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An Endoclip in Time Saves Nine

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An Endoclip in Time Saves Nine ENDOSCOPY: OPENING NEW EYES, SERIES #5 Andrew K. Roorda, M.D., Series Editor An Endoclip in Time Saves Nine Swapna Gayam Matthew Weed Srinivasan Ganesan INTRODUCTION CLIPS AVAILABLE FOR USE ndoclips are metallic accessory devices that are BY THE ENDOSCOPIST deployed via the working channel of the endo- Multiple endoclips, of varying shapes and sizes, are Escope. Once deployed, they exert pressure, bring- commercially available. Some endoclips have unique ing two mucosal surfaces together within the features. While most endoclips have two prongs, the gastrointestinal tract. In recent years the use of endo- TriClip (Cook Endoscopy, Winston-Salem, NC, USA) clips in endoscopy has increased. This is due to their has three prongs. The re-openable jaws of the Resolu- proven efficacy and safety profile in hemostatic appli- tion Clip (Boston Scientific, Natick, MA, USA) facili- cations along with multiple emerging non-hemostatic tate repositioning of the clip (if needed) and allow for indications. While in most instances they provide additional clip applications. The Olympus QuickClip definitive management by the endoscopist, they can (Olympus America, Center Valley, PA, USA) is rotat- also aid in subsequent radiographic (radiotherapy of able which improves maneuverability. malignancy or vascular embolization) and surgical (tumor resection) management. In some cases their use INDICATIONS FOR ENDOCLIP USE/PLACEMENT can spare the patient from a surgical procedure (in the case of perforations and anastomotic fistulas or leaks). Gastrointestinal Bleeding The purpose of this paper is to discuss endoclip fea- tures, indications, and complications. Upper Gastrointestinal Bleeding Acute non-variceal upper-GI bleeding (NVUGIB) Swapna Gayam, M.D., Matthew Weed, M.D., Srinivasan remains a significant cause of morbidity and mortality. Ganesan, M.D., Section of Digestive Diseases, Depart- It is responsible for approximately 300,000 hospital ment of Medicine, West Virginia University School of admissions and 30,000 deaths per year in the United Medicine, Morgantown, West Virginia. States.1 While predominantly caused by peptic ulcers 8 PRACTICAL GASTROENTEROLOGY • MARCH 2011 An Endoclip in Time Saves Nine ENDOSCOPY: OPENING NEW EYES, SERIES #5 (>80%), other sources of NVUGIB include angiodys- modalities. Additionally, several meta-analysis have plasias, Mallory-Weiss Syndrome (MWS), Dieulafoy been performed comparing endoclips to thermocoagu- lesions, mucosal inflammation and malignancy.2–3 lation and injection alone.7–8 The results of these Several endoscopic modalities can be utilized to analyses demonstrated endoclipping alone or in com- achieve hemostasis including injection of epinephrine, bination with injection was superior to injection alone thermal coagulation and mechanical devices such as in definitive hemostasis, rebleeding rates or need for band ligation and endoclips. surgery. There was no difference, though, comparing endoclips with thermotherapy alone or in combination. Peptic Ulcer Bleeding Thus, endoclips have proven to be a valuable modality Several studies have investigated the safety and effi- either alone or in combination for treating peptic ulcer cacy of endoclips in achieving hemostasis in peptic bleeding. ulcer bleeding. In 1988, Hachisu described the use of An additional use of endoclips in the setting of pep- an improved endoclip in 51 patients with gastrointesti- tic ulcers is the displacement of an adherent clot that nal bleeding.4 Permanent hemostasis was achieved obscures the source of bleeding (Figures 1A and 1B). It in 84.3% of patients with lesions that included: is therefore, readily accessible if the bleeding vessel is esophageal ulcer (1), Mallory-Weiss tear (4), gastric suddenly revealed eliminating the need to prepare and ulcer (24), duodenal ulcer (7), Dieulafoy lesion (3), exchange instruments through the channel. gastric cancer (3), and post-polypectomy sites (9). There have been some limitations to endoclip use In another study, Binmoeller et al. applied nearly in bleeding peptic ulcers, however. Ulcers in the pos- 255 endoclips in 88 patients with non-variceal upper terior duodenal bulb, posterior wall of the stomach and GI bleeding (78 for active spurting or oozing sources along the lesser curvature have had multiple reports of and 10 for non-bleeding visible vessel).5 Patients were failed deployment.7 followed for a mean duration of 397 days. Primary hemostasis was achieved in all patients. Only 5 Dieulafoy Lesions patients had recurrent bleeding of which 4 were suc- Dieulafoy lesions produce massive bleeding from a cessfully retreated with endoclips. During follow up it caliber-persistent arteriole that protrudes through nor- was