- Email: [email protected]
Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video)
Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video) Quan-Lin Li, MD, Ping-Hong Zhou, MD, PhD, Li-Qing Yao, MD, Mei-Dong Xu, MD, PhD, Wei-Feng Chen, MD, Jian-Wei Hu, MD, Ming-Yan Cai, MD, Yi-Qun Zhang, MD, PhD, Yun-Shi Zhong, MD, PhD, Wen-Zheng Qin, MD, Meng-Jiang He, MD Shanghai, People’s Republic of China
Peroral endoscopic myotomy (POEM) has recently been described as a scar-free and less-invasive surgical myotomy option for treating achalasia.1-5 This procedure incorporates concepts of natural orifice transluminal endoscopic surgery and achieves endoscopic myotomy by using a submucosal tunnel as the operating space. Initial published experience in humans is more than encouraging despite a relatively short follow-up. Common complications of POEM include mucosal injury, subcutaneous emphysema, mediastinal emphysema, pneumothorax, pneumoperitoneum, and pleural effusion.1-6 Postoperative delayed bleeding in the submucosal tunnel is a rare complication after POEM, and only 1 patient with delayed bleeding has been reported in the literature to date.6 Despite its low incidence, delayed bleeding can result in serious conditions, such as massive bleeding, hemorrhagic shock, and death. Thus, early
Abbreviations: EGJ, esophagogastric junction; ESD, endoscopic submucosal dissection; POEM, peroral endoscopic myotomy; PPI, proton pump inhibitor. DISCLOSURE: This study was supported by grants from the Medical Leading Project of Shanghai Municipal Science and Technology Committee (10411969600), and the Major Project of Shanghai Municipal Science and Technology Committee (10411955900, 11411950502 and 11DZ2280400). The authors disclosed no financial relationships relevant to this publication.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.04.172 Received January 25, 2013. Accepted April 10, 2013. Current affiliation: Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China. Reprint requests: Ping-Hong Zhou, MD, PhD, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 FengLin Road, Shanghai 200032, P. R. China.
370 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 2 : 2013
diagnosis and management of delayed bleeding are critical to good patient outcomes. This study aimed to provide a better understanding of this severe complication, with emphasis on its early features and effective management.
PATIENTS AND METHODS Study design A total of 428 consecutive achalasia patients underwent successful POEM at the Endoscopy Center of Zhongshan Hospital, Fudan University, between August 2010 and July 2012. Procedural details were recorded prospectively in a database. The Eckardt symptom score was used to evaluate the symptom relief objectively. Patients with postoperative delayed bleeding in the submucosal tunnel were identified from the database, and their medical records were thoroughly reviewed. All included patients provided written informed consent to undergo POEM after receiving detailed verbal and written explanations of the POEM procedure and other possible treatment options. The study protocol was approved by the Institutional Research Ethics Committee.
POEM POEM was attempted with a single-channel gastroscope (GIF-H260; Olympus Medical Systems Co, Tokyo, Japan) and a hybrid-knife (ERBE Elektromedizin GmbH, Tübingen, Germany), triangle-tip knife (KD-640L; Olympus), or hook-knife (KD-620LR; Olympus). A transparent cap (D-201-11802; Olympus) was attached to the gastroscope tip. Other equipment included an injection needle (NM4L-1; Olympus), hemostatic forceps (FD-410LR; Olympus), clips (HX-610-90, HX-600-135; Olympus and Resolution clips; Boston Scientific, Natick, Mass), a high-frequency generator (VIO 200D; ERBE), and an argon plasma coagulation unit (APC300; ERBE). Room air was used for initial procedural insufflation and CO2 was used for subsequent insufflation with a CO2 insufflator (UCR; Olympus). Prophylactic intravenous antibiotics and proton pump inhibitors (PPIs) were introduced 30 minutes before the procedure. POEM was performed as described previously.1,5 Briefly, submucosal injection and an initial mucosal incision were first performed at the 5- to 6-o’clock position on the posterior esophagus, approximately 10 cm proximal www.giejournal.org
Li et al
to the esophagogastric junction (EGJ). A submucosal tunnel was created passing over the EGJ and approximately 3 cm into the proximal stomach. The myotomy was begun 2 cm distal to the mucosal entry point, approximately 6 to 8 cm above the EGJ, and was extended for a distance of 2 to 3 cm toward the stomach. After careful hemostasis, the mucosal incision site was closed with 4 to 6 hemostatic clips. During the procedure, the mucosa incision, submucosal tunneling, and muscular cutting were performed by using ENDO CUT Q (ERBE Surgical Systems, Inc, Marietta, Ga) at 50 W, effect 3. Minor bleeding was often treated by forced coagulation (60 W) using the knife tip. Pulsating bleeding from larger vessels was generally grasped and coagulated with a hemostatic forceps by using a forced coagulation mode at 50 W. When large vessels were visible during the operation, they were precoagulated by using hemostatic forceps in the forced coagulation mode at 50 W.
