Hemostatic Powder in Gastrointestinal Tumor Bleeding: Are We There Yet?

We read with great interest the article by Pittayanon et al1Pittayanon R. et al.Gastroenterology. 2023; Google Scholar published in the recent issue of Gastroenterology. We applaud the authors for conducting this key randomized controlled trial with adequate power and strong methodology to compare hemostatic powder (TC-325) with the current standard endoscopic treatment. This study is another step forward in the use of hemostatic powder in the management of patients with gastrointestinal (GI) tumor bleeding. However, a few aspects of this study need further consideration. First, the study reported that patients in the TC-325 group performed better with regard to immediate hemostasis, 14-day rebleeding rates, and 30-day rebleeding rates. It is impressive that the rates of immediate hemostasis (100%) and 30-day rebleeding (2.1%) were lower than those rates reported in previous studies, although there is much variation. In a recent meta-analysis by Kharna et al,2Kharna et al..Google Scholar immediate hemostasis was reported in 94.1% of patients, early rebleeding (<72 hours) in 13.9% of patients, and delayed rebleeding (>72 hours) in 11.4% of patients. Second, it is important to note the demographics of the selected study population, which had an Eastern Cooperative Oncology Group (ECOG) score of ≤2 and a mean Charlson Comorbidity Index of 4.4 in the TC-325 group. The ECOG score has been strongly associated with prognosis in GI cancers,3Demirelli B. et al.Nutr Cancer. 2021; 73: 230-238Crossref Scopus (23) Google Scholar and the lower ECOG score could hypothetically represent patients in earlier stages of cancer, although no previous studies are available to demonstrate such a correlation. Although the current study reported the size of the tumor, it did not report the cancer stage in the patient population. Third, the use of proton pump inhibitors (PPIs) before or after endoscopy was not reported in this study. In day-to-day clinical practice, PPIs are commonly used in patients with upper GI bleeding, including bleeding secondary to tumors. Gastric acid can promote more bleeding by dissolving the clot and digesting the tumor tissue because it lacks the mucosal and epithelial barrier.4Adler D.G. et al.Gastrointest Endosc. 2004; 60: 497-504Abstract Full Text Full Text PDF PubMed Google Scholar In 1 randomized controlled trial that studied the effect of PPIs in patients with inoperable gastric cancer, there was no significant reduction in the incidence of tumor bleeding.5Kim Y.I. et al.J Gastric Cancer. 2017; 17: 120-131Crossref Scopus (8) Google Scholar However, that study was prematurely ended because of a low recruitment rate. Nevertheless, the effectiveness of PPIs in preventing or treating upper GI tumor bleeding remains to be investigated. Overall, this is an important study that attempted to analyze the efficacy of the use of hemostatic powder in patients with active GI tumor bleeding. Future studies are needed to improve the generalizability of the study findings and to assess the economic impact of using hemostatic powder. Hemostatic Powder vs Standard Endoscopic Treatment for Gastrointestinal Tumor Bleeding: A Multicenter Randomized TrialGastroenterologyVol. 165Issue 3PreviewTC-325 hemostatic powder provided better control in active gastrointestinal bleeding from cancer and less recurrent bleeding at 1 month compared to standard endoscopic hemostatic modalities. Full-Text PDF