Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions.

Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.

AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review.

DESCRIPTION: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS: This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.

Efficacy of hemostatic powders as monotherapy or rescue therapy in gastrointestinal bleeding related to neoplastic or non-neoplastic lesions.

BACKGROUND: Hemostatic powder (HP) in gastrointestinal bleeding (GIB) is mainly used as rescue therapy after failure of conventional hemostatic procedures (CHP). AIM: To define the best field of application and the efficacy of HP as first choice monotherapy or rescue therapy. METHODS: We compared the efficacy of HP monotherapy, HP rescue therapy, and CHP in the management of active GIB due to neoplastic and non-neoplastic lesions. RESULTS: A total of 108 patients, 43 treated with HP as either first choice or rescue therapy and 65 with CHP, were included in the study. The most frequent sources of bleeding were peptic ulcer and malignancy. Immediate hemostasis rates were: HP monotherapy = 100% in peptic ulcer and 100% in malignancy; HP rescue therapy = 93.2% in peptic ulcer and 85.7% in malignancy; CHP = 77.9% in peptic ulcer and 41.7 in malignancy. Definitive hemostasis rates were: HP monotherapy = 50% in peptic ulcer and 45.5% in malignancy; HP rescue therapy = 73.3% in peptic ulcer and 85.7% in malignancy; CHP = 69.1% in peptic ulcer and 33.3% in malignancy. No difference was found in terms of additional intervention between the three groups. CONCLUSIONS: HP is highly effective as monotherapy and rescue therapy in GIB. GIB related to malignancy may be the best field of application of HP, but confirmatory studies are necessary.

Randomized controlled trial of hemostatic powder versus endoscopic clipping for non-variceal upper gastrointestinal bleeding.

BACKGROUND AND AIMS: Despite advances in pharmacological and endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB), mortality is still relevant. TC-325 (Hemospray-Cook Medical) is a mineral powder with adsorptive properties, designed for endoscopic hemostasis. There are still no comparative trials studying this new hemostatic modality. The objective of this research was to compare the use of TC-325 (associated with epinephrine injection) with the combined technique of endoscopic clipping and epinephrine injection for the treatment of patients with NVUGIB. METHODS: We conducted a pilot randomized controlled trial with patients that presented NVUGIB with an actively bleeding lesion at the endoscopic evaluation. Patients were randomized either to the Hemospray or Hemoclip group. The randomization list was generated by a computer program and remained unknown throughout the entire trial. All patients underwent second-look endoscopy. RESULTS: Thirty-nine patients were enrolled. Peptic ulcer was the most frequent etiology. Primary hemostasis was achieved in all Hemospray cases and in 90% of Hemoclip group (p = 0.487). Five patients in Hemospray group underwent an additional hemostatic procedure during second-look endoscopy, while no patient in the Hemoclip group needed it (p = 0.04). Rebleeding, emergency surgery and mortality rates were similar in both groups. No toxicity, allergy events, or gastrointestinal obstruction signs were observed in Hemospray group. CONCLUSIONS: TC-325 presents similar hemostatic results when compared with conventional dual therapy for patients with NVUGIB. Hemospray's excellent primary hemostasis rate certifies it as a valuable tool in arduous situations of severe bleeding or difficult location site.

Outcomes from an international multicenter registry of patients with acute gastrointestinal bleeding undergoing endoscopic treatment with Hemospray.

BACKGROUND AND AIM: Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. PATIENTS AND METHODS: Prospective data (Jan 2016-May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5 min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post-therapy. RESULTS: Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8-14) and median complete Rockall score (RS) was 7 (IQR: 6-8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314 = 53%) and Forrest Ib the most common bleed type in PUD (100/167 = 60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven-day and 30-day all-cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. CONCLUSIONS: These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates.

The role of endoscopy as non-invasive procedure to manage gastrointestinal complications during extracorporeal membrane oxygenation.