Postprocedure management A chest CT scan was performed on the first postoperative day on 300 of 428 of enrolled patients (70.1%), including the 3 patients with delayed bleeding. Postoperative observations assessed chest pain, hematemesis or melena, dyspnea, abdominal pain or distention, cyanosis, and signs of peritonitis. Postoperative medications included a PPI, antibiotics, and hemocoagulase injection. Patients were not allowed oral fluids/food intake for 24 hours after POEM and were placed on a liquid diet for an additional 24 hours. Patients were discharged with a PPI and were placed on a soft diet for 2 weeks. Patients were asked to discontinue PPI medication and start a regular diet 4 to 8 weeks after POEM.
Definition of delayed bleeding If clinical signs of postoperative hematemesis, melena, retrosternal pain, hypotension, and/or tachycardia occurred, then delayed bleeding was suspected. A hematoma observed on a chest CT scan should also be considered as an early sign of postoperative bleeding. Emergency endoscopy was performed in patients suspected of delayed bleeding in the submucosal tunnel to confirm the existence of a submucosal hematoma.
RESULTS
Delayed bleeding after POEM for achalasia
3 patients, after thoroughly investigating the database and their surgical notes. In 1 patient, a small hematoma was observed by CT before any clinical manifestation occurred; this patient then reported progressive serious retrosternal pain from the first day after surgery and vomited fresh blood on the third day. Two other patients suddenly vomited large amounts of fresh blood on the first and third days after surgery, respectively; no submucosal hematoma was observed on CT scans before hematemesis occurred in these 2 patients. Distinct clinical signs of hypotension and tachycardia were not observed in any of the 3 patients before the development of hematemesis or retrosternal pain. Emergency exploratory gastroscopy was performed immediately on patients with post-POEM bleeding, revealing a hematoma along the mucosa covering the submucosal tunnel. After removing metal clips of mucosal entry, a large number of blood clots were discovered inside the submucosal tunnel and were removed. In the first patient, the bleeding source could not be identified, and a Sengstaken–Blakemore tube was directly placed into the stomach and lower esophagus to compress the bleeding sites. In the other 2 patients, active bleeding points were identified and coagulated with a hemostatic forceps in the forced coagulation mode. Almost all of the bleeding spots were from the cut muscular edges. A Sengstaken–Blakemore tube was placed immediately in 1 patient, but tube placement was delayed in the other patient until the third day after performing endoscopic hemostasis because of major blood drainage from the nasogastric tube. A PPI, antibiotics, and hemocoagulase were administered to all 3 patients. Intermittent balloon deflation was performed every 24 hours. The Sengstaken–Blakemore tube gastric balloon was permanently deflated on the first day after placement, and the esophageal balloon was deflated on the second day after insertion. The emergency endoscopic diagnosis and hemostasis technique for treating delayed bleeding are shown in Figure 1 and Video 1 (available online at www.giejournal. org). Successful hemostasis was achieved in all 3 patients without the need for surgical intervention or blood transfusions. Two ulcers at the EGJ appeared in 1 patient before discharge, but satisfactory healing was seen at the 3-month follow-up endoscopy. Treatment success (Eckardt score %3) was achieved in all 3 patients. The Eckardt scores decreased between pretreatment and posttreatment from 6, 8, and 7 to 0, 1, and 0, respectively, by the 3- to 12-month follow-up.
