Efficacy of Topical Metal Polyacrylates for the Prevention and Treatment of Bleeding After Retrograde Cholangiopancreatography

Relevance In recent years, local hemostatic agents have become widespread, as their application at the incision area of the major duodenal papilla can stop or prevent bleeding. Aim of study To study the efficacy of topical application of incomplete silver salt of polyacrylic acid (PAAg) (Haemoblock) for the prevention and treatment of bleeding from the papillosphincterotomy area.

Material and methods The prospective study included 211 patients who were hospitalized at the Regional Clinical Hospital in Ryazan from 2020 to 2023. In the main group of patients, for the purpose of hemostasis and prevention of bleeding, the area of the dissected major duodenal papilla was irrigated with 20 ml of an aqueous solution of PAAg. In the control group, irrigation was carried out with 20 ml of 0.9% sodium chloride. The main group included 111 patients (44 men, 67 women, mean age 55.09±20.97), the control group included 100 patients (43 men, 57 women, average age 53.85±20.34).

Results In the main group of patients, bleeding from the MDP incision was observed in 83 cases after papillosphincterotomy, and in 82 cases in the control group. After irrigation with an aqueous solution of PAAg, bleeding from the MDP incision was arrested within 120 seconds in the main group in 70 patients, and in 51 patients in the control group, after irrigation with 0.9% sodium chloride solution. Within 300 seconds from the initiation of irrigation, hemostasis occurred in 12 of the 13 remaining patients in the main group with ongoing bleeding and in 27 of 31 patients in the control group. In two patients in the control group, bleeding was managed in 300 seconds without additional methods of endoscopic hemostasis. The use of additional methods of endoscopic hemostasis due to ongoing bleeding in the main group was required in one patient; the incision area was injected with an adrenaline solution. In the control group, additional endoscopic hemostasis was performed on two patients: in one case, injection with an adrenaline solution, in the other, diathermocoagulation of the incision area of MDP. In the early postoperative period, delayed bleeding was detected in 3 patients of the main group, which was significantly lower than the same indicator in the control group (7 observations).

Conclusions Local application of PAAg for the treatment of early bleeding in papillosphicterotomy showed a significantly faster onset of hemostasis.

1. Revishvili ASh, Olovyannyy VE, Sazhin VP, Markov PV, Gogiya BSh, Gorin DS, et al. Khirurgicheskaya pomoshch’ v Rossiyskoy Federatsii. Moscow; 2023. (in Russ.)

2. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52(2):127–149. PMID: 31863440. https://doi.org/10.1055/a-1075408.

3. Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781–1788. PMID: 17509029. https://doi.org/10.1111/j.1572-0241.2007.01279.x

4. Katsinelos P, Lazaraki G, Chatzimavroudis G, Gkagkalis S, Vasiliadis I, Papaeuthimiou A, et al. Risk factors for therapeutic ERCP-related complications: an analysis of 2,715 cases performed by a single endoscopist. Ann Gastroenterol. 2014;27(1):65–72. PMID: 24714755.

5. Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998;48(1):1–10. PMID: 9684657. https://doi.org/10.1016/s0016-5107(98)70121-x

6. Ferreira LE, Baron TH. Post-sphincterotomy bleeding: who, what, when, and how. Am J Gastroenterol. 2007;102(12):2850–2858. PMID: 18042116. https://doi.org/10.1111/j.1572-0241.2007.01563.x

7. Lesmana CRA, Sandra S, Paramitha MS, Gani RA, Lesmana LA. Endoscopic Management Using Novel Haemostatic Agents for Immediate Bleeding during Endoscopic Retrograde Cholangio-Pancreatography. Can J Gastroenterol Hepatol. 2023;2023:5212580. PMID: 37077936. https://doi.org/10.1155/2023/5212580

8. Matsushita M, Takakuwa H, Shimeno N, Uchida K, Nishio A, Okazaki K. Prophylactic injection of hypertonic saline-epinephrine oral to the papilla for prevention of postsphincterotomy bleeding. J Clin Gastroenterol. 2010;44(8):e167–e170. PMID: 20628312. https://doi.org/10.1097/MCG.0b013e3181e5ceca

9. Kyurdzidi SO, Uvarova EV, Khashchenko EP. The local hemostasis with using polymetalacrylates. Pediatric and Adolescent Reproductive Health. 2022;18(1):41–46 (in Russ.) https://doi.org/10.33029/1816-2134-202218-1-41-46

10. Forbes GL, Merkulova A, Pinheiro A, Lee J, Zeng P, Abdalian S, et al. Poly (acrylic acid) (PAA) is a contact system activator with properties to stop hemorrhage. Thromb Res. 2020;193:142–145. PMID: 32559571. https://doi.org/10.1016/j.thromres.2020.06.011.

11. Ito T, Yamaguchi S, Soga D, Yoshimoto T, Koyama Y. Preparation of a Bioadhesive Poly(Acrylic Acid)/Polyvinylpyrrolidone Complex Gel and Its Clinical Effect on Dental Hemostasis. Gels. 2022;8(8):462. PMID: 35892721. https://doi.org/10.3390/gels8080462

12. Othman M, Aschi A, Gharbi A. Polyacrylic acids-bovine serum albumin complexation: Structure and dynamics. Mater Sci Eng C Mater Biol Appl. 2016;58:316–323. PMID: 26478316. https://doi.org/10.1016/j.msec.2015.08.057.

13. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 2009;70(1):80–88. PMID: 19286178. https://doi.org/10.1016/j.gie.2008.10.039

14. Plotkin AV, Pokrovskij EZH, Voronova GV, Menglet KA. The evaluation of the effectivity of hemostatic activity of Haemoblock for local topical use Haemoblock in different surgical situations. Multicenter clinical trials. The Bulletin of Contemporary Clinical Medicine. 2015;8(1):56–62. (in Russ.)

15. Andreev AI, Ibragimov RA, Kuznetsov MV, Fatykhov AM, Anisimov AY. Clinical experience of using “Haemoblock” hemostatic solution in surgical practice. Kazan Medical Journal. 2015;96(3):451–455. (In Russ.) https://doi.org/10.17750/KMJ2015-451

16. Tereshchenko SG, Plotkin AV, Mecheva LV. Intraorgan use of Hemoblock for prevention and arrest of bleedings in endoscopic excision of gastric polyps. Russian Sklifosovsky Journal Emergency Medical Care. 2019;8(1):30–34. https://doi.org/10.23934/2223-9022-2019-8-1-30-34