Endoscopy 2013; 45(S 02): E104-E105
DOI: 10.1055/s-0032-1326280
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic clip tamponade of bleeding: a novel adjunct technique for endoscopic mucosal resection

W. C. Chen
1  Department of Medicine, The Methodist Hospital, Weill Cornell Medical College, Houston, Texas, USA
,
D. M. Maru
2  The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
,
S. C. Abraham
2  The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
,
D. Tan
2  The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
,
G. S. Raju
2  The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
› Institutsangaben
Weitere Informationen

Corresponding author

G. S. Raju, MD
The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd, GI Division – Unit 1466
Houston, TX 77030-4009
USA   
Fax: +1-713-694-5398   

Publikationsverlauf

Publikationsdatum:
22. März 2013 (online)

 

Endoscopic mucosal resection (EMR) of large nonpolypoid neoplasms of the colon may be complicated by immediate, early (first 24 hours), or delayed bleeding [1]. Endoscopic hemostasis of immediate bleeding can be achieved by epinephrine injection, cauterization of the bleeding site, and mechanical tamponade by resnaring the stalk or deployment of a band, clip, or detachable snare [1] [2] [3] [4].

Inadvertent entrapment of tumor tissue during clip deployment to control immediate bleeding after snare resection during piecemeal EMR may interfere with further snare resections and require surgery, as highlighted by patient #1 ([Table 1]; [Fig. 1]). This problem could be easily overcome using a novel technique of “endoscopic clip tamponade” (ECT) for 3 minutes to control bleeding followed by reopening of the clip and completion of the EMR procedure, as described in patients #2 – #4 ([Table 1]).

Table 1

Outcome of endoscopic mucosal resection (EMR) procedures in four patients with varying methods of endoscopic hemostasis employed for management of bleeding.

Case number

Age, years; sex

Site; size, cm

Method of endoscopic hemostasis

Outcome of EMR

Surgery

Pathology

1

77; F

Cecum; 5

Clip deployment

Aborted during first colonoscopy; failed during second colonoscopy

Right hemicolectomy

Tubulovillous adenoma with high grade dysplasia

2

57; F

Rectum; 5

Clip tamponade

Successful
(2 pieces)

No

Tubulovillous adenoma

3

44; M

Sigmoid colon; 5

Clip tamponade

Successful
(4 pieces)

No

Villous adenoma with foci high grade dysplasia

4

52; M

Cecum; 4

Clip tamponade

Successful

(5 pieces)

No

Tubulovillous adenoma with focal high-grade dysplasia

Zoom Image
Fig. 1 Endoscopic appearances of the procedure in patient #1 in which clip deployment for hemostasis resulted in a failed endoscopic mucosal resection (EMR) showing: a a 5-cm laterally spreading granular tumor in the cecum; b clip tethering of the polyp to the wall; c failed lifting of the lesion after submucosal injection.

Piecemeal EMR was undertaken with a stiff snare after injection of indigo carmine solution into the submucosa to lift the lesion ([Fig. 2 a]). With this technique, bleeding after first resection was controlled using the technique of endoscopic clip tamponade ([Fig. 2 b]). After the bleeding site was localized with a water jet, a clip with a reopening function (Resolution Clip, Boston Scientific, Natick, Massachusetts, USA) was applied immediately to the bleeding site. If bleeding persisted, the clip was reopened and reapplied more accurately to achieve hemostasis. Once hemostasis had been confirmed, the clip was held in place for a minimum of 3 minutes. It was then reopened and removed from the operating field. Resection of the remaining polyp was completed ([Fig. 2 c]), and the EMR defect was closed with clips ([Video 1]).

Zoom Image
Fig. 2 Endoscopic appearances in a patient who underwent clip tamponade that successfully achieved hemostasis showing: a successful lifting of the lesion with submucosal injection; b endoscopic clip tamponade of bleeding; c completion of the endoscopic mucosal resection (EMR).


Qualität:
A case showing hemostasis being achieved by clip tamponade following acute post-polypectomy bleeding.

We demonstrated that endoscopic clip tamponade controlled arterial bleeding and allowed successful completion of the EMR. Hasty deployment of clips to control arterial bleeding prior to completion of the resection may preclude subsequent endoscopic resection and require surgery.

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#

Competing interests: None


Corresponding author

G. S. Raju, MD
The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd, GI Division – Unit 1466
Houston, TX 77030-4009
USA   
Fax: +1-713-694-5398   


Zoom Image
Fig. 1 Endoscopic appearances of the procedure in patient #1 in which clip deployment for hemostasis resulted in a failed endoscopic mucosal resection (EMR) showing: a a 5-cm laterally spreading granular tumor in the cecum; b clip tethering of the polyp to the wall; c failed lifting of the lesion after submucosal injection.
Zoom Image
Fig. 2 Endoscopic appearances in a patient who underwent clip tamponade that successfully achieved hemostasis showing: a successful lifting of the lesion with submucosal injection; b endoscopic clip tamponade of bleeding; c completion of the endoscopic mucosal resection (EMR).