Three patients (0.7%, 3/428) experienced delayed bleeding in the submucosal tunnel after POEM. The clinical characteristics and outcomes of the patients with delayed bleeding are shown in Table 1. None of these patients had any predisposing factor to bleeding, such as hypertension, coagulation disorders, and antiplatelet/anticoagulant therapy before undergoing POEM. There were no special difficulties related to tunnel creation or myotomy performance in these
Although the incidence of delayed bleeding in the submucosal tunnel after POEM was very low (0.7%), in
www.giejournal.org
Volume 78, No. 2 : 2013 GASTROINTESTINAL ENDOSCOPY 371
DISCUSSION
Delayed bleeding after POEM for achalasia
Li et al
TABLE 1. Patient characteristics and outcomes
Patient
Age, y
Sex
Course, y
Previous treatment
Operation time, min
Myotomy length, cm
Early manifestations
1
69
M
15
Botox injection
50
12
Hematemesis
2
25
M
3
No
30
8
Retrosternal pain, hematemesis
3
44
F
10
Pharmacologic treatment
90
11
Hematemesis
absolute numbers, we have encountered several cases because of the large POEM patient population that our study included. Because a small amount of blood is often restricted to the closed space of the submucosal tunnel, early diagnosis of delayed bleeding is more difficult when it occurs within the tunnel. After sufficient blood has accumulated, it flows out of the tunnel, and clinical evidence of bleeding is observed as vomiting of fresh blood and the occurrence of melena. Progressive serious retrosternal pain also occurs at the early bleeding stage because of gradually increasing pressure in the submucosal tunnel. When the patient’s heart rate increases and blood pressure falls, the possibility of severe internal bleeding should be considered. In this case series, hematemesis occurred in all 3 patients with delayed bleeding, whereas progressive serious retrosternal pain only occurred in 1 patient. These 2 symptoms are the major early manifestations of delayed bleeding into the submucosal tunnel. When delayed bleeding is suspected, emergency exploratory gastroscopy should be performed immediately. Hematomas are often found along the lining of the submucosal tunnel. Chest CT scans can detect early signs of postoperative bleeding. A hematoma can often be observed by CT before any clinical manifestations occur; however, routine CT scans after POEM are probably not warranted in all patients. Hemostasis is often difficult to achieve during emergency endoscopy because the massive amount of blood present in the confined submucosal tunnel space results in a poor visual field. Blood and any blood clots at the wound and in the tunnel should be patiently and meticulously cleared to expose the bleeding site(s). When the active bleeding points are identified, coagulation using hemostatic forceps can be performed, as is done for delayed bleeding after endoscopic submucosal dissection (ESD).7 After electrocoagulation, placement of a Sengstaken–Blakemore tube is recommended to compress potentially unidentified bleeding sites. Hemorrhage points are sometimes difficult to distinguish because of the very large wound surface area and the poor visual field within the bleeding submucosal tunnel. In reality, a
Sengstaken–Blakemore tube can provide compressive hemostasis when the bleeding source cannot be clearly identified. In this study, the delayed bleeding in all 3 patients was successfully controlled by endoscopic hemostasis involving Sengstaken–Blakemore tube insertion and/or electrocoagulation, without the need for surgical intervention or blood transfusions. It is difficult to predict and prevent delayed bleeding after POEM procedures because of its low incidence and unknown risk factors. POEM expands on techniques used in ESD to create the submucosal tunnel, and the incidence of immediate and/or delayed bleeding may be decreased because of more precise visual control and using established ESD hemostasis techniques. Insufficient coagulation of visible vessels influences the likelihood of delayed bleeding, and routine preventive coagulation of visible vessels lowers the delayed bleeding rate.8 Endoscopic clipping by using metal clips is a method for preventing delayed bleeding after endoscopic resection,7,9 but clips usually cannot be used in the submucosal tunnel. Because endoscopic myotomy is often begun approximately 6 to 8 cm above the EGJ and extends for a distance of 2 to 3 cm toward the stomach, there is a large wound surface post-myotomy, which is a significant risk factor for delayed bleeding after ESD.10 Bleeding usually occurs at the cut muscular edges because of an abundance of small blood vessels and collateral circulation in the muscle layers of the esophagus.5 Preventive coagulation of suspected bleeding points by using hemostatic forceps significantly reduces the risk of delayed bleeding. Other methods such as PPI therapy and second-look endoscopy11 may not be useful for preventing delayed bleeding after POEM. In summary, vomiting of fresh blood and progressive serious retrosternal pain are the major early manifestations in patients with delayed bleeding in the submucosal tunnel after POEM. Emergency endoscopic diagnosis and hemostasis should be performed immediately after symptom emergence. It is worth mentioning that a Sengstaken–Blakemore tube is particularly effective for providing compressive hemostasis to staunch post-POEM bleeding.
