Endoscopic mucosal resection (EMR) is a standard technique for removing duodenal adenomas but carries a relatively high risk of clinically significant delayed bleeding (CSDB), reported in 8–18% of cases. CSDB contributes to patient morbidity and increased healthcare utilization. Preventive measures such as clip closure and prophylactic coagulation can reduce this risk but are technically demanding and time-consuming. In contrast, topical hemostatic agents are quick and easy to apply. Novel hemostatic powders may therefore offer a simpler and more efficient strategy to reduce CSDB following duodenal EMR.
A Polysaccharide Hemostatic System (PHS (Endoclot); Olympus, Tokyo, Japan) is a hemostatic powder applied to the resection site using controlled air pressure. The powder consists of absorbable modified polymers (AMP), which degrade naturally. By absorbing water from blood, AMP particles concentrate platelets, red blood cells, and coagulation proteins, thereby accelerating the clotting cascade. An air compressor ensures consistent air pressure, allowing uniform powder application to the resection site, forming a protective layer over the resection plane.
A total of 34 duodenal EMRs were performed using the novel hemostatic powder. Of these patients, 55.9% were male, with a mean age of 61 years (95% CI: 47.3-74.7). Most polyps were located in the second part of the duodenum (D2; 41.2%) and had a median size of 20 mm (IQR 20). Piecemeal resection was performed in 88.2% of cases. Application of the hemostatic agent was successful in 33 procedures (97.1%). Delayed bleeding occurred in 6 patients (17.6%) at a median of 19 hours post-EMR (IQR 110). Among these, a hemoglobin drop of ≥1.5 mmol/L was observed in 3 patients (8.8%), hematemesis in 2 (5.9%), hematochezia in 3 (8.8%), and melena in 5 (14.7%). Three patients were treated conservatively, and three underwent successful endoscopic hemostasis with clip placement.
Table 1. (Post-)Procedural and histologic characteristics
|
Characteristic |
Duodenal EMR (n=34) |
|
Sedation Propofol Midazolam |
32 (94.1) 2 (5.9) |
|
Non-lifting sign (yes), n (%) |
8 (23.5) |
|
Piecemeal EMR (yes), n (%) If piecemeal, number of pieces, median (IQR)* |
30 (88.2) 4 (3) |
|
Macroscopic complete resection (yes), n (%) |
30 (88.2) |
|
Successful application of hemostatic agent (yes), n (%) |
33 (97.1) |
|
Bleeding (yes), n (%) Intraprocedural Post-procedural (delayed) |
2 (5.9) 6 (17.6) |
|
Timing of post-procedural bleeding (hours after EMR), median (IQR) |
19 (110) |
|
Perforation (yes), n (%) |
0 (0) |
|
Histology Tubular adenoma Tubulovillous adenoma Sessile serrated adenoma |
16 (47.1) 17 (50%) 1 (2.9) |
EMR: endoscopic mucosal resection; IQR: interquartile range
*: unknown for 12 patients
Compared with previous studies, this novel hemostatic agent does not appear to reduce the risk of CSDB. However, definitive conclusions cannot yet be drawn, as the study is ongoing and aims to include a total of 53 cases.