PuraStat (3-D Matrix Europe SAS, France) is a novel self-assembling peptide hemostatic
hydrogel that currently is used in surgery and in digestive endoscopy, where it has
been shown to be effective and safe as a rescue therapy for both upper and lower acute
gastrointestinal bleeding [1] and as prophylactic treatment after wide endoscopic mucosal resections and submucosal
dissections [2].
We performed cholangioscopy (Spyglass DSII, US Boston Scientific) in a 78-year-old
man with cholangitis and massive hepatolithiasis. After electrohydraulic lithotripsy
(Northgate Autolith IEHL) and stone fragment retrieval, fresh blood started oozing
from one of the intrahepatic biliary ducts, inside a biliary cystic dilatation at
the IV hepatic segment.
Because the bleeding site was inaccessible using endoscopic hemostatic devices, a
feasible option was off-label application of hemostatic hydrogel. The hemostatic hydrogel
catheter is compatible with a 2.8-mm diameter working channel, whereas the cholangioscope
working channel has a 1.2-mm diameter. Therefore, we transferred the hemostatic hydrogel
from the 1-mL prefilled syringe to a 10-ml Luer-lock syringe. After suctioning out
the previously instilled 0.9 % saline to avoid dissolving the hemostatic agent, we
pushed the hemostatic hydrogel through the working channel, aiding its progression
with an air-filled syringe ([Video 1]). The hemostatic hydrogel effectively covered the bleeding point, resulting in complete
hemostasis.
Video 1 Full-length video showing the procedure.
Both cholangioscopy and hemostatic hydrogel application within biliary ducts would
seem situations of increased risk for subsequent cholangitis; however, the formulation
of the hemostatic hydrogel is water-based, unlike other hemostatic agents available,
which are powders. Moreover, as recommended, we administered an intravenous antibiotic
before the procedure and we monitored the patient on the ward. No further cholangitis
or bleeding episodes occurred, and the patient was discharged home 3 days later.
Conclusions
In conclusion, off-label hemostatic hydrogel application may be useful for obtaining
hemostasis in the biliary tract, where procedures or devices such as injection of
diluted epinephrine and clip deployment are technically not applicable.