372 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 2 : 2013
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Li et al
Delayed bleeding after POEM for achalasia
TABLE 1. Continued Hemoglobin decrease, g/L
Active bleeding indentified
Endoscopic electrocoagulation
Sengstaken–Blakemore tube insertion
Hospital stay, d
12
No
No
Immediately
6
15
Yes
Yes
Third day after first hemostasis
14
10
Yes
Yes
Immediately
12
Figure 1. Emergency endoscopic diagnosis and hemostasis of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy. A, B, A hematoma was found along the mucosa covering the submucosal tunnel. C, The metal clips at the tunnel entry were removed. D, A large number of blood clots inside the submucosal tunnel. E, F, Removing the blood clots. G, H, An active bleeding point was identified and coagulated. I, A Sengstaken–Blakemore tube was placed on the third day after first endoscopic hemostasis because of rebleeding.
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Volume 78, No. 2 : 2013 GASTROINTESTINAL ENDOSCOPY 373
EUS-guided approach to the right hepatic duct
Park et al
REFERENCES 1. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010;42:265-71. 2. Zhou PH, Yao LQ, Zhang YQ, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia: 205 cases report. Gastrointest Endosc 2012;75(4 Suppl):AB132-3. 3. von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 2012;107:411-7. 4. Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012;256:659-67. 5. Zhou PH, Li QL, Yao LQ, et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45:161-6. 6. Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy
7.
8.
9.
10.
11.
(POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012;26:3267-72. Mukai S, Cho S, Nakamura S, et al. Postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method for the prevention of delayed bleeding after ESD. Surg Endosc 2013;27:1292-301. Takizawa K, Oda I, Gotoda T, et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection–an analysis of risk factors. Endoscopy 2008; 40:179-83. Matsumoto M, Fukunaga S, Saito Y, et al. Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors. Jpn J Clin Oncol 2012;42:1028-34. Okada K, Yamamoto Y, Kasuga A, et al. Risk factors for delayed bleeding after endoscopic submucosal dissection for gastric neoplasm. Surg Endosc 2011;25:98-107. Kim HH, Park SJ, Park MI, et al. Clinical impact of second-look endoscopy after endoscopic submucosal dissection of gastric neoplasms. Gut Liver 2012;6:316-20.
Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video) Se Jeong Park, MD,* Jun-Ho Choi, MD,* Do Hyun Park, MD, PhD, Joon Hyuk Choi, MD, Sang Soo Lee, MD, PhD, Dong-Wan Seo, MD, PhD, Sung Koo Lee, MD, PhD, Myung-Hwan Kim, MD, PhD Seoul, Korea
Drainage of an obstructed bile duct can be approached in several ways, and EUS-guided biliary drainage (EUS-BD) has been proposed as an effective alternative for percutaneous transhepatic biliary drainage (PTBD) after failed
Abbreviations: EUS-BD, EUS-guided biliary drainage; EUS-HD, EUSguided hepaticoduodenostomy; IHD, intrahepatic duct; IQR, interquartile range; PTBD, percutaneous transhepatic biliary drainage.
ERCP. EUS-guided transgastric imaging of the dilated left intrahepatic duct (IHD) makes it possible to drain the left biliary system.1-4 However, patients with isolated right IHD obstruction are not considered as candidates for EUS-BD.5 We evaluated the technical feasibility and safety of EUS-guided hepaticoduodenostomy (EUS-HD) in cases of isolated right IHD obstruction.
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
PATIENTS AND METHODS
*Drs S. J. Park and Jun-Ho Choi contributed equally to this article.
Reprint requests: Do Hyun Park, MD, PhD, Associate Professor of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul 138-736, Korea.
ERCP and EUS-BD were performed by a single experienced endoscopist (D.H.P.). Trainees were not involved in ERCP. EUS-BD was performed at the time of failed ERCP as a same session. Our inclusion criteria were as follows: (1) patients with failure of biliary decompression of right IHD obstruction through ERCP because of surgically altered anatomy, or missing right IHD on balloon occlusion retrograde cholangiography with a hilar biliary stricture, or failed selective guidewire cannulation because of a high-grade hilar biliary stricture and (2) patients who refused PTBD and wanted EUS-BD performed during the same session as the failed ERCP. Our exclusion criteria were (1) refusal to participate in the study protocol, (2) left intrahepatic or distal biliary obstruction for ordinary EUS-BD including hepaticogastrostomy and choledochoduodenostomy, (3) pregnancy, and (4) patients younger than 18 years. All enrolled patients were given antibiotics before and after the procedure.
