Effective application of self-assembling peptide matrix with the gel immersion technique and red dichromatic imaging for hemostasis of postendoscopic sphincterotomy bleeding

Endoscopic sphincterotomy is an essential procedure during endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis or treatment of pancreaticobiliary disease; however, postendoscopic sphincterotomy bleeding occasionally occurs and is a potentially life-threatening adverse event [1]. Recently, a novel self-assembling peptide matrix (PuraStat; 3-D Matrix Europe SAS, France), which is approved for hemostasis in gastrointestinal endoscopic procedures, was launched [2]. Because of its characteristics, this product is not effective in achieving hemostasis of pooled blood, as the peptide matrix assembles when the solution comes into contact with body fluids. For effective hemostasis, the peptide matrix gel should be applied as close as possible to the bleeding point of the injured vessel wall. Herein, we report the effective application of PuraStat for hemostasis of postendoscopic sphincterotomy bleeding while securing an endoscopic field of view with the gel immersion technique [3] and red dichromatic imaging (RDI; Olympus, Japan) [4] [5] ([Video 1]).

Video 1 A novel self-assembling peptide matrix (PuraStat) is successfully applied to achieve hemostasis of postendoscopic sphincterotomy bleeding, with the endoscopic field of view secured with the gel immersion technique and red dichromatic imaging.

An 85-year-old man underwent ERCP for acute cholangitis due to a common bile duct stone. The stone was successfully removed with a balloon extractor following endoscopic sphincterotomy ([Fig. 1]). After removal of the stone, bleeding occurred at the endoscopic sphincterotomy site ([Fig. 2]); therefore, we performed hemostasis using the peptide matrix gel. We used the gel immersion technique and RDI to secure the endoscopic field of view and detect the bleeding point ([Fig. 3]). As the flowing blood does not spread and mix with the gel, we applied the peptide matrix gel and put the endoscope into the gel. RDI was used to provide color contrast between the bleeding point and the pooled peripheral blood. The peptide matrix was applied directly onto the bleeding point using a dedicated catheter ([Fig. 4]), and complete hemostasis was achieved ([Fig. 5]). The patient’s clinical course was uneventful after the procedure.

Fig. 1 Endoscopic sphincterotomy was performed before removal of the common bile duct stone.

Fig. 2 Endoscopic image of the postendoscopic sphincterotomy bleeding under: a white-light imaging; b red dichromatic imaging (RDI) mode 2, with the bleeding point (arrow) clearly observed owing to the color contrast between fresh blood and pooled blood.

Fig. 3 A dedicated catheter was used to deliver a self-assembling peptide matrix gel (PuraStat) and the bleeding point (arrow) could be clearly seen using the gel immersion technique under red dichromatic imaging as the mixing of blood and body fluids was prevented.

Fig. 4 After the endoscopic field of view had been secured with the gel immersion technique and red dichromatic imaging, the catheter could be placed onto the injured vessel wall, allowing effective hemostasis with the peptide matrix.

Fig. 5 Endoscopic images of the postendoscopic sphincterotomy bleeding site under: a white-light imaging; b red dichromatic imaging.

Understanding the characteristics of various devices and techniques can lead to an effective and safe procedure.

Endoscopy_UCTN_Code_TTT_1AR_2AK

Publication History

Article published online:
30 September 2022

• References

• 1 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149
• 2 Subramaniam S, Kandiah K, Chedgy F. et al. A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial. Endoscopy 2021; 53: 27-35
• 3 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811
• 4 Hirai Y, Fujimoto A, Matsutani N. et al. Evaluation of the visibility of bleeding points using red dichromatic imaging in endoscopic hemostasis for acute GI bleeding (with video). Gastrointest Endosc 2022; 95: 692-700.e3
• 5 Inoue T, Ibusuki M, Kitano R. et al. Usefulness of red dichromatic imaging for post-endoscopic sphincterotomy bleeding. Endoscopy 2022; DOI: 10.1055/a-1806-1605.