Novel hemostatic technique for intraoperative bleeding during underwater endoscopic submucosal dissection

Aims The strong advantage of underwater endoscopic submucosal dissection (UESD) is the buoyancy and pressure of the water provided by water jet function of the endoscope, which works as a natural counter-traction and helps us to make mucosal flap easily. On the other hand, the mixture of blood and water during intraoperative bleeding makes the visual field poor and requires additional procedure time for suction of water before hemostasis and refilling the lumen with water to resume the procedure. To overcome the problem of UESD, we developed the “Catch and Press Technique (CPT)” as an effective method for hemostasis of bleeding during UESD. CPT is performed as follows: ① Keep the visual field good by continuously flushing water with water jet function of endoscope, ② Reduce the blood flow by applying transparent hood on the culprit vessel and recognize the point of bleeding, and ③ Pressing the point of bleeding with the tip of the ESD knife, following the bleeding is stopped and coagulated with the tip of knife. In this study, we aimed to evaluate the efficacy of CPT.

Methods This is a retrospective observational study. Intraoperative bleeding events with CPT were extracted from the treatment videos of duodenal ESD performed by one expert endoscopist (> 100 DESDs and>2000 ESDs regardless of organ) between Jan. and Mar. 2024. In CPT, coagulation was mainly performed by spray coagulation mode (effect 1.2) with high frequecy unit(VIO3; ERBE). Technical success of CPT was defined as follows: (1) hemostasis using the tip of DualKnife J(KD-655Q; Olympus), (2) without suction of the water in the lumen, and (3) without the use of a hemostatic forceps. The time of hemostasis defined as time between appearance of bleeding and confirmation of hemostasis.

Results 15 lesions in 15 patients were identified. Lesion location (superior duodenal angulus/second part/inferior duodenal angulus/third part), mean tumor diameter, and macroscopic type (0-I/0-IIa) were 1/8/5/1, 31±16 mm, and 3/12, respectively. The en-bolc resection rate was 100%, the mean treatment time was 42±32 min. A total of 243 intraoperative bleeding events in 15 ESDs were eligible. The median number of the events per case was 15 (range 2-37). The success rate of CPT was 87.2% (212/243) and the median hemostatic time was 14 sec. The 243 events were divided into venous and arterial bleeding group. The success rates of CPT in the venous and arterial group were 97.4% (150/154) and 69.7% (62/89), respectively. The median hemostasis time in the venous and arterial group was 12 sec and 26 sec, respectively. In the failure of CPT (31 cases), 31 required suction of water, 15 required hemostatic forceps and the median hemostatic time was 55 sec.

Conclusions The success rate of hemostasis by CPT for intraoperative bleeding in UESD is high. CPT may contribute to efficient hemostasis in underwater condition.

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Artikel online veröffentlicht:
27. März 2025