Endoscopic detachable snare ligation: a new treatment method for colonic diverticular hemorrhage

• Introduction
• Patients and methods
• Results
• Discussion
• References

Background and study aims: Colonic diverticular hemorrhage is the most common cause of lower intestinal bleeding. We tried to develop a convenient and reliable hemostatic method, endoscopic detachable snare ligation (EDSL), to treat diverticular hemorrhage and retrospectively explored its safety and efficacy.

Patients and methods: The definitive bleeding diverticulum was ligated with a detachable snare, instead of a rubber band, in a procedure similar to endoscopic band ligation. Removal of the scope to attach a ligation device and reinsertion for treatment are not needed in this method.

Results: From November 2013 to September 2014, EDSL was used to treat 8 patients with colonic diverticular hemorrhage. The mean procedure time required for hemostasis after identification of the bleeding diverticulum was 5 ± 2 minutes. Sustained hemostasis was achieved in 7 patients (88 %), and early rebleeding occurred in 1 patient, in whom the applied suction seemed inadequate. No complications occurred in any patient.

Conclusions: EDSL may be a safe and effective treatment for colonic diverticular hemorrhage. However, additional studies are warranted to confirm these initial exploratory data.

Introduction

Diverticular hemorrhage is the most common cause of lower gastrointestinal bleeding, accounting for 20 % to 42 % of cases [1] [2] [3]. Its course is generally less severe than that of upper gastrointestinal hemorrhage, and the bleeding resolves spontaneously in 70 % to 80 % of patients [1] [4]. However, rebleeding occurs in 25 % to 47 % of patients and requires medical intervention [1] [4] [5].

Endoscopic clipping and, recently, endoscopic band ligation (EBL) are frequently used to achieve hemostasis in patients with colonic diverticular hemorrhage. Although endoscopic clipping is technically easier than EBL, the rate of rebleeding is quite high (33 %) [6]. EBL can achieve immediate hemostasis in most patients, even when the site of bleeding is located at the diverticular dome or the hemorrhage is massive (each situation recognized to cause difficult endoscopic clipping). However, for the EBL procedure, it is necessary to remove the colonoscope in order to place the band ligation device on the scope tip [7] [8]. Additionally, EBL is more expensive than endoscopic clipping. We tried to develop a novel endoscopic hemostatic method, endoscopic detachable snare ligation (EDSL), to address these issues.

Patients and methods

The preliminary efficacy and safety of EDSL were studied retrospectively. Two well-trained endoscopists with extensive experience in the detachable snare ligation procedure for large polyps performed the EDSL procedures consecutively. Patients presenting with bloody stools and progressive anemia were candidates for this study. Packed red blood cells were transfused to address anemia when necessary, and bowel preparation with polyethylene glycol was administered before colonoscopy when possible. Informed consent for the endoscopic hemostasis procedure was obtained from all patients except in an emergency case. The study was approved by the ethics committees of the University of Tsukuba and Koyama Memorial Hospital and was performed in accordance with the Japanese ethical guidelines for clinical research.

A colonoscope with a water jet system (PCF-Q260AZI or CF-H290I; Olympus, Tokyo, Japan) was used, and a transparent hood (MAJ-663; Olympus) was attached to the tip of the colonoscope. The definitive site of bleeding (actual active bleeding, visible exposed blood vessel, or tightly adherent clot despite vigorous irrigation) was identified by suctioning the diverticular mucosa into the suction cup of the hood. When the source of bleeding had been identified ([Fig. 1a]), we marked the area adjacent to the diverticulum with an endoscopic clip (HX-610 – 090; Olympus) to avoid losing the location of the diverticulum ([Fig. 1b]). A detachable snare (Endoloop, HX-20Q-1; Olympus) with the same diameter as the tip of the hood was chosen. The target lesion was subsequently placed in the 5 – to 7-o’clock position to facilitate successful loop placement. The source of bleeding was confirmed by suctioning the diverticulum into the suction cup of the hood ([Fig. 1c]). The detachable snare was inserted and expanded over the tip of the transparent hood until it opened at the rim of the ligation chamber ([Fig. 1 d]). Then, the target colonic diverticulum was packed inside the hood under full endoscopic suction and tightly tied at the base with the detachable snare ([Fig. 1e]). After hemostasis had been confirmed, the excess wire of the ligating snare was removed with cutting forceps to prevent it from falling off upon contact with stool ([Fig. 1f], [Video 1]). The procedure time was defined as the total time from inserting the scope to cutting the excess wire of the ligating snare.

Results

Of the 19 patients with colonic diverticular hemorrhage who were treated at our institutions between November 2013 and September 2014, 8 patients were treated with EDSL. Their characteristics and clinical outcomes are presented in [Table 1]. There were 7 male patients, whose mean age was 69 ± 7.4 years. Of the bleeding diverticula, 6 were located in the ascending colon and 2 in the sigmoid colon. Bowel preparation with polyethylene glycol was administered to 7 patients before the examinations, and 1 patient had no preparation because of an emergency situation. There was a past history of diverticular bleeding in 4 patients. An oral antithrombotic agent had been prescribed to 2 patients.

The mean total procedure time was 34 ± 22 minutes. The mean EDSL procedure time required for hemostasis after identification of the bleeding diverticulum was 5 ± 2 minutes. Definitive diverticular bleeding (active bleeding in 6 patients, exposed vessel in 1 patient, and blood clot in 1 patient) was completely controlled in 7 patients, and early rebleeding from a treated diverticulum in the ascending colon was observed in 1 patient on day 4 after the procedure. Rebleeding was from the nearby snaring site and was stopped with clipping. In this latter case, it was difficult to maintain the position of the colonoscope at the site of bleeding; consequently, the applied suction seems to have been inadequate. No complications, including perforation, occurred. In 4 patients, a follow-up colonoscopy was performed at 1 or 2 months after hemostasis, and scar formation was observed in each treated diverticulum ([Fig. 2]).

