Creighton University/St. Joseph's Medical Center Phoenix, AZ, United States
Zaid Ansari, MD1, Shehroz Aslam, MD2, Mustafa Alani, MD3, Tanuj Sharma, MD4, Indu Srinivasan, MD5, Andrew M. Weinberg, DO6, Keng-Yu Chuang, MD1 1Creighton University School of Medicine Phoenix Program, Phoenix, AZ; 2Creighton University, Dignity Health St. Joseph's Medical Center, Phoenix, AZ; 3Creighton University/St. Joseph's Medical Center, Phoenix, AZ; 4St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, Phoenix, AZ; 5Creighton University/Valleywise Health, Phoenix, AZ; 6St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, Valleywise Health, Peoria, AZ
Introduction: The Over-The-Scope Clip (OTSC®) system (Ovesco) and Padlock Clip® (PC) Defect Closure System (Steris) are endoscopic tools developed to manage severe gastrointestinal hemorrhage, perforation, and surgical leaks. The removal of either system is very difficult if not impossible. Here we report a case of failed PC hemostasis salvaged by OTSC.
Case Description/Methods: A 33-year-old male with alcoholic cirrhosis presented to the ED after a syncopal episode and melena. He was hypotensive, tachycardic and his labs showed a hemoglobin of 6.9, lactic acid of 3.8, creatinine of 1.98, and bilirubin of 16. He was admitted to the MICU for hemorrhagic shock. The patient reported recent admission to another hospital where multiple EGD were performed. Our EGD showed active bleed from two large duodenal bulb ulcers where a PC and a standard endoclip, previously placed at the outside hospital, were seen in position. We decided to treat these ulcers using OTSCs after the endoclip was removed; the PC was left in place as removal was impossible for this type of device and the OTSC was placed directly over the PC. Complete hemostasis of both ulcers was achieved. As the patient became hemodynamically unstable again, a second look EGD was performed two days later, The OTSC clips were in good positions and no signs of bleed were noted. The patient however continued to deteriorate and eventually died despite stable hemoglobin level without overt signs of GI bleed.
Discussion: In the only randomized control trial comparing OTSC with PC, an ex vivo model experiment demonstrated that OTSC consistently halted spurting bleeding but not PC. Both systems utilize a design similar to that for endoscopic band ligation. Steris recommends treating lesions no greater than 2 cm using PC while no official size limit was recommended by Ovesco for OTSC. OTSC could be removed using a specialized cutter but PC cannot be removed once placed. Here we report the first case where failed hemostasis using PC was salvaged by OTSC while the PC device was left in place.
Figure: Top: Previously placed Padlock Clip and endoclip Bottom: Two Over-The-Scope Clips placed on top of the previous Padlock Clip; Interval removal of endoclip
Zaid Ansari indicated no relevant financial relationships.
Shehroz Aslam indicated no relevant financial relationships.
Mustafa Alani indicated no relevant financial relationships.
Tanuj Sharma indicated no relevant financial relationships.
Indu Srinivasan indicated no relevant financial relationships.
Andrew Weinberg indicated no relevant financial relationships.
Keng-Yu Chuang indicated no relevant financial relationships.
Zaid Ansari, MD1, Shehroz Aslam, MD2, Mustafa Alani, MD3, Tanuj Sharma, MD4, Indu Srinivasan, MD5, Andrew M. Weinberg, DO6, Keng-Yu Chuang, MD1. P1535 - OTSC System Use After Padlock Clip Failure to Achieve Hemostasis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.