A 64 year old man had a colonoscopy under the UK Bowel Cancer Screening Programme having been found to be FOB +ve using the FIT test.
Four weeks ago, an index colonoscopy was performed showing a 4cm LST-G at the hepatic flexure. The LST was not biopsied and a tattoo was placed on the contralateral wall. He now attends for an elective polypectomy… (see video).
The video shows the EMR procedure and highlights the use of snaretip softcoagulation to treat the edges of the defect, use of a Coagrasper to treat large vessels and bleeding vessels on the base and also the use of Purastat to reduce the risk of delayed bleeding and possibly promote wound healing.
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PuraStat® (3-D Matrix Ltd, Tokyo) is a slightly viscous liquid that is applied to a bleeding area. This self-assembling synthetic peptide forms a transparent gel which induces haemostasis [1]. Contact between PuraStat and blood causes the acidic peptide solution to be neutralized and exposed to ions, resulting in the formation of ß-sheets that then form a 3-dimensional scaffold structure. This transparent adherent barrier permits further endoscopic therapy to be performed. PuraStat can be applied to the general area of bleeding and does not require precise application to the exact point of bleeding. It is applied through a thin catheter inserted through the biopsy channel of the endoscope and can be used in confined areas.
PuraStat® is licensed as a CE marked device for use in exudative haemorrhage from vessels in solid organs and within the GI tract. PuraStat has been used in treatment and prevention of bleeding in patients undergoing ESD and EMR [2-8].
In a UK randomised controlled trial of 101 patients undergoing ESD, participants were randomised to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used [9]. Follow-up endoscopy was performed at 4 weeks to assess wound healing. There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P less than 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02).
REFERENCES
1.Uraoka T et al, Gastrointest Endosc. 2016 Jun;83(6):1259-64. A novel fully synthetic and self-assembled peptide solution for endoscopic submucosal dissection-induced ulcer in the stomach.
https://www.ncbi.nlm.nih.gov/pubmed/26608126
2.Yoshida M et al J Gastroenterol Hepatol. 2014 Dec;29 Suppl 4:77-9. Initial clinical trial of a novel hemostat, TDM-621, in the endoscopic treatments of the gastric tumors.
https://www.ncbi.nlm.nih.gov/pubmed/25521738#
3.Pioche M, Camus M, Rivory J et al; Endosc Int Open, 2016 4(4): E415-9; A self-assembling matrix-forming gel can be easily and safely applied to prevent delayed bleeding after endoscopic resections
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4831935/
4.Subramaniam S, Kandiah K, Thayalasekaran S, et al, Gut 2017;66:A214-A215.
PTH-019 Bleeding during endoscopic resection: a novel extracellular scaffold matrix is a safe and effective haemostatic agent
https://gut.bmj.com/content/66/Suppl_2/A214
5.Subramaniam S, Kandiah K, Thayalasekaran S, Longcroft-Wheaton G and Bhandari P; Haemostasis and prevention of bleeding related to ER: The role of a novel self-assembling peptide. United European Gastroenterol J. 2019 Feb; 7(1): 155–162.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374844/
6.Attardo S et al, P.06.8 USE OF PURASTAT IN GASTRO-INTESTINAL BLEEDING – SINGLE CENTER EXPERIENCE, Digestive and Liver Disease, March 2018, Volume 50 (2), Supplement, Page e182
https://www.dldjournalonline.com/article/S1590-8658(18)30528-0/pdf
7.Soons E, Turan A, van Geenen E, Siersema P. Application of a novel self-assembling peptide to prevent hemorrhage after EMR, a feasibility and safety study. Surg Endosc. 2021;35(7):3564-3571. doi:10.1007/s00464-020-07819-7
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8195920/
8.Sankar S, O'Neill K, Bagot D'Arc M, et al. Clinical Use of the Self-Assembling Peptide RADA16: A Review of Current and Future Trends in Biomedicine. Front Bioeng Biotechnol. 2021;9:679525. Published 2021 Jun 2. doi:10.3389/fbioe.2021.679525
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216384/
9.Subramaniam S, Kandiah K, Chedgy F et al; A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial; Endoscopy 2021; 53(01): 27-35
https://www.thieme-connect.com/products/ejournals/abstract/10.1055/a-1198-0558
