Endoscopic hemoclip placement and endoscopic band ligation for Dieulafoy's lesions

Letters to the Editor

REFERENCES 1. Wirth R, Bauer J, Sieber C. Necrotizing Candida infection after percutaneous endoscopic gastrostomy: a fatal and rare complication. JPEN J Parenteral Enteral Nutr 2008;32:285-7. 2. Alkhatib A, Kawji AS, Adler DG. First reported case of a Candida glabrata perihepatic abscess as a complication of percutaneous endoscopic gastrostomy tube placement. J Clin Gastroenterol 2007;41:335-6. 3. Sridhar AV, Nichani S, Luyt D, et al. Candida peritonitis: a rare complication following early dislodgement of percutaneous endoscopic gastrostomy tube. J Paediatr Child Health 2006;42:145-6. 4. Gillanders IA, Davda NS, Danesh BJ. Candida albicans infection complicating percutaneous endoscopic gastrostomy. Endoscopy 1992;24:733. 5. Patel AS, DeRidder PH, Alexander TJ, et al. Candida cellulitis: a complication of percutaneous endoscopic gastrostomy. Gastrointest Endosc 1989;35:571-2. http://dx.doi.org/doi:10.1016/j.gie.2012.01.027

Endoscopic hemoclip placement and endoscopic band ligation for Dieulafoy’s lesions To the Editor: I am interested in the article entitled “Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy’s lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation” by Ahn et al.1 Theirs was a retrospective, nonrandomized study comparing two different modalities in the treatment of Dieulafoy’s lesion. The authors concluded that endoscopic hemoclip placement and endoscopic band ligation are both suitable for treating Dieulafoy’s lesions. There are some major points in this study that warrant discussion. First, it is difficult to apply endoscopic hemoclip placement or endoscopic band ligation in actively bleeding Dieulafoy’s lesions without injections of diluted epinephrine beforehand. In the Ahn et al1 study, epinephrine injection was needed in 26 patients (39.4%). Therefore, endoscopic hemoclip placement or endoscopic band ligation cannot be performed alone in active bleeding Dieulafoy’s lesions. Second, the exact locations of the Dieulafoy’s lesions were not described in the study. In our experience, neither endoscopic hemoclip placement nor endoscopic band ligation are easily performed when a lesion occurs over the posterior wall of the duodenal bulb or high on the lesser curvature of the stomach. In contrast, it is easy to thermocoagulate bleeders over these locations with the side of a heater probe. In our previous study, among patients with difficult-to-approach bleeders, we obtained a better hemostatic rate in the heater probe group than in the hemoclip group (9/11 patients vs 3/10; P ⫽ .02417).2 If we excluded difficult-to-approach bleeders, hemoclip placement and heater probes were comparable in arresting bleeding.3 Third, the rebleeding rate (5/34, 14.7%) for endoscopic hemoclip placement in their study was higher than in other reports and in our studies.2-4 Because of the strong www.giejournal.org

force of endoscopic hemoclip placement, it is safe for the prevention of rebleeding after placement. The high rebleeding rate noted by Ahn et al1 may be linked to improper placement of the hemoclip (positional or technical factors) or inadequate proton pump inhibitor usage after therapy. A high dose of proton pump inhibitor has been shown in the literature and in our previous study5,6 to be effective in reducing rebleeding. Unfortunately, the dose of proton pump inhibitor was not described in this study. Hwai-Jeng Lin, MD, FACG Division of Gastroenterology and Hepatology Department of Internal Medicine Taipei Medical University Hospital Taipei Medical University Taipei, Taiwan

REFERENCES 1. Ahn DW, Lee SH, Park YS, et al. Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy’s lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation. Gastrointest Endosc 2012;75:32-8. 2. Lin HJ, Hsieh YH, Tseng GY, et al. A prospective, randomized trial of Endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding. Am J Gastroenterol 2002;97:2250-4. 3. Lin HJ, Perng CL, Sun IC, et al. Endoscopic hemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection for peptic ulcer bleeding. Dig Liver Dis 2003;35:898-902. 4. Sung JJY, Tsoi KKF, Lai LH, et al. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 2007;56:1364-73. 5. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. 6. Lin HJ, Lo WC, Lee FY, et al. A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy. Arch Intern Med 1998; 158:54-8. http://dx.doi.org/doi:10.1016/j.gie.2012.01.017

Response: We appreciate Dr Lin’s interest in our study on endoscopic treatment for Dieulafoy’s lesion (DL).1 The author of the letter raised some important points that we would like to comment on. In our study, epinephrine injection was required in more than half of the patients (52.9%) who had DL with active bleeding. Therefore, we agree with Dr Lin’s point that endoscopic hemoclip placement (EHP) or endoscopic band ligation (EBL) cannot be performed solely in DLs with active bleeding, especially in DLs that cannot be easily approached. In our study, 42 of 66 (63.6%) patients had a DL in “difficult-to-approach” region such as the cardia, the posterior wall or lesser curvature side of the proximal body, or the posterior wall of the duodenal bulb. However, primary Volume 75, No. 6 : 2012 GASTROINTESTINAL ENDOSCOPY 1293