374 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 2 : 2013
www.giejournal.org
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.04.183 Received February 20, 2013. Accepted April 16, 2013. Current affiliations: Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
Peroral endoscopic myotomy (POEM) has recently been described as a scar-free and less-invasive surgical myotomy option for treating achalasia.1-5 This procedure incorporates concepts of natural orifice transluminal endoscopic surgery and achieves endoscopic myotomy by using a submucosal tunnel as the operating space. Initial published experience in humans is more than encouraging despite a relatively short follow-up. Common complications of POEM include mucosal injury, subcutaneous emphysema, mediastinal emphysema, pneumothorax, pneumoperitoneum, and pleural effusion.1-6 Postoperative delayed bleeding in the submucosal tunnel is a rare complication after POEM, and only 1 patient with delayed bleeding has been reported in the literature to date.6 Despite its low incidence, delayed bleeding can result in serious conditions, such as massive bleeding, hemorrhagic shock, and death. Thus, early
Abbreviations: EGJ, esophagogastric junction; ESD, endoscopic submucosal dissection; POEM, peroral endoscopic myotomy; PPI, proton pump inhibitor. DISCLOSURE: This study was supported by grants from the Medical Leading Project of Shanghai Municipal Science and Technology Committee (10411969600), and the Major Project of Shanghai Municipal Science and Technology Committee (10411955900, 11411950502 and 11DZ2280400). The authors disclosed no financial relationships relevant to this publication.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.04.172 Received January 25, 2013. Accepted April 10, 2013. Current affiliation: Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China. Reprint requests: Ping-Hong Zhou, MD, PhD, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 FengLin Road, Shanghai 200032, P. R. China.
370 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 2 : 2013
diagnosis and management of delayed bleeding are critical to good patient outcomes. This study aimed to provide a better understanding of this severe complication, with emphasis on its early features and effective management.
PATIENTS AND METHODS Study design A total of 428 consecutive achalasia patients underwent successful POEM at the Endoscopy Center of Zhongshan Hospital, Fudan University, between August 2010 and July 2012. Procedural details were recorded prospectively in a database. The Eckardt symptom score was used to evaluate the symptom relief objectively. Patients with postoperative delayed bleeding in the submucosal tunnel were identified from the database, and their medical records were thoroughly reviewed. All included patients provided written informed consent to undergo POEM after receiving detailed verbal and written explanations of the POEM procedure and other possible treatment options. The study protocol was approved by the Institutional Research Ethics Committee.
POEM POEM was attempted with a single-channel gastroscope (GIF-H260; Olympus Medical Systems Co, Tokyo, Japan) and a hybrid-knife (ERBE Elektromedizin GmbH, Tübingen, Germany), triangle-tip knife (KD-640L; Olympus), or hook-knife (KD-620LR; Olympus). A transparent cap (D-201-11802; Olympus) was attached to the gastroscope tip. Other equipment included an injection needle (NM4L-1; Olympus), hemostatic forceps (FD-410LR; Olympus), clips (HX-610-90, HX-600-135; Olympus and Resolution clips; Boston Scientific, Natick, Mass), a high-frequency generator (VIO 200D; ERBE), and an argon plasma coagulation unit (APC300; ERBE). Room air was used for initial procedural insufflation and CO2 was used for subsequent insufflation with a CO2 insufflator (UCR; Olympus). Prophylactic intravenous antibiotics and proton pump inhibitors (PPIs) were introduced 30 minutes before the procedure. POEM was performed as described previously.1,5 Briefly, submucosal injection and an initial mucosal incision were first performed at the 5- to 6-o’clock position on the posterior esophagus, approximately 10 cm proximal www.giejournal.org
Li et al
to the esophagogastric junction (EGJ). A submucosal tunnel was created passing over the EGJ and approximately 3 cm into the proximal stomach. The myotomy was begun 2 cm distal to the mucosal entry point, approximately 6 to 8 cm above the EGJ, and was extended for a distance of 2 to 3 cm toward the stomach. After careful hemostasis, the mucosal incision site was closed with 4 to 6 hemostatic clips. During the procedure, the mucosa incision, submucosal tunneling, and muscular cutting were performed by using ENDO CUT Q (ERBE Surgical Systems, Inc, Marietta, Ga) at 50 W, effect 3. Minor bleeding was often treated by forced coagulation (60 W) using the knife tip. Pulsating bleeding from larger vessels was generally grasped and coagulated with a hemostatic forceps by using a forced coagulation mode at 50 W. When large vessels were visible during the operation, they were precoagulated by using hemostatic forceps in the forced coagulation mode at 50 W.
