This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Endoclot is an hemostatic powder made of a starch-derived compound that absorbs water when in contact with blood or liquids, creating a gel matrix over the bleeding lesion. It also accelerates in-situ coagulation process due to hybrid concentration of platelets and coagulation factors. Hemostatic powders are considered an endoscopic hemostatic option for upper and lower non-variceal bleeding, which are easy to use and have a good safety profile. These are useful for diffuse bleeding, poor visualization settings, and neoplastic lesions with oozing bleeding. Its delivery system has a dedicated catheter for endoscopic application. However, one of the disadvantages of this system is that the catheter tip may accidentally contact liquid inside the working channel or the gastrointestinal lumen, increasing the risk of premature catheter occlusion. This particular disadvantage is more significant in cases of difficult-to-access bleeding sites, large amounts of intraluminal secretions or blood, or anatomic modifications due to surgery or tumor burden, all of which may increase the risk of technical failure of the procedure. The conventional technique states that prior to catheter insertion, the working channel must be flushed with air to remove residual liquids that may remain inside it. During the catheter insertion, the air compressor must be turned on and must avoid suction in order to keep the tip dry. Despite following the recommendations to keep the tip dry, sometimes it is not possible to completely avoid its contact with liquids or blood. When the anatomy is distorted due to tumor burden or surgically modified anatomy, it is especially difficult to maneuver, making the procedure susceptible to technical failure. The proposed technique modification shown in this video aims to avoid premature catheter occlusion due to powder reaction with liquid inside the tip. The parts of the system should be connected in the conventional way. Once it is connected, non-toxic modeling clay is applied to the catheter tip to occlude the distal 2-3 mm. It is important to ensure that the modeling clay completely occludes the tip without leaving gaps between the clay and the catheter walls in order to create sufficient inner pressure that can eject the plug. Once the dispenser is connected, it must be held in an upright position before and during catheter insertion through the working channel. For the modified technique, during the catheter insertion with the already occluded tip, the air compressor must be set off. Once a catheter is inserted and the movements for the application have been planned, the air compressor must be turned on. Immediately afterwards, the clay plug will come out. Then, the powder dispenser must be turned downside to allow the powder to pour out. This patient was diagnosed with an advanced non-resectable ampullary adenocarcinoma that invaded the drodenal wall. A plastic biliary stent was placed two months prior during the initial oncologic approach. The duodenoscopy with a frontal view endoscope showed a distorted anatomy due to tumor burden as well as significant amount of liquid and oozing bleeding which challenged the visualization of the patient's vision. As shown here, the catheter tip, if already occluded, does not interfere with suction if needed. Once the lesion is targeted and the movement's planned, the plug is ejected to start spraying. The following patient presented with upper gastrointestinal bleeding due to a gastric adenocarcinoma. A frontal view gastroscopy showed a large neoplastic lesion with multiple recent bleeding areas and a focal area with an adeared clot. The proposed modification for the endoscopic and mostatic powder application technique shown in this video is based on the tip occlusion before the catheter insertion through the working channel. The method discussed was conceived for the endoclot system, but it can be adapted for any through-the-scope catheter-based delivery system. This technique reduces the risk of premature tip occlusion due to the powder-fluid reaction inside the catheter tip, thus avoiding technical failure.

Endoclot

hemostatic powder

non-variceal bleeding

endoscopic procedures

catheter occlusion