Discussion

The EDSL treatment for colonic diverticular hemorrhage seemed safe and effective in this preliminary study. The process of hemostasis in the EDSL procedure was almost the same as that in the EBL procedure, except that different ligation materials were used. Both procedures involved suction, eversion, and ligation (with a rubber band and elastic O-ring in EBL, and with a detachable wire snare in EDSL) of the target diverticulum. Therefore, EDSL is expected to be similar to EBL in regard to efficacy and limitations.

However, our EDSL method provides an advantagein comparison with EBL. In EDSL, the colonoscope does not have to be removed after the bleeding diverticulum has been located. This can result in a shorter time to hemostasis; the mean EDSL procedure time required for hemostasis was 5 minutes in our study. It is known that diverticula on the right side of colon are more common in Asian populations than in the populations of Western countries [9]. Indeed, six of the eight bleeding diverticula in our patients were located in the ascending colon, and the procedures would have taken longer if the colonoscope had been removed from the right side of the colon and then reinserted. This improved procedure time alleviates the treatment burden for both operators and patients, especially elderly patients with significant co-morbidities. In addition, the process of suction, eversion, and irrigation used to detect the diverticulum responsible for hemorrhage might induce active massive bleeding, and the operative field of view might be lost while the endoscope is being removed and reinserted. This risk is avoided in EDSL, which can be performed immediately after identification of the bleeding diverticulum, with the scope remaining inserted at all times.

The major limitation in applying EBL to treat colonic diverticular hemorrhage is reported to be insufficient suction of the diverticulum into the hood, which is likely to occur in the case of a diverticulum with a small orifice and a large dome [8]. The diverticulum for which hemostasis failed in the present study is a case of insufficient suction. Additionally, the failure of snare deployment and risk for diverticulum entrapment are other possible problems. Although we did not experience such technical problems, they should be studied further.

Perforation may be the chief concern in the endoscopic treatment of diverticular bleeding because diverticula do not have a muscular layer. Cases of perforation have not been reported in EBL [6] [7] [8] [10]. Akimaru et al. used a detachable snare with forceps (n = 6) or suction (n = 3) to ligate the wall of the large bowel of a Landrace pig at nine different sites. The large bowel was subsequently removed after 2 weeks, and scar formation was observed at all ligated sites without any perforations [11]. In the present study, our patients did not experience any abdominal pain or adverse events requiring surgery after EDSL. The risk of perforation during EDSL should be carefully assessed further in many patients, and the cut-through issues reported during the ligation of polyps should be extensively studied.

The associated cost of EDSL is one-sixth that of EBL. Because it is difficult to place the clip only on the exposed vessel, the diverticulum is often closed in a zipper-like fashion with several clips. If three or more clips are needed, the total cost is higher than that of EDSL.

EDSL may be safe and effective for colonic diverticular hemorrhage. Additionally, this method is convenient and may be cost-saving in comparison with conventional methods. The present study has several limitations. The study design was retrospective, the sample size was small, and the long-term rates of rebleeding and complications are unknown. Further evaluation is needed to confirm the advantages of EDSL.

Competing interests: The authors have declared no conflicts of interest associated with this study.

Acknowledgments

The authors wish to thank all the members of the Division of Gastroenterology and Endoscopy at the University of Tsukuba Hospital and Koyama Memorial Hospital for the excellent secretarial and technical assistance they have provided.

• References

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Corresponding author

• References

• 1 Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92: 419-424
  PubMedSearch in Google Scholar
• 2 Chaudhly V, Hyser MJ, Gracias VH et al. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg 1998; 64: 723-728
  PubMedSearch in Google Scholar
• 3 Jensen DM, Machicado GA, Jutabha R et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342: 78-82
  CrossrefPubMedSearch in Google Scholar
• 4 McGuire HH Jr. Bleeding colonic diverticula: a reappraisal of natural history and management. Ann Surg 1994; 220: 653-656
  CrossrefPubMedSearch in Google Scholar
• 5 Aytac E, Stocchi L, Gorgun E et al. Risk of recurrence and long-term outcomes after colonic diverticular bleeding. Int J Colorectal Dis 2014; 29: 373-378
  CrossrefPubMedSearch in Google Scholar
• 6 Setoyama T, Ishii N, Fujita Y. Endoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25: 3574-3578
  CrossrefPubMedSearch in Google Scholar
• 7 Shibata S, Shigeno T, Fujimori K et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis. Endoscopy 2014; 46: 66-69
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Ishii N, Setoyama T, Deshpande GA et al. Endoscopic band for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75: 382-387
  CrossrefPubMedSearch in Google Scholar
• 9 Kang JY, Melville D, Maxwell JD. Epidemiology and management of diverticular disease of colon. Drugs Aging 2004; 21: 211-228
  CrossrefPubMedSearch in Google Scholar
• 10 Farrell JJ, Graeme-Cook F, Kelsey PB. Treatment of bleeding colonic diverticula by endoscopic band ligation. An in-vivo and ex-vivo pilot study. . Endoscopy 2003; 35: 823-829
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Akimaru K, Suzuki H, Tsuruta H et al. Eversion and ligation of a diverticulum: report of an inspirational case and subsequent animal study. J Nippon Med Sch 2008; 75: 157-161
  CrossrefPubMedSearch in Google Scholar