Hemostasis via an endoscopic full-thickness suturing device with extended cap length method and red dichromatic imaging for deep colonic diverticular bleeding

Abstract

Figures

Endoscopic images. a Active bleeding was observed from a diverticulum in the ascending colon (green dotted circle). b A marking clip was placed near the responsible diverticulum. c A clip was inserted into the diverticulum, which yielded hemostasis. d Primary hemostasis was achieved; however, the diverticulum was so deep that the clips were hidden. e Rebleeding was observed from the previously clipped diverticulum. f Endoscopic band ligation yielded temporary hemostasis. g During the third colonoscopy for recurrent bleeding, we discovered that the previously applied band had detached. h An endoscopic image under white-light imaging. i An endoscopic image under red dichromatic imaging. j The entire diverticulum was suctioned into an OTS-clip via an extended cap length method. k The OTS-clip was successfully deployed. l The OTS-clip was firmly fixed, resulting in successful hemostasis.

Schema of an OTS-clip deployed using an extended cap length method. a Schema of the normal deployment of the OTS-clip. b Appearance of the normal deployment of the OTS-clip. The cap length (from the endoscope tip to the tip of the OTS-clip cap) is 6 mm. c An endoscopic view of the normal deployment of the OTS-clip. d Schema of the OTS-clip deployed via the extended cap length method (ECLM). e Appearance of the OTS-clip deployed via the ECLM. The cap length (from the endoscope tip to the tip of the OTS-clip cap) is 12 mm. f An endoscopic view of the OTS-clip deployed via the ECLM. The endoscopic view is slightly narrower than that with normal deployment, but it does not interfere with the procedure.

Full text

Diverticular bleeding accounts for approximately 60% of cases of acute lower gastrointestinal bleeding and is a common disease 1 . Endoscopic hemostasis is mainly achieved using endoclips or endoscopic band ligation (EBL), although rebleeding may occur. For such cases, an OTS-clip has been reported as an effective option 2 3 . Furthermore, red dichromatic imaging (RDI) can facilitate the identification of the diverticular bleeding site 4 5 . Herein, we describe a case of recurrent diverticular bleeding successfully treated by modifying the OTS-clip setup with an extended cap length method (ECLM) to increase the suction depth and by using RDI to improve the visualization of the bleeding site ( Video 1 ). A 74-year-old man who was taking aspirin for essential thrombocythemia was presented with hematochezia. Computed tomography revealed multiple diverticula, and upon emergency colonoscopy, we discovered active bleeding from a diverticulum of the ascending colon. After marking clips were fixed near the diverticulum, hemostasis was achieved via clipping; however, the diverticulum was so deep that the clips were hidden ( Fig. 1 a–d ). Rebleeding occurred the following day, and EBL yielded temporary hemostasis ( Fig. 1 e, f ), but bleeding recurred several hours later. As both clipping and EBL had failed, hemostasis via an OTS-clip was planned during third colonoscopy. Because the diverticulum was deep and the band had detached ( Fig. 1 g ), the OTS-clip was attached with an extended cap to increase the suction width ( Fig. 2 ). RDI was used to enhance the visibility of the bleeding site within the diverticulum. The diverticulum was fully inverted into the elongated OTS-clip cap, and the clip was deployed, resulting in complete hemostasis ( Fig. 1 h–l ). No further bleeding occurred.

Hemostasis achieved via an OTS-clip with an extended cap length method and red dichromatic imaging for bleeding from a deep colonic diverticulum.Video 1

Endoscopic images. a Active bleeding was observed from a diverticulum in the ascending colon (green dotted circle). b A marking clip was placed near the responsible diverticulum. c A clip was inserted into the diverticulum, which yielded hemostasis. d Primary hemostasis was achieved; however, the diverticulum was so deep that the clips were hidden. e Rebleeding was observed from the previously clipped diverticulum. f Endoscopic band ligation yielded temporary hemostasis. g During the third colonoscopy for recurrent bleeding, we discovered that the previously applied band had detached. h An endoscopic image under white-light imaging. i An endoscopic image under red dichromatic imaging. j The entire diverticulum was suctioned into an OTS-clip via an extended cap length method. k The OTS-clip was successfully deployed. l The OTS-clip was firmly fixed, resulting in successful hemostasis.

Schema of an OTS-clip deployed using an extended cap length method. a Schema of the normal deployment of the OTS-clip. b Appearance of the normal deployment of the OTS-clip. The cap length (from the endoscope tip to the tip of the OTS-clip cap) is 6 mm. c An endoscopic view of the normal deployment of the OTS-clip. d Schema of the OTS-clip deployed via the extended cap length method (ECLM). e Appearance of the OTS-clip deployed via the ECLM. The cap length (from the endoscope tip to the tip of the OTS-clip cap) is 12 mm. f An endoscopic view of the OTS-clip deployed via the ECLM. The endoscopic view is slightly narrower than that with normal deployment, but it does not interfere with the procedure.

In conclusion, an OTS-clip attached via the ECLM enabled the complete inversion and reliable hemostasis of a deep diverticulum. Combined with RDI, this approach may be useful as treatment for refractory diverticular bleeding.

Endoscopy_UCTN_Code_TTT_1AQ_2AZ