A novel endoscopic electrocoagulation hemostasis technique for uncontrolled intraprocedural bleeding: series connection of foreign body forceps and hemostatic forceps

Intraprocedural bleeding is unavoidable during endoscopic procedures [1] [2]. Minor bleeding from small vessels can typically be managed with an electric knife, while significant bleeding from larger vessels requires the use of hemostatic forceps [3] [4]. In cases of uncontrollable severe bleeding, clips can be used as rescue treatment, but their use may impede subsequent procedures. Here, we introduce a method using foreign body forceps and hemostatic forceps to achieve hemostasis for emergency massive bleeding during endoscopic full-thickness resection (EFTR).

A 72-year-old woman was referred to our hospital for the treatment of a gastric mass. Endoscopy, endoscopic ultrasound, and upper abdominal enhanced computed tomography were performed ([Fig. 1]). Following consultation with the patient and her family, EFTR was chosen as the optimal treatment approach.

Fig. 1 Examinations before endoscopic full-thickness resection of a gastric mass in a 72-year-old woman. a Endoscopy showed a raised lesion with a central depression at the gastric antrum–body junction. b Endoscopic ultrasound demonstrated a hypoechoic mass about 3.1 × 3.5 cm in size, with heterogeneous anechoic areas, originating from the muscularis propria layer. c Upper abdominal enhanced computed tomography showed a soft tissue density mass measuring 4.4 × 3.6 cm, with calcification in the gastric antrum, protruding into the abdominal cavity (yellow arrowhead).

During the procedure, sudden bleeding occurred that could not be controlled using the electric knife ([Video 1], [Fig. 2] a). Despite repeated attempts with hemostatic forceps (FG-44NR-1; Olympus, Tokyo), bleeding persisted. Given the potential depth of the bleeding site and the longer jaws of foreign body forceps (4.5 mm, FD-410LR; Olympus) compared to hemostatic forceps (3.6 mm), we used a foreign body forceps to clamp the bleeding site, despite its lack of electrocoagulation capabilities. We then extracorporeally connected the foreign body forceps in series with a hemostatic forceps ([Fig. 2] b). This enabled charging of the distal end of the foreign body forceps and successful hemostasis of the bleeding site ([Fig. 2] c,d).

A novel endoscopic electrocoagulation technique for hemostasis of uncontrolled intraprocedural bleeding: series connection of foreign body forceps and hemostatic forceps.Video 1

Fig. 2 Series connection of foreign body forceps and hemostatic forceps for hemostasis of uncontrolled intraprocedural bleeding. a Sudden bleeding occurred during an endoscopic full-thickness resection, which could not be controlled using the electric knife and hemostatic forceps. b Extracorporeal connection of a hemostatic forceps in series with the foreign body forceps that was clamping the bleeding site. c This series connection enabled the distal end of the foreign body forceps to be charged, thereby providing electrocoagulation functionality. d This enabled successful hemostasis of the sudden bleeding. e The lesion was completely resected. f The wound was closed with a pursestring suture of clips and nylon ring.

Finally, the lesion was completely removed, and the wound was closed with a pursestring suture of clips and nylon ring ([Fig. 2] e,f). Postoperative recovery was uneventful, with no rebleeding. Histopathology revealed a gastric schwannoma [5] ([Fig. 3]).

Fig. 3 Histopathology of postoperative specimen. a Histology showed a spindle-cell tumor (hematoxylin and eosin, × 100). b Immunohistochemical staining of S-100 was positive, confirming the diagnosis of a gastric schwannoma (× 100).

This connection in series of forceps to enable hemostasis highlights the adaptability of endoscopic equipment and the imaginative innovation on the part of the endoscopist, providing a novel approach for managing uncontrollable intraprocedural bleeding without interrupting the operation.

Endoscopy_UCTN_Code_TTT_1AO_2AD

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Libânio D, Pimentel-Nunes P, Bastiaansen B. et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55: 361-389
• 2 Rajan E, Wong Kee Song LM. Endoscopic full thickness resection. Gastroenterology 2018; 154: 1925-1937.e2
• 3 Gralnek IM, Stanley AJ, Morris AJ. et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy 2021; 53: 300-332
• 4 Mullady DK, Wang AY, Waschke KA. AGA Clinical practice update on endoscopic therapies for non-variceal upper gastrointestinal bleeding: Expert review. Gastroenterology 2020; 159: 1120-1128
• 5 Albshesh A, Kaufmann MI, Levy I. Gastric schwannoma. Clin Gastroenterol Hepatol 2020; 18: e142-e143

Publikationsverlauf

Artikel online veröffentlicht:
09. April 2024