Safety and Effectiveness of Endoscopic Band Ligation for Colonic Diverticular Bleeding in Elderly Patients

Abstract

<b><i>Introduction:</i></b> Colonic diverticulosis increases with age, leading to a higher risk of colonic diverticular bleeding (CDB) in the elderly. As life expectancy continues to increase, the need for endoscopic hemostasis for CDB in the elderly can also be expected to increase. However, there have been no reports to date on the feasibility of endoscopic hemostasis for elderly CDB patients. Several recent studies have addressed the effectiveness of endoscopic band ligation (EBL) for CDB. In this study, we evaluate the safety and effectiveness of EBL in elderly CDB patients compared to younger CDB patients. <b><i>Methods:</i></b> We retrospectively analyzed the medical records of consecutive patients treated with EBL for the first time at a tertiary referral center between March 2011 and November 2017. Patients were grouped according to age into those at least 75 years old (the Elderly) and those <75 years old (the Nonelderly). Patient characteristics, technical success, and complications were compared between the two groups. <b><i>Results:</i></b> EBL was performed in 153 patients during the study period (49 Elderly patients and 104 Nonelderly patients). Elderly patients were less likely to be male (<i>p</i> < 0.001) and had lower hemoglobin levels on admission (<i>p</i> < 0.001). Bleeding on the right side of the splenic flexure was observed more frequently in the Nonelderly (<i>p</i> = 0.002). Charlson Comorbidity Index (CCI) and use of antithrombotic agents were significantly higher in the Elderly (<i>p</i> < 0.001 and <i>p</i> < 0.001, respectively). Active bleeding tended to be observed more frequently in the Elderly (<i>p</i> = 0.054), while the difference was not significant. There were no significant differences in the shock index, procedure time, or units of packed red blood cells transfused between the 2 groups. No significant differences in the technical success rate (97.1 vs. 98%, <i>p</i> = 0.76), early rebleeding rate (10.2 vs. 14.4%, <i>p</i> = 0.47), or other complications (2 vs. 1%, <i>p</i> = 0.58) were observed. Perforation and abscess formation were not observed in either group. Female gender, left-sidedness, higher CCI, and lower hemoglobin level were all significantly more frequently observed in the Elderly on multiple logistic regression analysis. <b><i>Discussion/Conclusion:</i></b> EBL may be similarly safe and effective for the treatment of CDB in the elderly as in the nonelderly.

Effectiveness of early colonoscopy in patients with colonic diverticular hemorrhage: Nationwide inpatient analysis in Japan

“…In particular, endoscopic band ligation methods have been reported to be effective in recent years. [35][36][37][38][39] Endoscopic band ligation is mainly reported in Japan and is not widely adopted in other countries. Because endoscopic band ligation was not covered by the national insurance system in Japan until 2018, the study period of this analysis was limited to 2017.…”

“…Numerous methods of hemostasis are currently included in the colonoscopic armamentarium such as epinephrine injection, coagulation, clipping and ligation. In particular, endoscopic band ligation methods have been reported to be effective in recent years 35–39 . Endoscopic band ligation is mainly reported in Japan and is not widely adopted in other countries.…”

Review article: Advances in the management of lower gastrointestinal bleeding

“…This technique is safe and effective, yielding initial haemostasis rates of 93%-100% with a low risk of complications (0%-2%). 55,56 Thermal therapy, including bipolar electrocoagulation, is another effective option for diverticular bleeding located at the neck but should be avoided if the bleeding is located at the base to prevent thermal injury to the thin-walled diverticulum that may lead to perforation. 57 Injection monotherapy with dilute epinephrine is associated with high rates of rebleeding and should be combined with another modality.…”

“…The colonoscope is then repositioned opposite the site of the bleeding, with suctioning of the diverticulum into the cap and deploying a band in a manner similar to variceal band ligation. This technique is safe and effective, yielding initial haemostasis rates of 93%–100% with a low risk of complications (0%–2%) 55,56 …”