INTRODUCTION: Gastrointestinal bleeding is a life-threatening complication in patients undergoing extracorporeal membrane oxygenation support. Despite data on increased mortality due to gastrointestinal bleeding, there is little data on the treatment of such conditions under extracorporeal membrane oxygenation, and on the possibilities of advanced endoscopic therapy to non-invasively solve these bleeding complications. No clear treatment in the case of extracorporeal membrane oxygenation support is recommended in the guidelines. METHODS: Retrospective observational cohort study including 134 veno-venous extracorporeal membrane oxygenation patients for acute respiratory failure from 2009 to 2018 at IRCCS-ISMETT (Italy). Patients were divided into two groups according to gastrointestinal bleeding episodes and reviewed for type of endoscopic therapy. Gastrointestinal bleeding group was characterized for pre-extracorporeal membrane oxygenation characteristics, management variables-including amount of transfusions and clinical outcomes. RESULTS: Fourteen (14) patients (10.4%) experienced upper (n = 13) or lower (n = 1) gastrointestinal bleeding. Gastrointestinal bleeding and no-gastrointestinal bleeding group had similar characteristics apart from higher creatinine in the gastrointestinal bleeding group (1.9 mg/dL (1.3-4.9) vs 1.2 mg/dL (0.7-1.8), p = 0.03). In 3 of the 14 patients (21%), endoscopy showed no signs of active bleeding (nasogastric or feeding tube decubitus), and no specific intervention was performed. Active bleeding was recognized in 11 of the 14 patients (79 %). No patients died of fatal bleeding in the gastrointestinal bleeding group. Endoscopic therapy was feasible, with a complete bleeding control in all the cases: five Hemospray®, two fibrin glue, two metallic clips, one combined approach metallic clips with epinephrine, and one cyanoacrylate. The extracorporeal membrane oxygenation course was significantly longer in the gastrointestinal bleeding group: 19.5 (15-36) days vs 13.5 (8-25) days, p = 0.01. No significant differences in mortality were found between the two groups (all p values > 0.05). CONCLUSION: Advanced endoscopic therapy during veno-venous extracorporeal membrane oxygenation may contribute to reducing the negative effects on mortality for gastrointestinal bleeding episodes.

Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review.

Despite the recent advances in endoscopic hemostatic techniques, the management of lower gastrointestinal bleeding could be sometimes challenging. Hemostatic powders such as Hemospray, EndoClot, and Ankaferd Blood Stopper have found their way into digestive endoscopy and are licenced in many countries especially for use in upper gastrointestinal bleeding. We reviewed the literature on the use of these hemostatic powders in different situations in lower gastrointestinal bleeding and looked at the success rate and rebleeding rate. Most of the data are derived from case reports, retrospective and prospective case series with absence of any randomized controlled trials. Hemostatic powders were used as primary or salvage therapy to control bleeding from polypectomy site, colonic tumors, diverticula, arteriovenous malformations, radiation proctitis, ischemic colitis, and surgical intestinal anastomosis. The rate of immediate control of bleeding is in the range of 88-100% with a recurrence rate of 3-13% except for radiation proctitis bleeding where rebleeding rate can be as high as 77%. Although there are many advantages for the use of local hemostatic agents in lower gastrointestinal bleeding, future randomized controlled trials comparing them with conventional methods are needed.

Topical hemostatic powder promotes reepithelialization and reduces scar formation after extensive esophageal mucosal resection.

The development of techniques for endoscopic resection has provided new strategies for radical conservative treatment of superficial esophageal neoplasms, even those that are circumferential, such as Barrett's neoplasia. However, it is necessary to prevent the formation of scar tissue that can be responsible for esophageal strictures following circumferential resection. Preliminary data have suggested the possible efficacy of a hemostatic powder in the promotion of wound healing. The study aims to assess the effectiveness of Hemospray (Cook Medical) in a swine model of post-endoscopic esophageal stricture. Our prospective controlled study included 21 pigs. A 6-cm circumferential submucosal dissection of the esophagus (CESD) was performed in each pig. Group 1 (n = 11) only underwent CESD and Group 2 (n = 10) had repeated Hemospray applications after CESD. Clinical, endoscopic, and radiological monitoring were performed, blood levels of four inflammatory or pro-fibrotic cytokines were assessed, and histological analysis was performed. Median esophageal diameter was greater in the group treated with Hemospray (2 mm [1-3] vs. 3 mm [2-4], P = 0.01), and the rate of symptomatic esophageal stricture was 100% and 60% in Groups 1 and 2, respectively (P = 0.09). The thicknesses of esophageal fibrosis and inflammatory cell infiltrate were significantly lower in Group 2 than in Group 1 (P = 0.002 and 0.0003, respectively). The length of the neoepithelium was greater in Group 2 than in Group 1 (P = 0.0004). Transforming growth factor-ß levels were significantly lower in Group 2 than in Group 1 (P = 0.01). The application of Hemospray after esophageal CESD reduces scar tissue formation and promotes reepithelialization, and therefore is a promising therapeutic approach in the prevention of post-endoscopic esophageal stricture.

[Hemospray: a novel therapeutic option in the management of acute upper gastrointestinal bleeding]. / Hemospray: Új lehetoség az akut felso gastrointestinalis vérzések ellátásában.