Postprocedure management A chest CT scan was performed on the first postoperative day on 300 of 428 of enrolled patients (70.1%), including the 3 patients with delayed bleeding. Postoperative observations assessed chest pain, hematemesis or melena, dyspnea, abdominal pain or distention, cyanosis, and signs of peritonitis. Postoperative medications included a PPI, antibiotics, and hemocoagulase injection. Patients were not allowed oral fluids/food intake for 24 hours after POEM and were placed on a liquid diet for an additional 24 hours. Patients were discharged with a PPI and were placed on a soft diet for 2 weeks. Patients were asked to discontinue PPI medication and start a regular diet 4 to 8 weeks after POEM.
Definition of delayed bleeding If clinical signs of postoperative hematemesis, melena, retrosternal pain, hypotension, and/or tachycardia occurred, then delayed bleeding was suspected. A hematoma observed on a chest CT scan should also be considered as an early sign of postoperative bleeding. Emergency endoscopy was performed in patients suspected of delayed bleeding in the submucosal tunnel to confirm the existence of a submucosal hematoma.
RESULTS
Delayed bleeding after POEM for achalasia
3 patients, after thoroughly investigating the database and their surgical notes. In 1 patient, a small hematoma was observed by CT before any clinical manifestation occurred; this patient then reported progressive serious retrosternal pain from the first day after surgery and vomited fresh blood on the third day. Two other patients suddenly vomited large amounts of fresh blood on the first and third days after surgery, respectively; no submucosal hematoma was observed on CT scans before hematemesis occurred in these 2 patients. Distinct clinical signs of hypotension and tachycardia were not observed in any of the 3 patients before the development of hematemesis or retrosternal pain. Emergency exploratory gastroscopy was performed immediately on patients with post-POEM bleeding, revealing a hematoma along the mucosa covering the submucosal tunnel. After removing metal clips of mucosal entry, a large number of blood clots were discovered inside the submucosal tunnel and were removed. In the first patient, the bleeding source could not be identified, and a Sengstaken–Blakemore tube was directly placed into the stomach and lower esophagus to compress the bleeding sites. In the other 2 patients, active bleeding points were identified and coagulated with a hemostatic forceps in the forced coagulation mode. Almost all of the bleeding spots were from the cut muscular edges. A Sengstaken–Blakemore tube was placed immediately in 1 patient, but tube placement was delayed in the other patient until the third day after performing endoscopic hemostasis because of major blood drainage from the nasogastric tube. A PPI, antibiotics, and hemocoagulase were administered to all 3 patients. Intermittent balloon deflation was performed every 24 hours. The Sengstaken–Blakemore tube gastric balloon was permanently deflated on the first day after placement, and the esophageal balloon was deflated on the second day after insertion. The emergency endoscopic diagnosis and hemostasis technique for treating delayed bleeding are shown in Figure 1 and Video 1 (available online at www.giejournal. org). Successful hemostasis was achieved in all 3 patients without the need for surgical intervention or blood transfusions. Two ulcers at the EGJ appeared in 1 patient before discharge, but satisfactory healing was seen at the 3-month follow-up endoscopy. Treatment success (Eckardt score %3) was achieved in all 3 patients. The Eckardt scores decreased between pretreatment and posttreatment from 6, 8, and 7 to 0, 1, and 0, respectively, by the 3- to 12-month follow-up.
