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Эндоскопия/Колопроктология
Intra-organ administraion of Haemoblok hemostat for the prevention and stop of bleeding during endoscopic removal of stomach polyps.
S.G. Tereshchenko
A.V. Plotkin
L.V. Mecheva
Relevance

Polyps of the digestive system are frequently encountered precancerous diseases, are subject to dynamic observation and with indications - to removal. Nowadays, the operation of choice is endoscopic polypectomy. This surgery has advantages in that it eliminates the focus of possible malignancy, but at the same time preserves the anatomy and function of the operated organ. Despite the high efficiency, endoscopic polypectomy can be complicated by bleeding. The issue of its prevention and stopping at endoscopic removal was repeatedly raised in clinical medicine. To prevent this complication, several methods have been developed: endoscopic injection
therapy with the administration of physiological solution, adrenaline solution, fibrin glue, superposition of the endoscopic ligature, and clipping. The leading value in our study was the intra-organ use of Haemoblok hemostat for the prevention and stop of bleeding during endoscopic removal of the stomach polyps.

Aim of the study

The purpose of this study is to evaluate the effectiveness of the intra-organ use of Haemoblok hemostat to prevent bleeding and stop it during endoscopic polypectomy.
Materials and methods of study

The study was carried out on 205 patients who were removed 396 polyps of the stomach.
Polyps were solitary and multiple.. Endoscopic polypectomy included preoperative preparation, endoscopic surgery and postoperative control. Endoscopic removal of polyps was carried out by electrocoagulation and electroexcision with OLYMPUS electrosurgical unit PSD-10. The electrocoagulation method used a diathermic probe, and a forceps for "hot biopsy". With the method of electroexcision, the polyp was cut off by a diathermic loop, thrown over the stem or base of the polyp, in the mode of "cutting" - "coagulation". For the capture and extraction of cut polyps, biopsy forceps, diathermic loop, Dormia baskets, extractors, trap devices of various companies were used. For injections and irrigation - disposable
and reusable endoscopic injectors and catheters of various manufacturers.
The patients were divided into two groups. The main group consisted of 63 persons, to whom 129 polyps were removed. The drug Haemoblockinjected into the base of the polyp to patients of the main group before removal of polyps of the stomach. Through the injector, 3 to 10 ml of the drug was injected into the base of the polyp until a distinct cushion was formed. In the group there were 19 men and 44 women, aged 30 to 85 years, according to the age groups, the patients were distributed as follows: 30-44 years old -1, 45-59 years old - 9, 60 -74 years old - 46, more than 75 years old -7, the average age was 65.5 ± 2.0 years. The polyps had the following localization: in the body of the stomach: t/ 3 -13, m/ 3-23, b/ 3 -37, antral section -56. , ........ on the front wall was located 28, the back one - 26, small curvature - 13, large one - 62. The size of the polyps was: from
0.5 to 1 cm -60, up to 1.5 cm -37, up to 2.0 cm -13, up to 3 cm -11, up to 4.0 cm 5, more than 4 cm - 3. 92 polyps had the stem, wide base - 37 ones. Among the polyps, hyperplastic formations predominated, in the main group there were 82, adenomas - 47.
With the submucosal introduction of Haemoblock, the hydraulic compression of the vessels of the polyp base was accompanied by an increase in local thrombogenesis. After the creation of the "cushion", the polyp was removed by electroexcision or coagulation using a standard procedure. After removal of the polyp to prevent possible bleeding, irrigate and/ or split the bed of the removed polyp. With the development of bleeding, the irrigation and/ or stabbing of the hemorrhage source by means of the Haemoblock was also performed. Irrigation was carried out using a proprietary spray catheter or a conventional catheter inserted into the biopsy endoscope channel. A source of blood circulation was sprayed from top to bottom in small portions using 50 to 100 ml of the drug. To enhance hemostasis, the endoptotic injection site of the remote polyp bed was used. The needle of the endoscopic injector, conducted through the biopsy channel of the endoscope, was punctured to the maximum depth in the zone of electrosurgical intervention in 2 -3 mm from the source of bleeding alternately from 5 to 6 points. Through the injector, the drug was injected into the organ wall until a distinct swelling roller was formed around the source of the bleeding. The control group consisted of 142 persons, to whom 267 polyps were removed. In the group there were 50 men and 92 women, according to the age groups, the patients were distributed as follows: 30 - 44 years old - 6, 45 - 59 years old - 34, 60 - 74 years old - 85, more than 75 years old - 17, the average age was 64.2 ± 1.6 years. The polyps had the following localization: in the body of
the stomach: t/ 3 -33, m/ 3-46, b/ 3 -65, antral section -123. , ........ on the front wall there were 78, the back one - 60, small curvature - 22, large one - 107. The size of the polyps was: from 0.5 to 1 cm -113, up to 1.5 cm -78, up to 2.0 cm -32, up to 3 cm -29, up to 4.0 cm 10, more than 4 cm - 5. 174 polyps, had the stem, wide base - 37 ones. In the control group, the hyperplastic formations over the adenomatous ones also predominated, respectively: 158 and 109. Patients of the control group were followed by the same methods of electrocoagulation and electroexcision without using the Haemoblok hemostat. To create a cushion, Novocain, saline solution, aminocaproic acid solution were used. To prevent bleeding after polypectomy, injection method and electrocoagulation were used. Patients of both groups had no significant differences in sex, age, age distribution, gastric location, size, mean size and number of removed polyps.
Patients of the main and control groups with bleeding had moderate bleeding. Comparative evaluation of the methods took into account the following indicators: the occurrence of bleeding from a thermal defect, the achievement of the final stop of bleeding, the recurrence of bleeding from a thermal defect.
Results of the research and their discussion

