Endoscopic reinforcement of the anastomosis followed by targeted endoscopic hemostasis for massive upper gastrointestinal bleeding after Whipple's surgery.

Although it occurs infrequently in patients undergoing the procedure, upper gastrointestinal (GI) bleeding after Whipple’s gastropancreaticoduodenectomy can be a devastating complication. Early GI bleeding that occurs within 24 to 48 hours postoperatively is an important cause of morbidity and mortality [1]. Emergency endoscopic procedures performed within a short time after major surgery have traditionally been discouraged on the grounds that insufflation may disrupt the anastomotic site and lead to perforation. Therefore, some experts use interventional radiology with embolization [2]. Herein, we present a novel endoscopic approach and solution to the management of a patient with renal failure and a contraindication to interventional radiology after Whipple's surgery. On the first day after undergoing a Whipple’s gastropancreaticoduodenectomy to resect a tumor of the pancreatic head, a 53-year-old woman developed massive hematemesis and a sudden drop in her hemoglobin level from 9.6 to 5.6g/dL, with associated hypotension and tachycardia. Because her creatinine level was 1.9mg/dL, the administration of intravenous contrast and thus interventional radiology were contraindicated. An emergency esophagogastroduodenoscopy (EGD), performed with minimal carbon dioxide (instead of air) insufflation, showed the stomach to be filled with clots and fresh blood (●" Fig.1a, ●" Video 1). After the stomach had been partially clearedof bloodandclotswith anovertube (Guardus; US Endoscopy, Mentor, Ohio, USA) (●" Video 1), active bleeding was