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Perry IE, Staursky D, Asfari MM, Vega KJ. Recurrent Duodenal Ulcer After Gastroduodenal Artery Embolization Due to Coil Migration Successfully Removed Endoscopically Resulting in Ulcer Healing. Cureus 2024; 16:e62972. [PMID: 38919859 PMCID: PMC11198983 DOI: 10.7759/cureus.62972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2024] [Indexed: 06/27/2024] Open
Abstract
Transarterial angiographic embolization using coils is an effective, common, and safe treatment for non-variceal upper gastrointestinal bleeding (UGIB) refractory to endoscopic therapy/management. Coil migration is a complication that can lead to rebleeding. Our patient experienced UGIB due to a recurring duodenal ulcer with coil protrusion following previous embolization for a bleeding duodenal ulcer that was not responsive to endoscopic therapy. The ulceration was successfully managed with endoscopic partial coil removal and medical therapy to achieve hemostasis and ulcer healing. Endoscopists should be aware of coil embolization complications and consider endoscopic removal in the appropriate clinical setting.
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Affiliation(s)
- Isaac E Perry
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - Daniel Staursky
- Department of Medicine, Augusta University Medical College of Georgia, Augusta, USA
| | - Mohammad Maysara Asfari
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - Kenneth J Vega
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
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2
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Yu Q, Funaki B, Ahmed O. Twenty years of embolization for acute lower gastrointestinal bleeding: a meta-analysis of rebleeding and ischaemia rates. Br J Radiol 2024; 97:920-932. [PMID: 38364312 PMCID: PMC11075984 DOI: 10.1093/bjr/tqae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2023] [Accepted: 02/07/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Transarterial embolization (TAE) for acute lower gastrointestinal bleeding (LGIB) can be technically challenging due to the compromise between achieving haemostasis and causing tissue ischaemia. The goal of the present study is to determine its technical success, rebleeding, and post-embolization ischaemia rates through meta-analysis of published literature in the last twenty years. METHODS PubMed, Embase, and Cochrane Library databases were queried. Technical success, rebleeding, and ischaemia rates were extracted. Baseline characteristics such as author, publication year, region, study design, embolization material, percentage of superselective embolization were retrieved. Subgroup analysis was performed based on publication time and embolization agent. RESULTS A total of 66 studies including 2121 patients who underwent embolization for acute LGIB were included. Endoscopic management was attempted in 34.5%. The pooled overall technical success, rebleeding, post-embolization ischaemia rates were 97.0%, 20.7%, and 7.5%, respectively. Studies published after 2010 showed higher technical success rates (97.8% vs 95.2%), lower rebleeding rates (18.6% vs 23.4%), and lower ischaemia rates (7.3% vs 9.7%). Compared to microcoils, NBCA was associated with a lower rebleeding rate (9.3% vs 20.8%) at the expense of a higher post-embolization ischaemia rate (9.7% vs 4.0%). Coagulopathy (P = .034), inotropic use (P = .040), and malignancy (P = .002) were predictors of post-embolization rebleeding. Haemorrhagic shock (P < .001), inotropic use (P = .026), malignancy (P < .001), coagulopathy (P = .002), blood transfusion (P < .001), and enteritis (P = .023) were predictors of mortality. Empiric embolization achieved a similarly durable haemostasis rate compared to targeted embolization (23.6% vs 21.1%) but a higher risk of post-embolization ischaemia (14.3% vs 4.7%). CONCLUSION For LGIB, TAE has a favourable technical success rate and low risk of post-embolization ischaemia. Its safety and efficacy profile has increased over the last decade. Compared to microcoils, NBCA seemed to offer a more durable haemostasis rate at the expense of higher ischaemia risk. Due to the heterogeneity of currently available evidence, future prospective and comparative studies are warranted. ADVANCES IN KNOWLEDGE (1) Acute LGIB embolization demonstrate a high technical success rate with acceptable rate of rebleeding and symptomatic ischaemia rates. Most ischaemic stigmata discovered during routine post-embolization colonoscopy were minor. (2) Although NBCA seemed to offer a more durable haemostasis rate, it was also associated with a higher risk of ischaemia compared to microcoils. (3) Coagulopathy, malignant aetiology, and inotropic use were predictors of rebleeding and mortality. (4) Routine post-embolization endoscopy to assess for ischaemia is not indicated.
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Affiliation(s)
- Qian Yu
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, 60637, United States
- Department of Surgery, Cleveland Clinic Florida, Weston, FL, 33331, United States
| | - Brian Funaki
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, 60637, United States
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, 60637, United States
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Toro Tole D, Maurel A, Hedger J, Kwan S, Weber D. A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2024; 28:309-315. [PMID: 38446116 DOI: 10.1016/j.gassur.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting. METHODS This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted. RESULTS The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data. CONCLUSION Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.
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Affiliation(s)
- David Toro Tole
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia.
| | - Amelie Maurel
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Joe Hedger
- School of Medicine, Flinders University, Darwin, Australia.
