Interesting technique to stop bleeding, but please don’t do this!

Thank you for your input Dr. Siau. First, I would refer you to the AGA 2020 CPU for non-variceal bleed Expert Review document, where you'll see this technique of “heating clips” described in the context of ESD hemostasis (it's not a novel one). This technique is not uniformly studied, so we cannot formally endorse or advise against, which is precisely why I referred to it as a “rescue” rather than standard. Second, perforation can happen with essentially all thermal hemostatics, bipolar probes, monopolar coagulation, coagulation graspers etc, so that risk is not unique to a technique. Lastly, the monkey GIF below genuinely made me laugh hahahaha

Thanks! I enjoyed seeing the demonstration, and the coag was expertly delivered - just a short tap and nothing more! Another second on the pedal, in an area with thinner wall, done by someone else, might be a different story, hence my word of caution! Good job and thanks for sharing!

I understand, & thank you for watching 😊 You have the best medical content on this platform, keep it up 👌🏻

When you use diathermy inappropriately 😝

Sure there are cases of success, but would you do this in the caecum / duodenum?

In those regions I am very very careful. Witnessed late perforations caused by APC for bleeding angiectasias in cecum and duodenum. Stomach on the other hand (as in my case) is different story. Overall, good and important point. Agree.

There’s a fine line between an expert like yourself using such an unlicensed technique vs any general endoscopist, hence the caution!

Words of wisdom 🙏

This is insane, he just cooked the bowel wall with extreme heat. Just deploy the clips, that's enough.

Stops the bleeding and makes it the surgeons problem a day later 🤦‍♂️

Ah, bleeding. You ain’t seen bleeding until you’ve seen a postpartum hemorrhage

I advise against this. If the clips are not ideally placed to ligate the vessel, it would not make good sense to energize them in hopes of getting lucky (Is the hope that the thermal spread would be so wide that it would cauterize a nearby vessel?) This other video deployed 40 seconds of monopolar energy (!!!) on a venous ooze which may just have resolved on its own. Unimaginable to me to just burn for so long. A topical agent is a better choice. In my opinion, the best choice is to cauterize first to achieve primary hemostasis and then clip.

You’re right that this needs an element of luck - if the base of the clips are far away from the vessel, one could be cooking for a long time. How the energy disperses or its risk of delayed bleeding are unknown. Also, should a complication happen, it would be hard to defend.

Not a doctor so wondering, did they just used cauterization? And how do they take it out, they didn't leave it in there right?

It’s a bit like passing an electric current down a lightning rod, with the base of it touching the inner layers of the bowel. The depth of energy dispersion is uncontrolled which can lead to thermal injury.

Cool... and yet. For some reason. It reminds me of this...

MacGyver endoscopy at its finest. When the snare tip coag failed, they turned the clips into improvised electrodes and cooked the vessel from the outside. Clever in a crisis… and exactly why the disclaimer belongs in bold. Innovation and perforation risk aren’t mutually exclusive. 🔥⚠️

You could do that, or count to 30 and it will have stopped!

@WelloraHealth True. Often everything you need to do is just wait. Deep thermal injury issue is important one. This was patient with hemophilia. In order to reduce risk, I injected submucosa before applying snare coagulation around clips. @AlmomaniMD

@WelloraHealth @AlmomaniMD If it’s haemophilia, it’s not going to stop 😜🙈

He had good control, why potentiating a hole!

Amazing thread! Keep on with these discussions 👍🏽

If the bleeding still persist after hemoclip, I would prefer to apply hemostatic agents on top.

WTF 😳… yeah, that’s coming back at 3:35am

Why not?

Potential for deep thermal injury ⚡️

Why not directly apply hemoclips??