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Emorragia GE superiore: d lità t ti hmodalità emostatiche
endoscopiche a confrontoendoscopiche a confronto
E M iEnzo MasciDirettore UOC Endoscopia
Diagnostica e Chirurgia EndoscopicaDiagnostica e Chirurgia EndoscopicaIRCCS Istituto Nazionale dei Tumori
Milano
11
G.I. HEMORRHAGEG.I. HEMORRHAGE(Italy)
100 NEW CASES/YRS./100.000 INHABITANTS100.000 INHABITANTS
100‐120 HOSP. ADM. CASES/YRS./100 000 INHABITANTS100.000 INHABITANTS
68% > 60 yrs.MORTALITY >70 a. 11.2%
< 60 a. 0.4%
DUAL THERAPY DUAL THERAPY vs. MONOTHERAPYvs. MONOTHERAPY
RECURRENT BLEEDINGRECURRENT BLEEDING NEED FOR SURGERYNEED FOR SURGERYRECURRENT BLEEDINGRECURRENT BLEEDING NEED FOR SURGERYNEED FOR SURGERY
R. Marmo A.J.G ‘07
NO CLEAR EVIDENCE THAT ANY NO CLEAR EVIDENCE THAT ANY TECHNIQUE IS SUPERIOR TOTECHNIQUE IS SUPERIOR TOTECHNIQUE IS SUPERIOR TO TECHNIQUE IS SUPERIOR TO INJECTION OF EPHINEPHRINE INJECTION OF EPHINEPHRINE ALONEALONE
COMBINED THERAPY IS THE COMBINED THERAPY IS THE TREATMENT OF CHOICE FORTREATMENT OF CHOICE FORTREATMENT OF CHOICE FOR TREATMENT OF CHOICE FOR HIGH RISK PATIENTS (Ia,Ib,IIa)HIGH RISK PATIENTS (Ia,Ib,IIa)HIGH RISK PATIENTS (Ia,Ib,IIa)HIGH RISK PATIENTS (Ia,Ib,IIa)
2 ENDOSCOPIC THERAPY2
• ASGE Guielinesno single modality superiorg y p
• UK Guidelineshemoclips partciculary useful for active bleeding largehemoclips partciculary useful for active bleeding large vessels
• NVU GI Bleeding Conference Canada• NVU GI Bleeding Conference Canada1) no single method is superior to the others2) the placement of clips is promising for high‐risk stigmata
44
55
Technical demanding cases3
• LARGE ULCER WITH PROTUBERANT VESSEL• POSTERIOR WALL IN DUODENUM• PROXIMAL LESSER CURVE IN STOMACH
• PATIENTS ON ANTITHROMBOTIC THERAPY
Pub Med
Animal TestingAnimal Testing
Treatment group H t ti
In a sterile Laparotomy Gastroepiploic vessels
Hemostatic Powder (n=5)
Control group Gastroepiploic vessels were dissected, inserted trough a gastrotomy,and freely exposed
Control group No Treatment (n=5)
and freely exposed in the gastric lumen, and the exposed vessel lacerated by needle knife
5 pigs “5 pigs “shamsham””vsvsvsvs
5 pigs Hemospray5 pigs Hemosprayp g p yp g p y
H2H2--blockers and Heparinblockers and Heparin
B. MangiavillanoB. Mangiavillano
Giday/Animal Study
C t l GControl Group •All animals died acutely (w/1 hour)
T t t GTreatment Group •All animals recovered for 7 days
No evidence of active bleeding in treatment group at day 7Mucosa appeared normal in all casesNo complications100% t h t i100% acute hemostasis
Necropsy in Hemospray Group•Healed gastrotomy•No foreign body granuloma in stomach and at injury sitej y•No evidence of emboli in lung or brain
Sung/PU Study
A t H t i 19/20 ti t ‡Acute Hemostasis: 19/20 patients ‡No Recurrent Bleeding: 17/19 patients †Procedural Adverse Events: NoneDevice‐related SAE: NoneMortality/SAE at 30‐day follow‐up: None (20
ti t )patients)
‡ Subsequently, 3 applications of hemostasis clips and 1 application of 8 mL adrenaline failed to maintain hemostasis. The patient was referred on for arterial embolization and was found to have a pseudoaneurysm.
† No active bleed was observed in two patients who had recurrent bleeding within 72 hours of the study procedure: the observation of recurrent bleeding was based upon clinical symptoms.clinical symptoms.
