Reply to Mavrogenis and Coumaros

We greatly appreciate the comments of Georgios and Dimitri in their letter [1] regarding our recent article on endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding [2]. We were also very interested to read their report of a case of uncontrolled post-endoscopic sphincterotomy bleeding even when a self-expandable metallic stent (SEMS) was being used.

Their comments emphasize three important points in achieving successful hemostasis when using a covered SEMS for uncontrolled post-endoscopic sphincterotomy bleeding, as follows: first, the use of several hemostatic methods; secondly, the usefulness of covered SEMSs; and thirdly, the possible migration of covered SEMSs. As we mentioned in our paper, endoscopists should have several hemostasis techniques for post-endoscopic sphincterotomy bleeding. Accordingly, an SEMS should be used only for uncontrolled cases in which standard endoscopic hemostatic techniques are not effective. As we have reported, all the covered SEMSs could be placed across the papilla and provided sufficient mechanical pressure, resulting in successful hemostasis in only a single session.

As the authors stated, and in agreement with our viewpoint, the temporary placement of SEMSs can achieve only temporary hemostasis. SEMSs are tubular stents originally designed to resolve benign or malignant bile duct strictures. If used for hemostasis of post-endoscopic sphincterotomy bleeding in patients without biliary strictures, such as those with bile duct stones, inward or outward SEMS migration, which causes rebleeding even after 2 weeks, is a possible adverse event. Particularly, in cases where the diameter of the bile duct is larger than that of a SEMS, as in their patient, it is possible that migration can easily occur because of the small extent of contact between the SEMS and the bile duct wall. In such cases, as the authors suggested, the use of a SEMS with a larger diameter in combination with several standard hemostatic methods may be the procedure of choice. However, at the same time, we should also consider alternative nonendoscopic hemostatic methods. As a next step, interventional radiology or even surgery may be indicated. Although endoscopists always aim for complete hemostasis using only endoscopic techniques, we must endeavor to find the optimal method to achieve this and consult radiologists or surgeons if needed.

References

• 1 Mavrogenis G, Coumaros D. Use of covered self-expandable metallic stents in post-endoscopic sphincterotomy bleeding.  Endoscopy. 2011;  43 1114
• 2 Itoi T, Yasuda I, Doi S. et al . Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding.  Endoscopy. 2011;  43 369-372