OXIDIZED CELLULOSE AS HEMOSTATIC AGENT TO PREVENT BLEEDING AFTER HIGH-RISK ENDOSCOPIC RESECTION OF RECTAL LATERALLY-SPREADING TUMOR (LST) OVERLYING HEMORRHOIDS

A 58-year-old male with a history of a hypertension, coronary heart disease and diabetes mellitus type II was referred for evaluation of a rectal tumor. The patient had undergone coronary artery stenting and was taking dual antiplatelet therapy. On colonoscopy he was found to have a laterally spreading tumor, granular type. The polypoid lesion extended from the anal verge, continued on top of internal hemorrhoids and extended proximally 5 cm into the rectum, covering about two thirds of the rectal circumference. The patient preferred endoscopic resection to a transrectal surgery procedure. The endoscopic resection was carried out using a gastroscope and with ESD-EMR hybrid technique. Post-resection inspection revealed a complete resection (endoscopic R0), several small vessels and exposed hemorrhoids. Prophylactic hemostasis was then achieved by applying oxidized regenerated cellulose. The oxidized cellulose was cut in 20 × 20 mm pieces, grasped with a clip, which had been previously advanced through the scope and then pushed through an overtube onto the resection site. The cellulose was attached through clipping proximally. The patient had an uneventful recovery without any rectal bleeding. Oxidized cellulose can be considered to be a “topical” hemostatic agent, similar to Hemospray®. The mechanism of action of cellulose is still unclear, but data show that it activates platelets and provides mechanical hemostasis by dehydrating or “sponge-like’ mechanisms. Indeed, OC is generally used in heavy bleedings, including liver surgery, due to its high absorptive capacity, and given by its dense fibrous composition; OC can absorb up to 7-times its physiological weight OC has the advantage of being biodegradable, biocompatible, reabsorbed by hydrolysis and without immunological risk.