INTRODUCTION: Early endoscopic diagnosis and endoscopic therapy are very important in cases of acute gastrointestinal bleeding. Hemospray is an inorganic powder with hemostatic properties recently proposed for the treatment of acute gastrointestinal bleeding. AIM: The aim of the authors was to report the first Hungarian experience obtained with Hemospray in patients with acute gastrointestinal bleeding. METHOD: During a 14-month period 10 acute upper gastrointestinal bleeder patients were treated endoscopically with Hemospray in 11 settings. In 5 patients previous endoscopic hemostatic methods failed and in the remaining 5 patients Hemospray was administrated as a first-line therapy. RESULTS: Primary hemostasis was achieved in 9 of the 10 patients treated with Hemospray. Two patients died during hospitalization (uncontrolled arterial bleeding in one patient and hepatic encephalopathy in the other one patient). Primary hemostasis and hemodynamic stability were achieved in each of the 4 patients who had thrombopenia. CONCLUSIONS: Hemospray as a rescue therapy may ensure primary hemostasis in severe acute gastrointestinal bleeding even in cases with thrombopenia.

Upper gastrointestinal active bleeding ulcers: review of literature on the results of endoscopic techniques and our experience with Hemospray.

INTRODUCTION AND OBJECTIVES: Acute gastrointestinal (GI) bleeding can lead from mild to immediately life-threatening clinical conditions. Upper GI bleeding (UGIB) is associated with a mortality of 6-10%. Spurting and oozing bleeding are associated with major risk of failure. Hemospray™ (TC-325), a new hemostatic powder, may be useful in these cases. Aim of this study is to review the efficacy of traditional endoscopic treatment in Forrest 1a-1b ulcers and to investigate the usefulness of Hemospray in these patients. PATIENTS AND METHODS: A MEDLINE search was performed and articles that evaluated hemostatic efficacy and rebleeding rate with traditional endoscopic techniques related to Forrest classification were reviewed. Patients with Forrest 1a-1b ulcers were treated with Hemospray, either as monotherapy or in association with other endoscopic techniques. Primary outcome was immediate hemostasis, secondary outcomes were recurrent bleeding and adverse events related to Hemospray use. RESULTS: Analysis of literature showed that mean initial hemostasis success rate in Forrest 1a-1b ulcers was of 92.8%, and mean rebleeding rate was of 13.3%. We enrolled 13 patients treated with Hemospray. Initial hemostasis was achieved in 100% and we reported three cases of rebleeding. No adverse events occurred. CONCLUSION: Forrest 1a-1b bleeding ulcer is very difficult to treat. Hemospray appears to be an effective hemostatic therapy for these ulcers. However, additional prospective studies are needed to validate these findings.

Hemospray® (hemostatic powder TC-325) as monotherapy for acute gastrointestinal bleeding: a multicenter prospective study.

Background: Hemostatic powders are used as second-line treatment in acute gastrointestinal (GI) bleeding (AGIB). Increasing evidence supports the use of TC-325 as monotherapy in specific scenarios. This prospective, multicenter study evaluated the performance of TC-325 as monotherapy for AGIB. Methods: Eighteen centers across Europe and USA contributed to a registry between 2016 and 2022. Adults with AGIB were eligible, unless TC-325 was part of combined hemostasis. The primary endpoint was immediate hemostasis. Secondary outcomes were rebleeding and mortality. Associations with risk factors were investigated (statistical significance at P≤0.05). Results: One hundred ninety patients were included (age 51-81 years, male: female 2:1), with peptic ulcer (n=48), upper GI malignancy (n=79), post-endoscopic treatment hemorrhage (n=37), and lower GI lesions (n=26). The primary outcome was recorded in 96.3% (95% confidence interval [CI]: 92.6-98.5) with rebleeding in 17.4% (95%CI 11.9-24.1); 9.9% (95%CI 5.8-15.6) died within 7 days, and 21.7% (95%CI 15.6-28.9) within 30 days. Regarding peptic ulcer, immediate hemostasis was achieved in 88% (95%CI 75-95), while 26% (95%CI 13-43) rebled. Higher ASA score was associated with mortality (OR 23.5, 95%CI 1.60-345; P=0.02). Immediate hemostasis was achieved in 100% of cases with malignancy and post-intervention bleeding, with rebleeding in 17% and 3.1%, respectively. Twenty-six patients received TC-325 for lower GI bleeding, and in all but one the primary outcome was achieved. Conclusions: TC-325 monotherapy is safe and effective, especially in malignancy or post-endoscopic intervention bleeding. In patients with peptic ulcer, it could be helpful when the primary treatment is unfeasible, as bridge to definite therapy.

Novel Use of Endoscopic Hemospray to Achieve Hemostasis in Pulmonary Hemorrhage: A Case Series.