determined that there was good clip retention. mal mucosa. They are typically found in the proximal There were no associated complications and clips did stomach along the lesser curvature.9 While only not impair mucosal healing of the ulcer. It was con- accounting for 1–2% of bleeding from an upper gas- cluded that endoclips were effective and safe method trointestinal source, their effects can be catastrophic of treating nonvariceal peptic ulcer disease. and the need for diagnosis and effective therapy is cru- In 2000, Lai et al. evaluated the efficacy of rotat- cial. In 2000, Chung et al. compared the efficacy of able clips in bleeding peptic ulcers and demonstrated endoclips, banding and injection therapy in 24 patients that ultimate hemostasis was achieved in 87% and presenting with bleeding from Dieulafoy lesions.10 96% in spurting versus oozing vessels, respectively.6 Nine patients had endoclips placed, bands were used in Patients in shock on presentation had hemostasis rates, three and the remaining 12 cases received injection for the same subgroups (71% and 83%). Non-shock therapy. Initial hemostasis between mechanical versus patients had 100% hemostasis regardless of subgroup injection therapy was 91% and 75%, respectively. classification. Rebleeding rates after endoclip place- Recurrence in bleeding was 8.3% and 33.3%, respec- ment were low at 8%. No immediate complications, tively. While none of the patients in the mechanical tissue injury or impaired ulcer healing was noted dur- therapy group required surgical intervention, 17% of ing the study. the injection therapy group did. Park et al. studied While endoclips have proven safe and effective for endoclip therapy alone with epinephrine injections in the treatment of bleeding peptic ulcers, several ran- 32 patients presenting with bleeding from Dieulafoy domized controlled studies have been conducted to lesions.11 Primary hemostasis between endoclips and compare clip therapy to other endoscopic treatment injections was 93.8% and 87.5% respectively. Endo- PRACTICAL GASTROENTEROLOGY • MARCH 2011 9 An Endoclip in Time Saves Nine ENDOSCOPY: OPENING NEW EYES, SERIES #5 Figure 1A. Large clot present in the stomach. Figure 1B. Movement of large clot using the Resolution Clip. clipping proved more effective in preventing recurrent of lower gastrointestinal bleeding. While surgical bleeding than injection, (0% v. 33 %, p < 0.05). Addi- resection has traditionally been indicated for recurrent tional studies have been performed comparing endo- bleeding, endoscopic hemostatic approaches appear to clips to other endoscopic modalities for controlling be a viable alternative. Multiple case reports have bleeding from Dieulafoy lesions. All have demon- described the effective use of endoclips to control strated efficacy in providing initial hemostasis and diverticular bleeding.16–18 Endoclip application can be reduction in rebleeding rates.7,12–13 Figure 2A shows to the culprit vessel within the dome16 or to close the an actively bleeding Dieulafoy lesion. Figure 2B margins of the diverticulum.18 While no head-to-head shows the same lesion with complete hemostasis after comparisons have been made with other endoscopic deployment of endoclips. therapeutic modalities, there is theoretical decreased risk of perforation. In addition, they can serve as a Mallory-Weiss Syndrome marker for either angiographic therapy or surgical 19 While bleeding from a Mallory-Weiss tear is usually approach if needed. self-limited, there are occasions when endoscopic ther- Post-polypectomy bleeding is another cause of apy is required due to active bleeding from a spurting clinically significant hematochezia. It can manifest or oozing blood vessel. Endoclips used to achieve immediately following removal of the polyp or occur hemostasis in this setting have been described. In one days to weeks later. Factors associated with higher bleeding risks include polyp location, number, size and study by Huang et al. in 2002, endoclipping and epi- 20 nephrine injections were compared.14 Another study in morphology (sessile or thick stalk). Early endo- 2008, by Cho et al., compared endoclips to band liga- scopic intervention can minimize blood loss from such tion.15 Both studies demonstrated equal efficacy in pri- bleeds. Endoclips have proven to be efficacious in pro- mary hemostasis and reduction in bleeding recurrence viding hemostasis to immediate and delayed post- between endoclips and their respective comparisons, polypectomy hemorrhage. Parra-Blanco et al. reported epinephrine injection or band ligation. 72 cases where endoclips were utilized in post- polypectomy bleeds.21 In cases involving peduncu- Lower Gastrointestinal Bleeding lated polyps, the clips were applied to the transected Diverticular bleeding is one of the most common types (continued on
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