Peptic ulcer (Forrest 1 aPeptic ulcer (Forrest 1 a‐‐1 b)1 b)PROSPECTIVE SINGLEPROSPECTIVE SINGLE‐‐ARM PILOT ARM PILOT
STUDYSTUDYSTUDYSTUDY
20 PatientsHemospray application within p y pp24 h of hospital ammission
(1‐2 application)(1‐2 application)Second look endoscopy at 72 h
Peptic ulcer (Forrest 1a Peptic ulcer (Forrest 1a ‐‐ 1b)1b)PROSPECTIVE SINGLEPROSPECTIVE SINGLE‐‐ARM PILOT ARM PILOT
STUDYSTUDYSTUDYSTUDY
Exclusion criteriaExclusion criteriaExclusion criteriaExclusion criteria•• Hemodynamic instabilityHemodynamic instability
I d l hI d l h•• Incorrected coagulopathyIncorrected coagulopathy•• Use of FANS or antiplatelets agent, that could be not discontinuedUse of FANS or antiplatelets agent, that could be not discontinued
PPI b f dPPI b f d•• PPI before endoscopyPPI before endoscopy
Immediate Immediate hemostasishemostasis ::
95%95%95%95%
Hemostasis Hemostasis at 72hat 72h:: 89.5%89.5%
SEAL‐Clinical Outcomes6
Hemospray Monotherapy
Hemospray + Additional
Standard endoscopic
6
Monotherapy Additional endoscopic therapy
endoscopic therapy + Hemospray
Number of Patients
39 8 24
Rockall Score (median)
5.5 (range 3‐10)
7(range 5‐10)
6.5(range 5‐7)
Primary Haemostasis
38/39(97%)
6/8(75%)
16/24(67%)
Rebleed(7 days)
6/38(16%)
1/6(17%)
6/16(38%)
Mortality(7 days)
3/39(8%)
0 2/24(8%)
Peptic ulcer (Forrest 1a Peptic ulcer (Forrest 1a ‐‐ 1b)1b)PROSPECTIVE SINGLEPROSPECTIVE SINGLE‐‐ARM PILOT ARM PILOT
STUDYSTUDYSTUDYSTUDYACUTE HEMOSTASIS 95% (19/20)ACUTE HEMOSTASIS 95% (19/20)ACUTE HEMOSTASIS 95% (19/20)ACUTE HEMOSTASIS 95% (19/20)1 Patient with pseudoaneurysm required arterial 1 Patient with pseudoaneurysm required arterial
b li tib li tiembolizationembolizationRECURRENCE OF BLEEDING AT 72 hRECURRENCE OF BLEEDING AT 72 h2 Patients2 PatientsNO ADVERSE EVENT REPORTED AT 30 DAYS NO ADVERSE EVENT REPORTED AT 30 DAYS THELEPHONE CALLTHELEPHONE CALL
Duodenal Ulcer
SEAL Product Evaluation (71)
Survey to Evaluate the Application ofSurvey to Evaluate the Application of
Hemospray™ in the Luminal Tract
Objective: To gain clinical experience with Hemospray in Europe and Canadap y p
Gastroduodenal ulceration 58% (n=41)Tumours 7% (n=5)Oesophageal ulceration 4% (n=3)p g ( )Dieulafoy lesion 4% (n=3)Post EMR 3% (n=2)GAVE 3% (n=2)Other causes 21%(n=15)
.
SEAL‐Ease of Application
90
60
70
80
40
50
60
rcen
t APCBipolar probe
20
30
40Pe
p pClipInjection
0
10
20
0
Comparable to Easier than More difficult No answer
SEAL‐Peptic ulcer outcomes
Hemospray Monotherapy
Hemospray + Additional
Standard endoscopicMonotherapy Additional
endoscopic therapy
endoscopic therapy + Hemospray
Number of peptic ulcers
18(46%)
6(75%)
17(71%)(46%) (75%) (71%)
Proportion Forrest 1a
7/18(39%)
3/6(50%)
8/17(47%)Forrest 1a (39%) (50%) (47%)
Proportion Forrest 1b
9/18(50%)
3/6(50%)
8/17(47%)Forrest 1b (50%) (50%) (47%)
Unclassified ulcer 2/18 0 1/17(11%) (6%)
SEAL‐Clinical Outcomes6
Hemospray Monotherapy
Hemospray + Additional
Standard endoscopic
6
Monotherapy Additional endoscopic therapy
endoscopic therapy + Hemospray
Number of Patients
39 8 24
Rockall Score (median)
5.5 (range 3‐10)
7(range 5‐10)
6.5(range 5‐7)
Primary Haemostasis
38/39(97%)
6/8(75%)
16/24(67%)
Rebleed(7 days)
6/38(16%)
1/6(17%)
6/16(38%)
Mortality(7 days)
3/39(8%)
0 2/24(8%)
SEAL‐Rebleeding
Hemospray Monotherapy
Hemospray + Additional
Standard endoscopicMonotherapy Additional
endoscopic therapy
endoscopic therapy + Hemospray
Total Rebleed 6 1 6
Forrest 1a Rebleed
3 0 2
F 1b 0 1 2Forrest 1b Rebleed
0 1 2
U l ifi d l 0 0 1Unclassified ulcer Rebleed
0 0 1
Non ulcer 3 0 1Non ulcer Rebleed
3 0 1
SEAL-Mortality
5 deathsLi di (2 i )Liver disease (2 patients)Myocardial infarction (1 patient)Aspiration pneumonia (1 patient)Perforation (1 patient)( p )
No deaths related to REBLEED
cancer-related upper GI bleeding 7
Early Clinical Evidence
7
Early Clinical Evidence
• Use of the endoscopically applied hemostatic d TC 325 i l d GIpowder TC‐325 in cancer‐related upper GI
hemorrhage: preliminary experience
Conclusion: Hemospray, which was recently described in the management of nonmalignant upper GI hemorrhage, may become the method of choice in neoplastic bleeding given its noncontact application, malleable nature, and ability to cover large and multiple areas of bleeding
Principle Investigators:
ability to cover large and multiple areas of bleeding.
