ENDOSCOPIC VACUUM THERAPY FOR THE MANAGEMENT OF NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING: A NOVEL INDICATION FOR AN OLD LIFE-THREATENING CONDITION

Background and study aims: Endoscopic vacuum therapy (EVT) is recognized as an effective approach for the management of transmural gastrointestinal defects. EVT-related mechanisms including macrodeformation, microdeformation, changes in perfusion, exudate control, and gastric and biliopancreatic secretions clearance promote healing and may also be adapted for the treatment of refractory gastrointestinal (GI) hemorrhage. During the COVID pandemia, we applied these principles of EVT in critically ill patients with duodenal hemorrhage. This approach was associated with high technical and clinical success rates. Based on our experience and underlying mechanism of action, we started to use EVT for Non-Variceal Upper Gastrointestinal Bleeding (NVUGIB). This study aims to report the initial results of EVT for the treatment of NVUGIB.

Patients and methods: Patients with NVUGIB treated with EVT as a primary or a rescue therapy from March 2022 to October 2023 were included in this study. A homemade-EVT (H-EVT) using a triple-lumen tube (TLT) to allow for nutrition and drainage through a single tube through the nostril was used. The H-EVT was manufactured on the aspiration lumen (gastric portion) of the TLT with gauze and antimicrobial incision drape. After intraluminal placement, the device was connected to a vacuum machine (-125 mmHg). The primary outcome was clinical success, defined as successful endoscopic hemostasis without rebleeding within 30 days. Secondary outcomes were technical success and safety profile. Subgroup analysis compared COVID AND NON-COVID related GI bleeding related Rebleeding and death related factors were alsoanalyzed.
Results: A total of 19 patients underwent EVT for NVUGIB, 8 related to COVID infection and 11 NON-COVID. Technical successwas 100% and overall clinical success rate 89.5%. All COVID NVUGIB were in duodenum (100% x 36.6%, p=0.012). Clinical success rates were similar for both COVID and non-COVID patients (90.9% x 89.5%, p = 1). One reebleding was reported in each group. The COVID patient was treated again with EVT . The NON-COVID was responding well to EVT. However, the surgical team removed the EVT after 3 days. Two days later reebleding occurred. He die after 2 embolizations coil attempts. Overall mortality was 36.8% (COVID: 65.5% x 18.2% NON-COVID [(p=0.0739]). All deaths were not associated with device adverse events and/or uncontrolled NVUGIB.
Conclusion: EVT appears to be safe and effective in the management of NVUGIB and may play a role in the management of this challenging condition, especially as a rescue therapy after conventional endoscopic hemostatic technique failure. This novel strategy may reduce the need for repeat endoscopy sessions, decrease associated healthcare costs, and improve outcomes and quality of life for patients with NVUGIB. More studies are warranted to confirm our findings.