In addition to hemostasis with electrocoagulation, argon knife, lancing, and sclerotherapy, endoscopic hemostasis with metal titanium clips is one of the more widely used means of hemostasis in the treatment of gastrointestinal bleeding. Skilled metal clip operation in appropriate cases can effectively stop bleeding and prevent rebleeding with few adverse effects. In our hospital, 35 cases of gastrointestinal bleeding were treated with metal clips for hemostasis, and the hemostasis was rapid and the success rate was high, which is reported as follows.
1. Clinical data
1.1 Selection of subjects
From 2002 to the present, our hospital applied endoscopic metal titanium clips (MD-850, Olympus) to treat 35 cases of gastrointestinal bleeding, among which, 25 cases were male and 10 cases were female, and the average age of patients was 46 years. Gastroscopy was performed within 12-48 hours after bleeding in all cases. There were 18 cases of active bleeding ulcers, 5 cases of gastric Dieulafoy lesions, 2 cases of intestinal vascular dysplasia, 6 cases of immediate bleeding after intestinal polypectomy, 3 cases of cardia mucosal lacerations, and 1 case of bleeding anastomotic ulcer. The ulcer was located in the anterior wall of the bulb in 7 cases, in the lateral side of the greater curvature of the bulb in 3 cases, in the posterior wall in 2 cases, in the lateral side of the lesser curvature of the gastric sinus in 3 cases, and in the fundus of the stomach in 3 cases. These 35 patients gushed blood in 15 cases, oozed blood in 14 cases, and had blood vessels exposed in 6 cases.
1.2 Clinical history
All patients had stable vital signs before endoscopy, and experienced endoscopists were selected to make trial clips before operation to ensure that various risks were minimized during operation, that the field of view was clear during endoscopy, and that clamping was performed on lesions that were bleeding or had a high risk of rebleeding during treatment. Specific operation: the release device for placing the titanium clip is inserted through the endoscopic biopsy clamp channel, the titanium clip is pushed out at a distance of about 3 cm from the lesion, the vasculature at the location of the lesion is approached in a vertical direction and then the surrounding tissue is clamped with deep pressure, then the release device is disconnected and the second titanium clip is prepared for implantation after the release device is withdrawn through the clamp channel. The lesion was repeatedly rinsed with saline after clamping by 1-3 metal clips, and the endoscope was withdrawn after confirming complete hemostasis. Upper gastrointestinal hemorrhagic lesions were routinely treated with proton pump inhibitors, mucosal protectants, and fasting for 12-24 hours. Intestinal lesions were not specially treated after surgery, and all were observed for 72 hours, and no further active bleeding was seen judged as successful treatment.
1,3 Results
At the 6-month follow-up after discharge, no rebleeding was seen except for one case due to recurrent ulcer and bleeding. In this one case of recurrent ulcer, endoscopic examination revealed that scarring had formed at the original ulcer and that the new bleeding foci originated from a newly developed sinus ulcer. Therefore, the success rate of using metal clips for peptic bleeding in our hospital was 100% during the 4-year period.
2. Discussion
2.1 Information about metal clips
The metal clips of Olympus endoscopic series can be used for (1) endoscopic marking; (2) hemostasis a: mucosal and submucosal tissue injury less than 3 cm; b: ulcerative bleeding ;c: arterial bleeding less than 2 mm (due to the limitation of the distance after the metal clip is opened); d: prevention of bleeding prior to polypectomy of polyps less than 1, 5 cm in diameter; e: bleeding from colonic diverticula; (3) for the treatment of perforation clamping of the gastrointestinal tract less than 0, 5 cm.
The rotatable releasers that release metal clips can be divided into HX-5LR-1 (via gastroscopy) and HX-5QR-1 (via enteroscopy) according to their use, and there is also a HX-6UR-1 releaser for endoscopy with a clamp tract diameter of 3, 2 mm or more. Our hospital has the above three sets of Olympus releasers according to their operational needs, and after 4 years of work, they are in good condition and simple to maintain on a regular basis, and can capable of treating more cases.
