Technology status evaluation report
Endoscopic hemostatic devices

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Background

Endoscopic hemostatic therapy has been shown to improve outcomes in upper GI bleeding.1, 2, 3 Hemostatic devices used for upper GI bleeding have also been applied to the colon.4, 5 Therapeutic modalities include contact thermal devices (eg, heater probe [HP], multipolar electrocautery [MPEC] probes, and hemostatic graspers), noncontact thermal devices (eg, argon plasma coagulator [APC]), injection needles, and mechanical devices (eg, band ligators, clips, and loops). Band ligators are the

Thermal hemostatic devices

Thermal devices generate heat either directly (eg, HP) or indirectly by passage of electrical current through tissue (eg, MPEC probe, APC, hemostatic grasper). Heating leads to edema, coagulation of tissue protein, and contraction of vessels and indirect activation of the coagulation cascade, resulting in a hemostatic bond.7 Tissue coagulation requires a temperature of approximately 70°C. Contact thermal devices also allow coaptation of vessels, which may contribute to hemostasis.8

Ease of use

Thermal hemostatic devices are relatively easy to use because they require only direct or indirect (eg, APC) contact with the target tissue. Use of argon plasma coagulation requires an endoscopist to have fine control of the endoscope because the optimal distance of 2 to 8 mm from the device to the tissue target must be maintained during energy delivery. Power generators for contact thermal probes and APCs are portable and use a standard 110-V outlet. Ten-French probes require an endoscope with

Peptic ulcer disease

Several meta-analyses including more than 1000 patients have shown that thermal hemostatic devices, injection therapy, and clips either in combination or alone are all highly successful in achieving initial hemostasis in bleeding peptic ulcer disease. Clips and thermal therapy, either alone or paired with injection therapy, are superior to injection therapy alone in preventing rebleeding and the need for surgery. There is no significant difference between clips and thermal therapy in rebleeding

Thermal hemostatic devices

Rare perforations of peptic ulcers treated with MPEC and precipitation of bleeding (the majority stopped with further application of MPEC) in as many as 18% of patients have been reported.20 Colonic perforation after treatment of angiodysplasia, particularly in the right colon, has been reported in as many as 2.5% of cases.77

The rate of perforation after treatment of GI bleeding with HP has been reported to be as high as 1.8% to 3%, and precipitation of bleeding has been reported in as many as

Financial considerations

Commonly used CPT (Current Procedural Terminology) codes for endoscopic hemostasis are shown in the Table 5, and the detailed instructions for use of these numerous individual codes are provided elsewhere.92Table 1, Table 2, Table 3, Table 4 contain the list price of frequently used hemostatic devices available in the United

Areas for future research

The optimal device for ablation of GAVE and angiodysplasia remains unclear. New technologies using radiofrequency ablation and cryotherapy may also hold promise in ablating GAVE,49, 50, 51 but require further study. The role of endoscopic therapy in diverticular bleeding remains unclear, as does the optimal modality for hemostasis. The patient group most likely to benefit from the use of mechanical hemostatic devices such as clips and loops in the prevention of immediate or delayed

Summary

Endoscopic therapy improves clinical outcomes for many causes of GI bleeding. There are many safe and effective devices available for endoscopic hemostatic therapy. Although there are few compelling data favoring a particular device for treatment of various etiologies of GI bleeding, patients with peptic ulcer disease requiring intervention will benefit from the combination of thermal therapy or clips and injection therapy compared with injection therapy alone. Selection of the optimal

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      Citation Excerpt :

      Thermal hemostatic devices, such as multipolar/bipolar electrocautery devices, heater probes, argon plasma coagulation, and hemostatic graspers, can be used to achieve hemostasis in active bleeding.28,36 Hemostasis occurs when heating tissue leads to edema, coagulation, vascular contraction, and activation of the clotting cascade.36 Mechanical therapy, such as an endoscopic clip or band, can also be used for obtaining hemostasis.

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    This document is a product of the ASGE Technology Committee. This document was reviewed and approved by the governing board of the American Society for Gastrointestinal Endoscopy.

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