Yen‐I Chen, MD, Alan N. Barkun, MD, MSc, Constantine Soulellis, MD, Serge Mayrand, MD P Gh li MDMD, Peter Ghali, MD
Montreal, Quebec, Canada
88
Bleeding in Recurrence of Cancer
Prevention of Bleeding after EMR
Hemostatis was
16 unselected
Hemostatis was achieved in:5/8 pts. on ATT(63%)pts. with UGIB (63%)and 8/8 not on therapy(p=0,20)
CONTRAINDICATIONCONTRAINDICATION
in patients with suspicion of:in patients with suspicion of:
fi t l ( t i t ti l)fi t l ( t i t ti l)•• fistula (gastrointestinal)fistula (gastrointestinal)
•• perforationperforationpp
FutureFuture
9
OTSC for BLEDDING9
OTSC for BLEDDING
99
Di l fDieulafoy
Autore
TITOLOSottotitolo
11
G.I. HEMORRHAGEG.I. HEMORRHAGE(Italy)
100 NEW CASES/YRS./100.000 INHABITANTS100.000 INHABITANTS
100‐120 HOSP. ADM. CASES/YRS./100 000 INHABITANTS100.000 INHABITANTS
68% > 60 yrs.MORTALITY >70 a. 11.2%
< 60 a. 0.4%
2 ENDOSCOPIC THERAPY2
• ASGE Guielinesno single modality superiorg y p
• UK Guidelineshemoclips partciculary useful for active bleeding largehemoclips partciculary useful for active bleeding large vessels
• NVU GI Bleeding Conference Canada• NVU GI Bleeding Conference Canada1) no single method is superior to the others2) the placement of clips is promising for high‐risk stigmata
Technical demanding cases3
• LARGE ULCER WITH PROTUBERANT VESSEL• POSTERIOR WALL IN DUODENUM• PROXIMAL LESSER CURVE IN STOMACH
• PATIENTS ON ANTITHROMBOTIC THERAPY
44
55
SEAL‐Clinical Outcomes6
Hemospray Monotherapy
Hemospray + Additional
Standard endoscopic
6
Monotherapy Additional endoscopic therapy
endoscopic therapy + Hemospray
Number of Patients
39 8 24
Rockall Score (median)
5.5 (range 3‐10)
7(range 5‐10)
6.5(range 5‐7)
Primary Haemostasis
38/39(97%)
6/8(75%)
16/24(67%)
Rebleed(7 days)
6/38(16%)
1/6(17%)
6/16(38%)
Mortality(7 days)
3/39(8%)
0 2/24(8%)
cancer-related upper GI bleeding 7
Early Clinical Evidence
7
Early Clinical Evidence
• Use of the endoscopically applied hemostatic d TC 325 i l d GIpowder TC‐325 in cancer‐related upper GI
hemorrhage: preliminary experience
Conclusion: Hemospray, which was recently described in the management of nonmalignant upper GI hemorrhage, may become the method of choice in neoplastic bleeding given its noncontact application, malleable nature, and ability to cover large and multiple areas of bleeding
Principle Investigators:
ability to cover large and multiple areas of bleeding.
Yen‐I Chen, MD, Alan N. Barkun, MD, MSc, Constantine Soulellis, MD, Serge Mayrand, MD P Gh li MDMD, Peter Ghali, MD
Montreal, Quebec, Canada
88
9
OTSC for BLEDDING9
OTSC for BLEDDING
1010
hemospray.cookmedical.com
Difficult Duodenal UlcerDifficult Duodenal Ulcer