Modified endoscopic vacuum therapy for duodenal hemorrhage in patients with severe acute respiratory syndrome coronavirus 2

The use of extracorporeal membrane oxygenation is eventually needed in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Hemorrhage is a frequent complication in these patients, including gastrointestinal bleeding, mainly caused by increased inflammatory state, hyperfibrinolysis, coagulopathy, platelet dysfunction, endotheliitis, anticoagulant use, thrombocytopenia, and the extracorporeal membrane oxygenation non-pulsatile blood flow [2] [3]. The duodenum is the most affected organ, probably due to the higher exposure to biliopancreatic secretion associated with reduction in gastrointestinal motility and perfusion ([Fig. 1]). In most cases, there is diffuse bleeding usually refractory to conventional endoscopic hemostatic therapies. Therefore, we present the first reports of a novel mechanism-based therapy for these critically ill patients. Such therapy is based on the use of endoscopic vacuum therapy that promotes deformation at the cytoskeletal level, exudate control, increased angiogenesis, and reduces aggressive mucosal factors such as gastric and biliopancreatic secretions [4] [5]. Thus, it treats vascular fragility associated with endotheliitis that is associated with gastrointestinal bleeding in these patients ([Fig. 2]). A modified endoscopic vacuum therapy using a triple-lumen tube to allow for nutrition and drainage with a single tube through the nares is used, as previously described ([Fig. 3], [Fig. 4]) [5].

Fig. 1 Pathophysiology of diffuse duodenal bleeding in patients with SARS-CoV-2 on extracorporeal membrane oxygenation support.

Fig. 2 Mechanism of action of the modified endoscopic vacuum therapy for the treatment of diffuse gastrointestinal bleeding.

Fig. 3 Modified endoscopic vacuum therapy: step-by-step process of manufacture. a Using ½-width gauze, wrap the fenestrated portion of the gastric decompression tube. b Use the antimicrobial incise drape to wrap the gauze around the gastric decompression tube. c Fix the modified sponge with sutures. d Use the 18G needle to make several holes in the antimicrobial incise drape – final appearance.

Fig. 4 Modified endoscopic vacuum therapy using a triple-lumen tube to allow for nutrition and drainage with a single device.

Initial esophagogastroduodenoscopy (EGD) typically demonstrated duodenal villous atrophy associated with diffuse bleeding, including active ulcers and visible vessels, which were refractory to conventional endoscopic hemostatic therapies, including hemostatic powder. After endoscopic vacuum therapy placement, all patients were hemodynamically stable within 4–7 days, with no signs of gastrointestinal bleeding. Follow-up EGD demonstrated a completely healed mucosa with no signs of villous atrophy or bleeding ([Video 1]).

Video 1 Modified endoscopic vacuum therapy for the treatment of duodenal hemorrhage in critically ill patients: a simple approach for a complex condition.

In our experience, this technique is associated with high technical and clinical success rates, allowing early enteral nutrition, with no adverse events and a low rate of rebleeding after endoscopic vacuum therapy removal. After the successful use of this approach in refractory cases, we no longer offer conventional endoscopic hemostatic therapies for patients with diffuse gastrointestinal bleeding associated with SARS-CoV-2 on extracorporeal membrane oxygenation, reducing the need for multiple endoscopic procedures and transfusions.

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• References

• 1 Ramanathan K, Antognini D, Combes A. et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med 2020; 8: 518-526
• 2 Yamada S, Ogawa H, Asakura H. Etiology and management of bleeding during ECMO in a COVID-19 patient. J Atheroscler Thromb 2021; 28: 402-403
• 3 Asakura H, Ogawa H. Overcoming bleeding events related to extracorporeal membrane oxygenation in COVID-19. Lancet Respir Med 2020; 8: e87-e88
• 4 Loske G, Schorsch T, Müller C. Intraluminal and intracavitary vacuum therapy for esophageal leakage: a new endoscopic minimally invasive approach. Endoscopy 2011; 43: 540-544
• 5 de Moura DTH, Hirsch BS, Boghossian MB. et al. Low-cost modified endoscopic vacuum therapy using a triple-lumen tube allows nutrition and drainage for treatment of an early post-bariatric surgery leak. Endoscopy 2021; [Epub ahead of print]