhage. Endoscopy 2015; 47: 1039-1042
• 3 Takahashi S, Inaba T, Tanaka N. Delayed perforation after endoscopic band ligation for treatment of colonic diverticular bleeding. Dig Endosc 2016; 28: 484
• 4 Agarwal A, Fang S, Pezhouh MK. et al. Full-thickness resection of a rectal scar using a modified over-the-scope clip after piecemeal resection of intramucosal cancer. Endoscopy 2017; 49: E151-E152
• 5 Wedi E, von Renteln D, Jung C. et al. Treatment of acute colonic diverticular bleeding in high risk patients, using an over-the-scope clip: a case series. Endoscopy 2016; 48: E383-E385

Publication History

Article published online:
05 March 2021