Su1355 Hemoclip Application to Treat and Prevent Post-Sphincterotomy Bleeding in High-Risk Patients Undergoing Therapeutic ERCP

Su1355 Hemoclip Application to Treat and Prevent Post-Sphincterotomy Bleeding in High-Risk Patients Undergoing Therapeutic ERCP Douglas A. Howell*, Emily A. Rolfsmeyer, Sam Yoselevitz, Jennifer Lewis, Bryce C. Mays, David Y. Lo Pancreaticobilary Center, Maine Medical Center, Portland, ME Background: Following ERCP sphincterotomy (ES), the risk of immediate or delayed bleeding is reported to be 2.0 5.3 %, but can rise to greater than 10% and perhaps as great as 25% in the setting of anti-coagulation therapy. In addition, patients with underlying liver disease or hematologic disorders, are at markedly greater risk of bleeding in this setting. Studies with epinephrine have not been conclusive, and although widely used it has not been demonstrated to be effective monotherapy. Treatment of a variety of GI bleeding disorders, including peptic ulcer, vascular anomalies, and post-polypectomy hemorrhage, has been increasingly performed using hemostatic clips. Mechanical clipping of post-sphincterotomy bleeding (PSB) has not been widely studied, in part due to the difficulty in placing the current generation of clips using ERCP endoscopes. In addition, the potential of inadvertent application of clips on the pancreatic orifice, demands caution. After refining the technique of clip placement, we present our initial single center experience. Patients: 30 ES patients (pts) were included in this study. 12 pts with significant intraprocedural bleeding during sphincterotomy, not controlled with epinephrine injection, underwent hemoclipping; 18 pts were identified as high-risk for delayed PSB: Pts were either on Coumadin (n 7), Plavix (n 6), or full dose Heparin (n 4). One pt had a platelet count 50,000. These 18 pts all underwent prophylactic hemoclipping. INR in all patients, ranged from 1.0 to 1.7. (Median 1.4) Indications for ES included cholangitis, CBD stones, dilated ducts, and suspected sphincter of oddi dysfunction. Methods: Two detachable short hemostatic clips (Quickclip, Olympus) were used after trimming back the outer sheath 1.5cm to facilitate their function over the ERCP elevator. The ERCP endoscope was then positioned above the sphincter, and the clips placed on opposing sides of the cut, taking care not to obstruct the pancreatic orifice. Results: Placement of two hemostatic clips using the standard ERCP endoscope was technically possible in 100% of patients. In the case of intraprocedural bleeding, all 11 cases were successfully stopped with hemoclip application without recurrence. No patients had evidence of delayed bleeding with a median follow-up of 22 days. There were no complications related to hemoclipping. As a result of this technique, anti-coagulation was able to be continued or resumed within 24 hours of the procedure. This study is currently ongoing. Conclusions: Although technically difficult, hemoclip application in the post-ES setting is feasible, safe, and may be an effective technique for the treatment and/or prevention of postsphincterotomy bleeding. Further experience is necessary before this can be accepted as a standard of care.