Hemospray as an efficient and effective bailout option to solve uncontrolled bleeding after complicated endoscopic mucosal resection or endoscopic submucosal dissection. Hemospray is a newer endoscopic hemostasis modality with proven safety and efficacy. However, the effect of hemospray is temporary and the use is costly. Therefore, the role in GI bleeding treatment algorithms is evolving and subject of ongoing discussion and research. Here we present two examples of the usefulness of this hemostasis technology for refractory hemorrhage after GI tumor resection when more conventional techniques of endoscopic hemostasis including mechanical injection and thermal therapies have failed to control the situation. A 68-year-old male with multiple medical comorbidities underwent ESD of gastric adenocarcinoma. This gastric cancer was located in the antrum and prepylorus and both staging CT and EUS were consistent with T1 disease. The known fungating partially circumferential adenocarcinoma of approximately 5 by 4 centimeters was found in the gastric antrum and prepyloric region of the stomach. The lesion was marked at its periphery and then lifted away from the muscularis propria with targeted submucosal injections. Using standard dissection techniques, the resection plane was extended, progressively separating the tumor from the underlying muscle layers and resected in block. Then the remaining stock was resected using a snare due to angulation of the stomach. Persistent bleeding was encountered throughout the case, which appeared to be from tumor-driven angiogenesis pathology. Multiple attempts were made to control bleeding, including mechanical tamponade with the SB short knife with the addition of soft coag current, argon plasma coagulation, and scope tamponade using the endoscope cap. However, despite the use of these hemostatic agents, the bleeding persisted and the decision was made to use a single application of hemospray to control the bleeding, which was immediately effective. Then a dual-channel flexible endoscope fitted with overstitched suturing device was advanced into position and the resection site was progressively closed with sutures, which were clinched into place under direct visualization. However, the resection site was only 80% closed due to adherent and mud-like quality of the hemospray, which made effective suturing problematic and the case was concluded. Patient was admitted to the postoperative observation unit and was discharged the following day without evidence of further bleeding throughout the postoperative course. Pathology of the gastric specimen measuring 4.1 by 2.7 centimeters showed a T1b invasive moderately differentiated adenocarcinoma, which involved the submucosa and was arising from tubular adenoma. Eventually underwent distal gastrectomy and regional lymphadenectomy with Roux-en-Y anastomosis for T1b gastric adenocarcinoma. A 71-year-old male with compensated cirrhosis due to non-alcoholic fatty liver disease presented with multiple large biopsy-proven gastric hyperplastic mass lesions in the prepyloric area involving the duodenal bulb and extending to D1. The largest of the prepyloric tumors were ulcerated and felt to be the source of ongoing occult GI blood loss as well as intermittent low-grade gastric outlet obstruction. The patient presented for EMR of lesions for the indication of gastric outlet obstruction and to eliminate the bleeding source. This mass lesion is located in the antrum and prepyloric region of the stomach causing intermittent gastric outlet obstruction with ulceration shown by the red arrow thought to be causing ongoing blood loss. This hyperplastic mass involves the duodenum as well. The decision was made to resect using CAP-band EMR. There was continuous venous bleeding post-resection. Initially, a snare tip and soft coag was used to treat bleeding. The bleeding persisted, so thermal hemostasis coag grasper was used next. Initially, this was successful, but then there was recurrent bleeding. An attempt was made to clip the lesion, but the lesion continued to bleed through the clip. Hemospray was then used as a bailout method and achieved successful hemostasis. The patient was admitted to the postoperative observation unit and was discharged the following day without evidence of further bleeding. Pathology of the gastric and duodenal tumors showed inflamed and eroded hyperplastic polyps with reactive epithelial changes. Postoperative bleeding is reported to occur in 5.3 to 15.6% of gastric ESD cases and 1.4 to 20% of gastric EMR cases. A review of 30 studies where hemospray was utilized 532 times showed 97% hemostasis during index endoscopy. Hemospray has been available internationally since 2011 and was approved by the FDA in the United States in 2018 for hemostasis of non-variceal GI bleeding. The sprayable powder has several benefits, achievement of rapid hemostasis without need for thermal, mechanical, or contact methods, reliable hemostasis for up to 48 hours, and can be used either as a primary treatment option or as a salvage approach. However, the technology is relatively expensive and generally not recommended as primary hemostasis approach when more conventional techniques are indicated. The use of hemospray should not be considered a first-line agent for post-EMR or ESD hemostasis, but these cases demonstrate the potential role of hemospray in salvage hemostasis due to its rapid and effective hemostasis in the setting of recalcitrant gastrointestinal mass resection bleeding after EMR and ESD. An incidental pearl we learned here is that the use of hemospray in this manner will make any subsequent resection site suturing technically challenging by limiting visualization of the resection site base and edges, and is likely only appropriate when refractory bleeding has defied more conventional hemostatic tools and techniques.

Hemospray

endoscopic mucosal resection

endoscopic submucosal dissection

hemostasis modality

bleeding control