Use of covered self-expandable metallic stents in post-endoscopic sphincterotomy bleeding

We read with interest the article by Itoi et al. on the use of covered self-expandable metallic stents (SEMSs) for uncontrolled bleeding following endoscopic sphincterotomy [1]. We agree with the authors that the covered SEMS is a useful treatment modality for management of recurrent post-endoscopic sphincterotomy bleeding, after failure of or in combination with other endoscopic methods, which include: (a) injection (epinephrine, fibrin glue); (b) thermal methods (heater probe, electrocoagulation, argon plasma coagulation); and (c) mechanical methods (balloon tamponade, clipping) [2] [3] [4] [5].

However, although the hemostatic use of SEMSs has been proven efficient in two recent case series [1] [6], it should not be considered to be a panacea. We had recently the experience of treating a 93-year-old woman who was admitted for removal of large bile duct stones. She had neither coagulopathy nor antiplatelet/anticoagulant treatment. At duodenoscopy the major papilla was found to be in a duodenal diverticulum. The main bile duct was dilated (maximal diameter 15mm), and we performed a sphincterotomy of 1.5 cm that was complicated by a heavy bleeding that obscured the visual field. After initial failure to manage the hemorrhage by injection of diluted epinephrine (1 : 20 000; 60 ml), a successful mechanical tamponade was achieved by placement of a totally covered SEMS (Wallflex; Boston Scientific, Natick, Massachusetts, USA) that was 10 × 80 mm in size. However the patient suddenly developed continuous hematemesis 2 hours later. Emergency duodenoscopy disclosed a slight distal migration of the stent and active bleeding at the apex of the sphincterotomy site. Repeated epinephrine injection failed to control the bleeding and finally N-butyl-2-cyanoacrylate and methacryloxysulfolane 1 ml (Glubran 2) diluted with Lipiodol 1 ml was injected at 4 aliquots of 1 ml per injection and led to hemostasis. However, 10 days later the patient presented with hematemesis and melena, that necessitated blood transfusion of 3 units of packed red blood cells. At duodenoscopy, the stent, that had still been in place 2 days previously as shown by plain abdominal X-ray, was seen to be completely dislodged, and rebleeding was seen. This time permanent hemostasis was achieved by the injection of diluted epinephrine and the placement of 6 clips (Quickclip2; Olympus, Tokyo, Japan).

Given this case, we would like to emphasize the following points. First, several hemostatic methods may be needed to control post-endoscopic sphincterotomy bleeding. Second, that placement of a covered SEMS is efficient when the stent is wide enough and suitably positioned to provide sufficient mechanic pressure. Third, that late post-endoscopic sphincterotomy bleeding may occur due to stent migration.

In conclusion, placement of a SEMS is a useful hemostatic method in cases of post-endoscopic sphincterotomy bleeding. However, endoscopists and manufacturers should be aware of the limitations and possible complications, particularly in cases where there is a large bile duct and/or extended sphincterotomy. We believe that the bleeding risk could be diminished by the temporary placement of a SEMS for at least 2 weeks, and by using totally or even partially covered SEMS of a bigger diameter, as for treatment of esophageal perforations or fistulas.

References

• 1 Itoi T, Yasuda I, Doi S et al. Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding.  Endoscopy. 2011;  43 369-372
• 2 Ferreira L E, Baron T H. Post-sphincterotomy bleeding: who, what, when, and how.  Am J Gastroenterol. 2007;  102 2850-2858
• 3 Katsinelos P, Kountouras J, Chatzimavroudis G et al. A novel technique of injection treatment for endoscopic sphincterotomy-induced hemorrhage.  Endoscopy. 2007;  39 631-636
• 4 Mutignani M, Seerden T, Tringali A et al. Endoscopic hemostasis with fibrin glue for refractory postsphincterotomy and postpapillectomy bleeding.  Gastrointest Endosc. 2010;  71 856-860
• 5 Oviedo J A, Barrison A, Lichtenstein D R. Endoscopic argon plasma coagulation for refractory postsphincterotomy bleeding: report of two cases.  Gastrointest Endosc. 2003;  58 148-151
• 6 Shah J N, Marson F, Binmoeller K F. Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding.  Gastrointest Endosc. 2010;  72 1274-1278