This article presents two cases of pulmonary hemorrhage successfully managed using TC-325, a novel hemostatic powder commonly known as Hemospray. Originally approved for endoscopic hemostasis in gastrointestinal bleeding, Hemospray's application in endobronchial bleeding control has not been widely reported. The cases highlight its efficacy in achieving immediate and sustained hemostasis in peripheral pulmonary bleeding, where conventional bronchoscopic therapies may be ineffective. The absence of adverse effects and the rapid cessation of bleeding underscore the potential of Hemospray as a valuable tool in the bronchoscopist's arsenal, especially in life-threatening hemoptysis scenarios. The ease of application and quick hemostatic effects position Hemospray as a pragmatic solution for cases with challenging bleeding sources. While further studies are warranted to validate its efficacy and safety in a larger cohort, these cases advocate for considering Hemospray as a potential game-changer in the comprehensive management of hemoptysis, addressing limitations or risks associated with conventional interventions.

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding.

Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.

Hemospray Versus Conventional Therapy for Non-variceal Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Hemospray (TC-325; Cook Medical, Winston-Salem, NC) has been used effectively in hemostasis in non-variceal upper gastrointestinal (GI) bleeding. Current guidelines suggest using Hemospray as a temporizing measure or adjunct technique. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of Hemospray as a modality for primary hemostasis. We searched MEDLINE, CENTRAL, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) databases from inception to August 1, 2022. Three independent reviewers performed a comprehensive review of all original articles describing the application of Hemospray as the primary method of hemostasis in non-variceal upper GI bleeding patients. Three reviewers independently reviewed and abstracted data and assessed study quality using the Cochrane risk of bias tool. Primary outcomes were (1) primary hemostasis rate, (2) rebleeding rate until hospital discharge or death, (3) need for surgery, and (4) overall mortality rate. Of the 211 studies identified, 146 underwent title and abstract review, and four were included in the systematic review. Pooled results from 303 patients showed that compared to standard of care, Hemospray has significantly higher odds of primary hemostasis (OR: 3.48, 95% CI: 1.09-11.18, p = 0.04). There was no statistically significant difference in terms of rebleeding rates (OR: 0.79, 95% CI: 0.24-2.55, p = 0.69), need for surgery (OR: 1.62, 95% CI: 0.35-7.41, p = 0.54), or overall mortality (OR: 1.08, 95% CI: 0.56-2.08, p = 0.83). This systematic review and meta-analysis prove that Hemospray is a better modality of primary hemostasis in non-variceal upper GI bleeding when used as a primary method. At the same time, there is no significant difference in complications, including rebleeding, need for surgical intervention, and all-cause mortality.

Hemostatic Spray TC-325 (Hemospray®) and Unexpected Esophageal Entrapment of Gastroscope With Airway Management Considerations: A Case Report.

Bleeding from the upper gastrointestinal tract is responsible for approximately 2% of all hospital admissions annually, with an up to 17% mortality rate. Therapeutic endoscopic interventions are often indicated for establishing hemostasis. These interventions include but are not limited to thermal coagulation with cautery, mechanical methods using band ligation or hemostatic clips, and hemostatic spray. Anesthesia providers are frequently involved in providing sedation for those endoscopic procedures. In 2018, the United States Food and Drug Administration approved a hemostatic spray, Hemospray® TC-325 (Cook Medical, Winston- Salem, NC, USA) for controlling nonvariceal upper gastrointestinal bleeding. The inorganic, mineral-based powder forms a mechanical tamponade by absorbing water and attracting clotting factors to the bleeding site. Adverse events associated with using the product are reported as rare but have included perforation and difficulty in removing the gastroscope. This case presents unexpected entrapment of the gastroscope in a patient's esophagus after the bleeding site was treated with Hemospray. Potential difficulties with airway management strategies are discussed.

Non-variceal upper gastrointestinal bleed as first presentation of primary systemic amyloidosis - A case report.

Gastrointestinal (GI) tract manifestations of amyloid deposition include diarrhea, GI hemorrhage, steatorrhea, or constipation. Here, we report an elderly female presenting with GI hemorrhage due to gastric ulceration and 4-6 polypoidal lesions with intermittent ooze in the duodenum as a first presentation of primary systemic amyloidosis. The bleed was managed with proton-pump inhibitors and hemospray application. She received chemotherapy for multiple myeloma after stabilization. A high index of suspicion is needed to diagnose amyloidosis causing GI hemorrhage.

Efficacy of hemostatic powders in lower gastrointestinal bleeding: Clinical series and literature review.

