Post written by Lorenzo Fuccio, MD, and Vito Sansone, MD, from the Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy.

The patient we described is a 87-year old woman, diagnosed with a Klatskin cholangiocarcinoma which was unsuitable for curative treatments, whom obtained a complete biliary drainage only after positioning of an internal-external biliary drainage and 2 uncovered metal stents. After a bout of melena and a sensible drop in hemoglobin level due to the biliary malignancy, her clinical condition was rapidly becoming unstable. In the video, we first show the active bleeding from the biliary tract. No stent placement was possible due to the already positioned one; therefore, we decided to try and obtain hemostasis spraying Hemospray in the common biliary duct, pushing it all the way to the left and right duct confluence, then withdrawing it all the way to the papilla, as is shown. The hemoglobin steadily rose to normal levels, and no symptoms of cholangitis were reported.

The main interest in this procedure resides in the management of a patient with a malignant biliary bleeding, not yet unstable but quickly becoming so. Therefore, a rapid referral to the ERCP room and the execution of a procedure (Hemospray usage) that does not require a particular skill set different from those of an ERCP operator, could avoid an almost invariably fatal event for the patient.

This method is a relatively easy technique, potentially life-saving, and rapidly performed in the setting of an unstable patient that in this case did not have a long-term life expectancy. Hemospray can be a tool even in this extreme setting, when other options are not available and there is not much time.

Obviously there are concerns due to the absence of a direct visualization of the bleeding site and the risk of a iatrogenic obstruction of the common bile duct due to Hemospray. In this case, there were no significant adverse effects from the procedure; however, further research has to be performed.

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