2.2 Case selection
According to our treatment experience, the same cases of upper gastrointestinal bleeding, those who bleed from ruptured esophageal or fundic varices based on medical history and endoscopic diagnosis, those who bleed diffusely, those who bleed from malignant ulcers with hard or brittle surrounding tissues, and those who bleed from arteries larger than 3 mm in diameter are not suitable for metal clips to stop bleeding. In our hospital, since the development of metal clip hemostasis, the selected cases have been performed according to the above principles, and through clinical operation experience we believe that in hemorrhagic lesions of the esophagus and bleeding gastric lesser curvilinear lesions clamp firmness is poor, also not suitable for metal clip treatment, which is consistent with the findings of relevant domestic studies1. In addition, deeper ulcers where vascular bleeding has stopped at the base of the ulcer and red thrombi or clots are seen in the exposed vessels should also be treated with caution as there is an increased risk of rebleeding if clamping is performed. In addition, it is reported in the literature ②③ that for thick-tipped polyps larger than 1 cm in diameter due to the presence of large vessels, there is a risk of bleeding and perforation with direct excision, metal clamping can be performed after excision and the bleeding rate decreases, and clamping can also be used to stop bleeding for persistent bleeding after polypectomy, but we experience that due to tissue coagulation caused by high-frequency current cautery and tissue hardening, and the cautery surface is large, multiple deep clamps should be used when performing clamping.
2,3 Application of combined hemostasis program
Although metal clip hemostasis has accurate and rapid hemostatic effect, but in some cases it is necessary to combine other hemostatic programs, not to blindly expand the scope of use of metal hemostatic clips. For example, when the visual field is blurred and the bleeding site is not fully revealed, the bleeding lesion can be exposed after flushing with ice saline or 1:10,000 epinephrine before performing metal clip hemostasis; in addition, since metal clips can only clamp the vascular stump, the effect is weak for the deeper vessels of larger and deeper ulcers, and deep clips may lead to perforation, while shallow clips have the risk of rebleeding, so the clips can be performed at the appropriate depth after choosing Therefore, epinephrine injection can be performed at the appropriate depth after clamping to stop bleeding. Three of the cases treated in our hospital received titanium clips and injection hemostasis, and one case received radiofrequency, titanium clips and injection hemostasis. Foreign scholars have reported that the combined use of titanium clips, epinephrine injection and/or lancing for the treatment of gastrointestinal bleeding has a significantly lower rebleeding rate than that treated with injection and titanium clips alone.4,5
2,4 Skilled operating technique
The metal tube sheath is very important in the installation of the metal clip; if it is artificially squeezed or severely deformed, the metal clip will not be released from the sheath. When opening the metal clip to ensure the maximum appropriate, need to slide the handle to push moderate, push not in place or move back too much can cause the metal clip opening degree is reduced, can not effectively clamp the lesion; In addition, the lesion and clamp direction is not perpendicular, the effect of the clamp is also affected, resulting in treatment failure. When the metal clip is closed, the metal clip can be detached from the metal tube sheath only when the sliding handle is smoothly pushed to a “click” feeling. This requires coordination between the operator and the assistant. Since blood and mucous membrane can cover the endoscopic lens causing unclear field of view, it is not possible to extend the placeholder out of the biopsy clamp tract at this time, and do not adjust the endoscopic manipulation angle button at will after extending, so as to avoid the distal end of the placeholder causing patient perforation and rebleeding.
2.5 Other precautions
MRI examination before receiving MRI before dislodging after placing more metal clips has certain effects on MRI; endoscopists should fully consider the endoscopic anatomical location, histological type, lesion type and patient condition before operation and prepare sufficient number of metal clips; metal clips dislodged too early can lead to rebleeding; placement of metal clips in case of bacterial infection can aggravate or prolong the infection; after clamping of deeper tissues if the patient has abdominal pain, perforation should be alerted.
3. Conclusion
Metal clips have advantages over other endoscopic means of hemostasis. Some authors have evaluated the endoscopic treatment of gastrointestinal bleeding and concluded that different options should be used according to the specific situation, such as injection and electrocoagulation are commonly used and effective, metal clips can be chosen for deeper ulcers and when there is vascular exposure, argon knife is suitable for superficial bleeding, lancing is suitable for esophageal variceal bleeding, tissue gel is used for fundic varices, etc. (8). We believe that metal clip hemostasis has the advantages of rapid, accurate, less trauma and less complications, and it can be fully utilized by experienced endoscopists and nurses skilled in the operation of suitable cases to reduce patients’ hospital stay and costs, and it is one of the effective means of endoscopic gastrointestinal hemostasis.