BACKGROUND: There is limited evidence on the efficacy of hemostatic powders in the management of lower gastrointestinal bleeding. AIMS: to revise our series of patients with lower gastrointestinal bleeding treated with hemostatic powders and to provide a pooled estimate of their efficacy based on the current literature. METHODS: Sixty-five patients underwent topical endoscopic application of hemostatic powder between 2016 and 2020. The primary endpoint was treatment success, with 7- and 30-day rebleeding rate, adverse events and mortality as secondary outcomes. Literature review was based on computerized bibliographic search on the main databases through December 2020. Pooled effects were calculated using a random-effects model. RESULTS: Overall, the powder was applied as monotherapy in 37 patients (56.9%), as combination therapy in 15 patients (23.4%), and as rescue therapy in 13 cases (19.9%). Hemostasis was achieved in 100% of patients. Rebleeding rate at 7- and 30-day was 7.7% and 9.2%, respectively. A total of 10 studies with 259 patients were included in the meta-analysis. Immediate hemostasis was achieved in 96.3% (93.4%-99.2%) patients, whereas pooled 7- and 30-day rebleeding rates were 9.6% (4.5%-14.6%) and 12.9% (7.2%-18.5%), respectively. CONCLUSION: Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.

Experience with the use of a hemostatic powder in 152 patients undergoing urgent endoscopy for gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: In the recent years, topical hemostatic powders have been used for the management of upper gastrointestinal bleeding. The aim of this study was to report on the use of an hemostatic powder (Hemospray®), outside regular hours, by on-call endoscopists during urgent endoscopic procedures. MATERIAL AND METHODS: In this retrospective multicenter cohort study, consecutive patients having undergone an urgent endoscopy with the use of Hemospray® from November 2015 to December 2018 in the Paris and suburbs area were included. We collected clinical, biological and endoscopic variables. The outcomes such as the recurrence, repeat endoscopy and hemostatic treatment need, complications and survival were also collected. RESULTS: A total of 152 patients (mean 65 years old, 70.4% male) were included. Amongst the 31 endoscopists, 11 were "more experienced", and performed 48% of the endoscopies. The most common causes of bleeding were peptic ulcer (47.7%), malignancy (22.2%) and esophagitis (12.4%). Most bleedings originated from the upper GI tract (95.0%). Hemospray® was used as a salvage therapy in 60.8% of cases. Other hemostatic techniques were used in 52.9% of cases. Immediate bleeding cessation was noted in 79.0% of cases, recurrence in 39.9% of cases, and 26.4% of patients benefited from a repeat endoscopic hemostasis. 34 (23.0%) patients required a non-endoscopic treatment. At day 30, the survival rate was 71.6%. One complication was reported (perforation). CONCLUSIONS: Hemostatic powder application by on-call endoscopists outside regular hours is technically feasible, but comes with a high risk of rebleeding in severely ill patients.

High rate of re-bleeding after application of Hemospray for upper and lower gastrointestinal bleeds.

BACKGROUND & AIMS: Hemospray (TC-325, Cook Medical) has recently been approved for use in GI bleeding. Specific clinical indications and predictors of success or failure have not been well delineated. METHODS: We conducted a retrospective cohort study of Hemospray use at a tertiary center. We assessed demographics and characteristics of Hemospray use. We analyzed outcomes of hemostasis, rebleeding, need for embolization or surgery, and death. RESULTS: 86 applications of Hemospray were identified. The most common etiology of upper GI bleeds were ulcers (67.1%) whilst the etiology of lower GI bleeds varied. Hemospray was applied as monotherapy in 28 procedures (32.6%). Immediate hemostasis rate was 88.4%, but there was a high rate of re-bleeding (33.7%). Most re-bleeds occurred within 7 days (86.2%). Syncope was an independent predictive factor re-bleeding at 7 days for EGD (OR = 12.16, 95% CI = 1.51-97.75, P = 0.019). Bleeding refractory to endoscopic treatment with hemospray required radiological embolization in 9 instances, and surgery in 9 instances. Hemospray therapy was protective against need for embolization (p < 0.05). 2 patients underwent liver transplantation and there was a total of 5 deaths. Hepatic disease was an independent predictor of death (OR = 47.15, 95% CI = 2.42-916.89, P = 0.011). CONCLUSION: Hemospray is effective in achieving immediate hemostasis but is plagued by high rates of rebleeding. Syncope is a predictor of rebleeding, and hepatic disease is a predictor of death in patients undergoing Hemospray therapy. Despite high rates of embolization and surgery, Hemospray may reduce need for embolization. Hemospray use during endoscopy should prompt physicians to consider early re-look endoscopy and more aggressive therapy.