Clin Endosc.  2022 Jan;55(1):150-155. 10.5946/ce.2020.217.

Practical Experiences of Unsuccessful Hemostasis with Covered Self-Expandable Metal Stent Placement for Post-Endoscopic Sphincterotomy Bleeding

• Yoshida M
• Inoue T
• Naitoh I
• Hayashi K
• Hori Y
• Natsume M
• Atsuta N
• Kataoka H

• KMID: 2525063
• DOI: http://doi.org/10.5946/ce.2020.217

Abstract

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Keyword

Endoscopic; Endoscopic retrograde cholangiopancreatography; Endoscopic sphincterotomy; Hemostasis; Self-expandable metal stents

Figure

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  Fig. 1. Endoscopic images from case 1. (A) An endoscopic image of the duodenal papilla before endoscopic sphincterotomy (ES). (B) On initial ES, post-ES bleeding was temporarily controlled after the conventional endoscopic hemostasis. (C) Emergency endoscopy showed delayed bleeding from the duodenal papilla 1 day after the initial ES. Balloon tamponade is attempted for hemostasis, resulting in failure, followed by placement of a covered self-expandable metal stent (CSEMS). (D) Bleeding continued from the 9 o’clock position, because of insufficient compression by the CSEMS. (E) Complete hemostasis by hemostatic forceps.

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  Fig. 2. Schematic characteristics of unsuccessful hemostasis using covered self-expandable metal stent placement for post-endoscopic sphincterotomy bleeding. The bleeding point was in the 3 o’clock position in 3 cases (43%), and 9 and 11–12 o’clock in 2 cases, respectively (29%). Hemostatic forceps (n=3), hypertonic saline epinephrine (HSE) (n=3), and hemoclip (n=1) achieved complete hemostasis.

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