Endoscopic removal of stomach polyps in various ways has a complication - bleeding of
varying intensity from the zone of the thermal defect. Despite the achievements of operative and therapeutic endoscopy, this problem remains significant till now because the bleeding complicating endoscopic polypectomy is not always amenable to endoscopic arrest and in some cases requires surgical intervention that aggravates the patient's condition. In the work we considered the treatment of patients with polyps of the stomach by the methods of operative endoscopy (electroexcision, electrocoagulation) from the standpoint of prevention and stopping bleeding, as a complication arising during the operation and in the postoperative period. The work is based on the results of treatment of 205 patients with single and multiple polyps of the stomach, who produced 396 endoscopic polypectomies for the period from 2007 to 2017. A comparative analysis of the results of endoscopic removal of stomach polyps after the infiltration of the base of the polyp with Haemoblock preparations, 5% aminocaproic acid, saline, and the efficacy of hemostasis in the development of bleeding from a thermal defect of the biotissue after irrigation and/ or infiltration with Haemoblock and other drugs of injectable hemostasis.
To achieve better results in preventing hemorrhage, a technique and methodology for
endoscopic infiltration with the Haemoblock preparation was developed, followed by
electroexcision of the polyps. The principle of the method is that before the operation, the
Haemoblock is injected into the stem of the polyp or its base. In case of bleeding, the bed of the removed polyp was irrigated/ cured with the drug Haemoblock. Endoscopic infiltration with Haemoblock before removal of polyps was undertaken by us in
63 patients, to whom 129 polyps were removed, by electroexcision - 105 polyps, electrocoagulation - 24 ones. The average size of the removed polyp was 15.3 + 1.6 mm, the average value of the number of removed polyps was 2.2 ± 0.6 polyps.
The results of treatment according to the developed method were compared with the results of removal of 267 polyps of the stomach in 142 patients after infiltration of the polyp base by other means. In the control group 203 polyps were removed by electroexcision, by electrocoagulation - 64 ones. The average size of the removed polyp was 15.0 + 1.1 mm, the average value of the number of removed polyps was 1.8 ± 0.2 polyps. In the study groups, patients were compared by sex, age, localization of polyps, size and quantity, basal therapy, bleeding from a thermal defect in the biotissue, achievement of primary/ final hemostasis, recurrence of bleeding. In the main group, in endoscopic polypectomy in 63 patients, the bleeding from the remote polyp bed developed in 3 (4.7%) patients with removal of 8 (6.2%) polyps, which was significantly
less than in the control group, where the bleeding was observed in 18 (12.6%) (p <0.05) of patients with the removal of 33 (12.3%) (p <0.05) polyps. In the main group, primary hemostasis with the use of the drug Haemoblock in the form of irrigation and/ or splitting of the bed of the removed polyp was positive in 7 cases, in 1 case it was necessary to add diathermocoagulation and clipping. In the control group, primary injectable hemostasis was effective in 6 patients, in 12 patients, diathermocoagulation and clipping were required for the final stop, which was significantly (p <0.05) more than in the main group. In 2 patients of the control group with bleeding, endoscopic procedures were ineffective, which required an operative intervention in the form of suturing the bed of remote polyps. Thereafter, there was no recurrence of bleeding from the thermal defect of the biotissue in the main group, in the control group a recurrence of bleeding from thermal defects occurred in 2 patients, at that hemostasis was achieved using endoscopic injection techniques. The use of the developed technique of prevention and stopping of bleeding during endoscopic polypectomy significantly reduced the percentage of bleeding complicating this operation.

Summary

The use of the Haemoblok hemostat for endoscopic removal of polyps for endoscopic infiltration of their base with subsequent electroexcision ensures the prevention of bleeding and the radical nature of intra-organ intervention. Use of endoscopic irrigation/ puncturing with Haemoblok hemostatin the development of bleeding from the thermal defect allows achieving reliable hemostasis in early and late post- polypeptic bleeding, which reduces the number of emergency operations. The method of endoscopic infiltration of the Haemoblok hemostat used both for prevention and for stopping bleeding in the complicated course of polypectomy is economically advantageous, it does not require additional expendable material and expensive equipment, a specially equipped room, and therefore it can be used in all endoscopy rooms and departments of surgical hospitals. These conditions allow us to recommend the intra-organ use of the drug Haemoblock for endoscopic removal of stomach polyps in a wide clinical practice.