Three patients (0.7%, 3/428) experienced delayed bleeding in the submucosal tunnel after POEM. The clinical characteristics and outcomes of the patients with delayed bleeding are shown in Table 1. None of these patients had any predisposing factor to bleeding, such as hypertension, coagulation disorders, and antiplatelet/anticoagulant therapy before undergoing POEM. There were no special difficulties related to tunnel creation or myotomy performance in these
Although the incidence of delayed bleeding in the submucosal tunnel after POEM was very low (0.7%), in
www.giejournal.org
Volume 78, No. 2 : 2013 GASTROINTESTINAL ENDOSCOPY 371
DISCUSSION
Delayed bleeding after POEM for achalasia
Li et al
TABLE 1. Patient characteristics and outcomes
Patient
Age, y
Sex
Course, y
Previous treatment
Operation time, min
Myotomy length, cm
Early manifestations
1
69
M
15
Botox injection
50
12
Hematemesis
2
25
M
3
No
30
8
Retrosternal pain, hematemesis
3
44
F
10
Pharmacologic treatment
90
11
Hematemesis
absolute numbers, we have encountered several cases because of the large POEM patient population that our study included. Because a small amount of blood is often restricted to the closed space of the submucosal tunnel, early diagnosis of delayed bleeding is more difficult when it occurs within the tunnel. After sufficient blood has accumulated, it flows out of the tunnel, and clinical evidence of bleeding is observed as vomiting of fresh blood and the occurrence of melena. Progressive serious retrosternal pain also occurs at the early bleeding stage because of gradually increasing pressure in the submucosal tunnel. When the patient’s heart rate increases and blood pressure falls, the possibility of severe internal bleeding should be considered. In this case series, hematemesis occurred in all 3 patients with delayed bleeding, whereas progressive serious retrosternal pain only occurred in 1 patient. These 2 symptoms are the major early manifestations of delayed bleeding into the submucosal tunnel. When delayed bleeding is suspected, emergency exploratory gastroscopy should be performed immediately. Hematomas are often found along the lining of the submucosal tunnel. Chest CT scans can detect early signs of postoperative bleeding. A hematoma can often be observed by CT before any clinical manifestations occur; however, routine CT scans after POEM are probably not warranted in all patients. Hemostasis is often difficult to achieve during emergency endoscopy because the massive amount of blood present in the confined submucosal tunnel space results in a poor visual field. Blood and any blood clots at the wound and in the tunnel should be patiently and meticulously cleared to expose the bleeding site(s). When the active bleeding points are identified, coagulation using hemostatic forceps can be performed, as is done for delayed bleeding after endoscopic submucosal dissection (ESD).7 After electrocoagulation, placement of a Sengstaken–Blakemore tube is recommended to compress potentially unidentified bleeding sites. Hemorrhage points are sometimes difficult to distinguish because of the very large wound surface area and the poor visual field within the bleeding submucosal tunnel. In reality, a
Sengstaken–Blakemore tube can provide compressive hemostasis when the bleeding source cannot be clearly identified. In this study, the delayed bleeding in all 3 patients was successfully controlled by endoscopic hemostasis involving Sengstaken–Blakemore tube insertion and/or electrocoagulation, without the need for surgical intervention or blood transfusions. It is difficult to predict and prevent delayed bleeding after POEM procedures because of its low incidence and unknown risk factors. POEM expands on techniques used in ESD to create the submucosal tunnel, and the incidence of immediate and/or delayed bleeding may be decreased because of more precise visual control and using established ESD hemostasis techniques. Insufficient coagulation of visible vessels influences the likelihood of delayed bleeding, and routine preventive coagulation of visible vessels lowers the delayed bleeding rate.8 Endoscopic clipping by using metal clips is a method for preventing delayed bleeding after endoscopic resection,7,9 but clips usually cannot be used in the submucosal tunnel. Because endoscopic myotomy is often begun approximately 6 to 8 cm above the EGJ and extends for a distance of 2 to 3 cm toward the stomach, there is a large wound surface post-myotomy, which is a significant risk factor for delayed bleeding after ESD.10 Bleeding usually occurs at the cut muscular edges because of an abundance of small blood vessels and collateral circulation in the muscle layers of the esophagus.5 Preventive coagulation of suspected bleeding points by using hemostatic forceps significantly reduces the risk of delayed bleeding. Other methods such as PPI therapy and second-look endoscopy11 may not be useful for preventing delayed bleeding after POEM. In summary, vomiting of fresh blood and progressive serious retrosternal pain are the major early manifestations in patients with delayed bleeding in the submucosal tunnel after POEM. Emergency endoscopic diagnosis and hemostasis should be performed immediately after symptom emergence. It is worth mentioning that a Sengstaken–Blakemore tube is particularly effective for providing compressive hemostasis to staunch post-POEM bleeding.
