Endoscopy 2020; 52(09): E344-E345
DOI: 10.1055/a-1122-8541
E-Videos

Combination of search, coagulation, clipping, and polyglycolic acid sheet to prevent delayed bleeding after gastric endoscopic submucosal dissection

Satoshi Abiko
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
,
Ayumu Yoshikawa
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
,
Kazuaki Harada
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
,
Naoki Kawagishi
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
,
Itsuki Sano
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
,
Hisashi Oda
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
,
Takuto Miyagishima
Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan
› Author Affiliations
 

The search, coagulation, and clipping method is reported to be significantly better than the existing approache in the prevention of delayed bleeding after gastric endoscopic submucosal dissection (ESD). However, it does not completely prevent post-ESD bleeding [1]. Another method combines the use of polyglycolic acid (PGA) sheets and fibrin glue to reduce the risk of delayed bleeding after gastric ESD [2], but a multicenter, prospective, randomized controlled study showed that use of PGA sheets alone was not effective in preventing delayed bleeding in patients at high risk for such bleeding [3]. We hypothesized that delayed bleeding could be prevented by combining the use of PGA sheets and fibrin glue with a modified search, coagulation, and clipping method that accommodates patients at high risk of delayed bleeding. Here we report on the prevention of delayed bleeding using this new combined approach.

First, a coagulation procedure was performed after lesion resection, mainly in the vessels at the margin of the ulcer base. Then, perforator vessels emerging between muscle layers were actively sought and clipped using hemoclips. Because perforator vessels may also be present in carbonized areas of the ulcer base, clipping was also actively performed in such areas; this constituted the modification of the search, coagulation, and clipping method ([Fig. 1]). Subsequently, several large and small PGA sheets were placed (based on the size of the ulcer base), using methods proposed by Kobayashi et al. [4] and Takimoto et al. [5], respectively. Finally, fibrin glue was sprayed ([Fig. 2]). All these steps constitute the polyglycolic acid sheets, fibrin glue, and modified search, coagulation, and clipping method (PMSCC) method.

Zoom Image
Fig. 1 A modified search, coagulation, and clipping method for preventing delayed bleeding after gastric endoscopic submucosal dissection. a First, a coagulation procedure was done after lesion resection, mainly in the vessels at the margin of the ulcer base. b Perforator vessels may also be present in carbonized areas of the ulcer base. Clipping was also actively performed in such areas, which is the modification of the search, coagulation, and clipping approach. c The modified approach was completed.
Zoom Image
Fig. 2 Use of polyglycolic acid (PGA) sheets and fibrin glue after the modified search, coagulation, and clipping method. a Large PGA sheets were placed using a wafer paper, thread, and hemoclip. b Completion of the polyglycolic acid sheets, fibrin glue, and modified search, coagulation, and clipping (PMSCC) method.

[Video 1] shows application of the PMSCC method in a 74-year-old man classified as having high risk of delayed bleeding because of oral warfarin administration. The ulceration followed gastric ESD (40 mm in diameter) in the posterior wall of the lesser curvature of the middle body of the stomach. We implemented the PMSCC method in nine patients at high risk of delayed bleeding. None of the nine patients experienced delayed bleeding.

Video 1 The polyglycolic acid sheets, fibrin glue, and modified search, coagulation, and clipping (PMSCC) method for prevention of delayed bleeding in a high risk patient.


Quality:

Although bleeding may be observed from perforator vessels in areas where PGA sheets are peeled off [3], we believe that if perforator vessels at the base of ulcers are clipped in advance then such delayed bleeding may be prevented.

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Competing interests

The author declares no conflict of interest.


Corresponding author

Satoshi Abiko
Department of Gastroenterology
Kushiro Rosai Hospital
13-23 Nakazono-cho
085-8533 Kushiro
Japan   
Fax: +81-154-25-7308   

Publication History

Publication Date:
18 March 2020 (online)

© Georg Thieme Verlag KG
Stuttgart · New York


Zoom Image
Fig. 1 A modified search, coagulation, and clipping method for preventing delayed bleeding after gastric endoscopic submucosal dissection. a First, a coagulation procedure was done after lesion resection, mainly in the vessels at the margin of the ulcer base. b Perforator vessels may also be present in carbonized areas of the ulcer base. Clipping was also actively performed in such areas, which is the modification of the search, coagulation, and clipping approach. c The modified approach was completed.
Zoom Image
Fig. 2 Use of polyglycolic acid (PGA) sheets and fibrin glue after the modified search, coagulation, and clipping method. a Large PGA sheets were placed using a wafer paper, thread, and hemoclip. b Completion of the polyglycolic acid sheets, fibrin glue, and modified search, coagulation, and clipping (PMSCC) method.