Novel method combining endoscopic band ligation and clipping for hemostasis of colonic diverticular bleeding

Several endoscopic modalities are used to treat colonic diverticular bleeding (CDB), a predominant lower gastrointestinal bleeding type [1] [2]. Most modalities involve clipping or endoscopic band ligation (EBL), which is preferred for preventing early rebleeding [3] [4] [5]; however, rebleeding often occurs even after EBL. Moreover, previous studies have debated whether EBL or clipping is more effective [3] [4] [5]. We have established a novel method combining EBL and clipping (i. e. the EBL-C method) for hemostasis of CDB.

A 49-year-old man presented with a chief complaint of bloody stools. Contrast-enhanced computed tomography revealed extravasation from the descending colonic diverticulum. We diagnosed him with CDB and performed emergency colonoscopy.

When a descending colonic diverticulum was aspirated and inverted, a visible vessel was found. Active bleeding occurred due to suction stimulation, and the diverticulum was identified as the bleeding source ([Fig. 1]). Endoscopic hemostasis was achieved by the EBL-C method ([Video 1]).

Fig. 1 Active bleeding from the diverticulum was confirmed with suction.

Video 1 Endoscopic hemostasis of colonic diverticular bleeding by combining endoscopic band ligation and clipping.

Endoscopic clipping was performed by placing a hemostatic clip (SureClip; Micro-Tech Co., Nanjing, China) onto the responsible vessel within the diverticulum. The endoscope was removed, and an EBL device (Sumitomo Bakelite Co., Ltd., Tokyo, Japan) was attached to its tip. It was then reinserted and directed toward the diverticulum marked with a clip. The diverticulum was aspirated with the clip into the EBL device and the elastic O-band was released ([Fig. 2]). No rebleeding occurred after treatment ([Fig. 3]).

Fig. 2 Endoscopic band ligation for hemostasis. a Aspiration of the diverticulum with the clip into the endoscopic band ligation device. b The O-band was released, and the procedure was completed.

Fig. 3 The endoscopic band ligation–clipping scar 1 month after the procedure.

Clipping involves grasping the exposed blood vessel part, whereas EBL involves grasping the root of the blood vessel. Therefore, the novel EBL-C combination treatment provided a stronger and more reliable hemostatic effect than that of each treatment alone ([Fig. 4]). The clip served as a marker during endoscopic reinsertion with the attached EBL device. Clipping hemostasis prevented bleeding during endoscopic reinsertion, thereby preventing visual field disorientation due to blood pools. In cases where clipping is insufficient, EBL can have a synergistic hemostatic effect.

Fig. 4 The endoscopic band ligation–clipping (EBL-C) method. Clipping: grasping the exposed part of the blood vessel. EBL: grasping the base of the blood vessel. EBL-C: combining EBL and clipping.

This is the first reported case describing the EBL-C method for hemostasis of CDB. The EBL-C method could be a simple alternative for CDB treatment with less risk of rebleeding compared with EBL or clipping alone, if confirmed in a large case series.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Gralnek IM, Neeman Z, Strate LL. Acute lower gastrointestinal bleeding. N Engl J Med 2017; 376: 1054-1063
• 2 Niikura R, Nagata N, Yamada A. et al. Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding. Gastroenterology 2020; 158: 168-175
• 3 Nagata N, Ishii N, Kaise M. et al. Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping. Gastrointest Endosc 2018; 88: 841-853
• 4 Kobayashi K, Nagata N, Furumoto Y. et al. Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: a large-scale multicenter cohort study. Endoscopy 2022; 54: 735-744
• 5 Nagata N, Niikura R, Ishii N. et al. Cumulative evidence for reducing recurrence of colonic diverticular bleeding using endoscopic clipping versus band ligation: systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36: 1738-1743

Publication History

Article published online:
13 July 2023