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Li et al
Delayed bleeding after POEM for achalasia
TABLE 1. Continued Hemoglobin decrease, g/L
Active bleeding indentified
Endoscopic electrocoagulation
Sengstaken–Blakemore tube insertion
Hospital stay, d
12
No
No
Immediately
6
15
Yes
Yes
Third day after first hemostasis
14
10
Yes
Yes
Immediately
12
Figure 1. Emergency endoscopic diagnosis and hemostasis of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy. A, B, A hematoma was found along the mucosa covering the submucosal tunnel. C, The metal clips at the tunnel entry were removed. D, A large number of blood clots inside the submucosal tunnel. E, F, Removing the blood clots. G, H, An active bleeding point was identified and coagulated. I, A Sengstaken–Blakemore tube was placed on the third day after first endoscopic hemostasis because of rebleeding.
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EUS-guided approach to the right hepatic duct
Park et al
REFERENCES 1. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010;42:265-71. 2. Zhou PH, Yao LQ, Zhang YQ, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia: 205 cases report. Gastrointest Endosc 2012;75(4 Suppl):AB132-3. 3. von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 2012;107:411-7. 4. Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012;256:659-67. 5. Zhou PH, Li QL, Yao LQ, et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45:161-6. 6. Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy
7.
8.
9.
10.
11.
(POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012;26:3267-72. Mukai S, Cho S, Nakamura S, et al. Postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method for the prevention of delayed bleeding after ESD. Surg Endosc 2013;27:1292-301. Takizawa K, Oda I, Gotoda T, et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection–an analysis of risk factors. Endoscopy 2008; 40:179-83. Matsumoto M, Fukunaga S, Saito Y, et al. Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors. Jpn J Clin Oncol 2012;42:1028-34. Okada K, Yamamoto Y, Kasuga A, et al. Risk factors for delayed bleeding after endoscopic submucosal dissection for gastric neoplasm. Surg Endosc 2011;25:98-107. Kim HH, Park SJ, Park MI, et al. Clinical impact of second-look endoscopy after endoscopic submucosal dissection of gastric neoplasms. Gut Liver 2012;6:316-20.
Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video) Se Jeong Park, MD,* Jun-Ho Choi, MD,* Do Hyun Park, MD, PhD, Joon Hyuk Choi, MD, Sang Soo Lee, MD, PhD, Dong-Wan Seo, MD, PhD, Sung Koo Lee, MD, PhD, Myung-Hwan Kim, MD, PhD Seoul, Korea
Drainage of an obstructed bile duct can be approached in several ways, and EUS-guided biliary drainage (EUS-BD) has been proposed as an effective alternative for percutaneous transhepatic biliary drainage (PTBD) after failed
Abbreviations: EUS-BD, EUS-guided biliary drainage; EUS-HD, EUSguided hepaticoduodenostomy; IHD, intrahepatic duct; IQR, interquartile range; PTBD, percutaneous transhepatic biliary drainage.
ERCP. EUS-guided transgastric imaging of the dilated left intrahepatic duct (IHD) makes it possible to drain the left biliary system.1-4 However, patients with isolated right IHD obstruction are not considered as candidates for EUS-BD.5 We evaluated the technical feasibility and safety of EUS-guided hepaticoduodenostomy (EUS-HD) in cases of isolated right IHD obstruction.
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
PATIENTS AND METHODS
*Drs S. J. Park and Jun-Ho Choi contributed equally to this article.
Reprint requests: Do Hyun Park, MD, PhD, Associate Professor of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul 138-736, Korea.
ERCP and EUS-BD were performed by a single experienced endoscopist (D.H.P.). Trainees were not involved in ERCP. EUS-BD was performed at the time of failed ERCP as a same session. Our inclusion criteria were as follows: (1) patients with failure of biliary decompression of right IHD obstruction through ERCP because of surgically altered anatomy, or missing right IHD on balloon occlusion retrograde cholangiography with a hilar biliary stricture, or failed selective guidewire cannulation because of a high-grade hilar biliary stricture and (2) patients who refused PTBD and wanted EUS-BD performed during the same session as the failed ERCP. Our exclusion criteria were (1) refusal to participate in the study protocol, (2) left intrahepatic or distal biliary obstruction for ordinary EUS-BD including hepaticogastrostomy and choledochoduodenostomy, (3) pregnancy, and (4) patients younger than 18 years. All enrolled patients were given antibiotics before and after the procedure.
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This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.04.183 Received February 20, 2013. Accepted April 16, 2013. Current affiliations: Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.