Ng Jia Lin, Marican Musfirah, Mathew Ronnie
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
ANZ J Surg. 2019 Mar;89(3):E56-E60. doi: 10.1111/ans.14895. Epub 2018 Oct 10.
Although most diverticular bleeding resolve spontaneously, up to 30% can bleed torrentially, necessitating angioembolization, endoscopic or surgical intervention. Non-contact endoscopic therapies, such as topical haemostatic powders, do not require precise targeting and are attractive because identification of specific culprit diverticulum is difficult. While their use in non-variceal upper gastrointestinal bleeding is well established, its role in lower gastrointestinal bleeding remains unclear. We used topical Hemospray in a novel setting of severe diverticular bleeding, evaluating its efficacy in achieving haemostasis, reducing re-bleeding and the need for re-intervention.
Consecutive patients from a tertiary colorectal unit who underwent colonoscopy and Hemospray for severe diverticular bleeding from November 2016 to October 2017 were included. Hemospray was endoscopically applied to colonic segments with major stigmata of recent haemorrhage.
Ten patients had a median time to colonoscopy of 22 h (range: 8-54) from admission. Median of 3.5 units (range: 0-10) of packed cells were transfused pre-endoscopy. All achieved immediate haemostasis without further haemodynamic instability or re-bleeding. No endoscopic, radiological or surgical re-intervention was required. Patients were fit for discharge within a median of 3 days (range: 2-7) following Hemospray. There were no morbidities, mortalities or readmissions for diverticular bleeding after a median follow-up of 9.5 months (range: 3-16).
This feasibility study shows that topical haemostatic powders can offer a safe and effective therapeutic endoscopic option in severe diverticular bleeding with high haemostatic rate. Prospective controlled trials are required to establish its efficacy compared to conventional therapy.
尽管大多数憩室出血可自行缓解，但高达30%的患者可能会出现大出血，需要进行血管栓塞、内镜或手术干预。非接触式内镜治疗，如局部止血粉，不需要精确瞄准，由于难以识别特定的出血憩室，因此具有吸引力。虽然其在非静脉曲张性上消化道出血中的应用已得到充分证实，但其在下消化道出血中的作用仍不明确。我们在严重憩室出血的新环境中使用局部止血喷雾，评估其在实现止血、减少再出血和再次干预需求方面的疗效。
纳入2016年11月至2017年10月在三级结直肠科接受结肠镜检查和使用止血喷雾治疗严重憩室出血的连续患者。在内镜下将止血喷雾应用于近期出血有主要迹象的结肠段。
10例患者从入院到结肠镜检查的中位时间为22小时（范围：8 - 54小时）。内镜检查前输注的浓缩红细胞中位数为3.5单位（范围：0 - 10单位）。所有患者均立即止血，无进一步的血流动力学不稳定或再出血。无需进行内镜、放射学或手术再次干预。止血喷雾治疗后，患者中位3天（范围：2 - 7天）即可出院。中位随访9.5个月（范围：3 - 16个月）后，无憩室出血导致的并发症、死亡或再次入院情况。
这项可行性研究表明，局部止血粉在严重憩室出血中可提供一种安全有效的内镜治疗选择，止血率高。与传统治疗相比，需要进行前瞻性对照试验以确定其疗效。
