Endoscopic Doppler Ultrasound Guided Coagulation Could Prevent Delayed Hemorrhage From Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancer: a Feasibility Study

Noriya Uedo1, Yoji Takeuchi1, Ryu Ishihara1, Koji Higashino1, Richard C. Wong2, Amitabh Chak2, Hiroyasu Iishi1

1. Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan, 2. Gastroenterology, School of Medicine, Case Western Reserve University, Cleveland, OH, United States

BACKGROUND AND AIM: After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), all visible exposed vessels were customary coagulated even if there was no evidence of bleeding at the end of procedure, however, delayed bleeding occur in some portions of patients (1.2-11.6%). Endoscopic Doppler ultrasound system (DOP-US, Vascular Technology Inc.) can predict risk of recurrent bleeding of non-bleeding visible vessel (NBVV) in patients with acute peptic ulcer. Aims of this study were to establish suitable method of DOP-US for post ESD ulcer and to evaluate whether it is feasible for investigating it could reduce delayed bleeding. METHODS: 30 ulcers in 30 patients underwent ESD for mucosal EGC that was larger than 2 cm without ulcer or scar or less than 3 cm with scar, were examined and treated by following protocol: A double channel endoscope (EVIS-2TQ260M, Olympus) that fitted with transparent attachment (D-201-13404, Olympus) was used. A DOP-US probe was inserted through accessory channel and was contacted on an ulcer base to search for a positive Doppler signal (DOP (+)) that is defined as pulsatile sound at shallow (1.5 mm) depth. The endoscopic appearance of areas with DOP (+) and any stigmata of bleeding and their presence or absence of Doppler signal were documented in a schematic map. Electrical coagulation (Soft coagulation 80W, ICC200, ERBE) by hemostatic forceps (FD-410LR, Olympus) was performed for areas with active bleeding and with DOP (+). NBVV that were negative for Doppler signal were left untreated. The coagulated areas were re-inspected for a persistent signal and coagulation or clip was added until the signal disappeared. Oral PPI was administered for eight weeks. RESULTS: 17 oozing hemorrhage were observed and four had DOP (+). After coagulation for all sites, hemorrhage was stopped and the DOP (+) became silent. 49 of 387 NBVV (12.7%) were DOP (+) and were coagulated (once in 39, twice in 6, and more than three times in 4 site including one clipping) until they became silent. The reminder of 338 NBVV and 13 adherent clots that were negative for Doppler signal were not treated. A total of 24 areas without any visible endoscopic stigmata were found to be DOP (+), and were coagulated until the signal turn to be silent. No delayed bleeding occurred in the 31 patients within 30 days. Long procedure time (mean 32 min) was a limitation of this procedure. CONCLUSION: Our settings and maneuver could detect blood flow signal on post ESD ulcer. This protocol warrants further studies to investigate whether use of DOP-US could reduce delayed bleeding and could avoid unnecessary coagulation for NBVV in post ESD ulcer for EGC.

Presented at Digestive Disease Week® (DDW®) 2010 in New Orleans, LA. More information can be found at www.ddw.org.

Vascular Technology, Inc. did not provide financial support for the following scientific sessions and did not influence the content in any way. However, research presented within these scientific sessions may have been supported by Vascular Technology, Inc.

Presenter: Noriya Uedo1, Yoji Takeuchi1, Ryu Ishihara1, Koji Higashino1, Richard C. Wong2, Amitabh Chak2, Hiroyasu Iishi1
Presentation Time: 11:18 AM-11:30 AM
Presentation: 347q. Endoscopic Doppler Ultrasound Guided Coagulation Could Prevent Delayed Hemorrhage From Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancer: A Feasibility Study
Presenter Company: 1. Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular DIseases, Osaka, Japan. 2. Gastroenterology, School of Medicine, Case Western Reserve University, Cleveland, OH, United States.
Abstract: Endoscopic Doppler Ultrasound Guided Coagulation Could Prevent Delayed Hemorrhage From Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancer: A Feasibility Study

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