| | - Sherman Kwan
- Department of Surgery, Royal Perth Hospital, Perth, Australia
| | - Dieter Weber
- Department of Surgery, Royal Perth Hospital, Perth, Australia
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Yu JH, Lee JW, Seo JY, Park JS, Park SJ, Kim SJ, Jang EJ, Park SW, Yeon JW. Factors influencing re-bleeding after trans-arterial embolization for endoscopically unmanageable peptic ulcer bleeding. Scand J Gastroenterol 2024; 59:7-15. [PMID: 37671790 DOI: 10.1080/00365521.2023.2253346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND/AIMS Acute peptic ulcer bleeding is the most common cause of non-variceal upper gastrointestinal bleeding (NVUGIB). Endoscopic hemostasis is the standard treatment. However, various conditions complicate endoscopic hemostasis. Transarterial visceral embolization (TAE) may be helpful as a rescue therapy. This study aimed to investigate the factors associated with rebleeding after TAE. METHODS We retrospectively investigated the records of 156 patients treated with TAE between January 2007 and December 2021. Rebleeding was defined as the presence of melena, hematemesis, or hematochezia, with a fall (>2.0 g/dl) in hemoglobin level or shock after TAE. The primary outcomes were rebleeding rate and 30-day mortality. RESULTS Seventy patients with peptic ulcer bleeding were selected, and rebleeding within a month after TAE occurred in 15 patients (21.4%). Among the patients included in rebleeding group, significant increases were observed in the prevalence of thrombocytopenia (73.3% vs. 16.4%, p<.001) and ulcers >1 cm (93.3% vs 54.5%, p = .014). The mean AIMS65 (albumin, international normalized ratio, mental status, systolic blood pressure, age >65 years) score (2.3 vs 1.4, p = .009) was significantly higher in the rebleeding group. Multivariate logistic analysis revealed that thrombocytopenia (odds ratio 31.92, 95% confidence interval 6.24-270.6, p<.001) and larger ulcer size (odds ratio 27.19, 95% confidence interval 3.27-677.7, p=.010) significantly increased the risk of rebleeding after TAE. CONCLUSION TAE was effective in the treatment of patients with high-risk peptic ulcer bleeding. AIMS65 score was a significant predictor of rebleeding after TAE, and thrombocytopenia and larger ulcer size increased the risk of rebleeding after TAE.
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Affiliation(s)
- Ji Hoon Yu
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Jeong Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Jun-Young Seo
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Ju Sang Park
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Sang Jong Park
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Sang-Jung Kim
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Eun Jeong Jang
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Sang Woon Park
- Division of Gastroenterology, Department of Internal Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
| | - Jae Woo Yeon
- Department of Radiology, Bundang Jesaeng General Hospital, Gyeonggi-do, Republic of Korea
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Garg T, Khorshidi F, Habibollahi P, Shrigiriwar A, Fang A, Sakiani S, Harfouche M, Diaz JJ, Nezami N. How I Do It: Endovascular Management of Acute Nonvariceal Gastrointestinal Bleeding. Semin Intervent Radiol 2023; 40:475-490. [PMID: 37927517 PMCID: PMC10622246 DOI: 10.1055/s-0043-1775850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Tushar Garg
- Division of Vascular and Interventional Radiology, Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fereshteh Khorshidi
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Peiman Habibollahi
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Apurva Shrigiriwar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Fang
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sasan Sakiani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Melike Harfouche
- Division Acute Care Surgery, University of South Florida/Tampa General Hospital, Tampa, Florida
| | - Jose J. Diaz
- Division Acute Care Surgery, University of South Florida/Tampa General Hospital, Tampa, Florida
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
- The Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, Colleague Park, Maryland
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6
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Hatchimonji JS, Mavroudis CL, Friedman A, Kaufman EJ, Syvyk S, Wirtalla CJ, Keele L, Reilly PM, Kelz RR. National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions. J Surg Res 2023; 290:310-318. [PMID: 37329626 PMCID: PMC10330654 DOI: 10.1016/j.jss.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/22/2023] [Accepted: 05/13/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Catherine L Mavroudis
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ari Friedman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Wirtalla
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Keele
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Division of Endocrine and Oncologic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Ephraim Joseph K, Devane AM, Abrams GA. Patient and endoscopic characteristics and clinical outcomes in subjects with non-variceal GI bleeding referred for transarterial embolization: a single-center experience. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3883-3891. [PMID: 36031627 DOI: 10.1007/s00261-022-03650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE Management of massive non-variceal upper gastrointestinal bleeding (NV-UGIB) can be challenging. Transarterial Embolization (TAE) is often the first therapeutic approach when endoscopic therapy fails before surgery. The purpose of this study is to analyze the technical success, and outcome for our patients with an NV-UGIB referred for TAE. METHOD This retrospective analysis included 74 consecutive patients with an NV-UGIB in whom TAE was performed after endoscopic treatment between February 2016 to May 2019 at Prisma Health-Upstate Greenville Memorial Hospital. RESULTS TAE was 98.7% technically successful, with a failure due to severe celiac stenosis, and 85.1% clinically successful. Most TAEs were performed empirically due to lack of extravasation yet were clinically as effective as targeted TAE. We noted a 30-day rebleeding rate and mortality rate of 14.8% and 13.5%, respectively. No complications were reported during the angiographic procedure. Subjects with coagulopathy had more rebleeding (45.5% vs. 17.5%, p = 0.040), and mortality (30% vs 7.4%, p = 0.012). Mortality was also associated with the number of transfused packed blood cells (13.6 ± 8.4 vs. 6.1 ± 5.4, p = 0.020) units and hypotension on admission (27.8% vs. 8.9%, p = 0.043). Interestingly, subjects that underwent left gastric artery (LGA) compared to non-LGA embolization had a higher rebleeding rate of (37.5% vs. 8.6%, p = 0.004) and a greater mortality rate of (37.5% vs. 6.9%, p = 0.002). CONCLUSION TAE is clinically effective in the presence or absence of contrast extravasation to treat uncontrolled or high-risk NV-UGIB. Less effective clinical outcomes regarding TAE targeting the LGA warrant further investigation.
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Affiliation(s)
- Kripalini Ephraim Joseph
- Department of Medicine, Gastroenterology & Liver Center, Prisma Health- Upstate, Greenville, SC, 29605, USA.
| | - Aron M Devane
- Department of Diagnostic and Interventional Radiology, University of South Carolina SOM - Greenville, Prisma Health -Upstate, Greenville, SC, 29605, USA
| | - Gary A Abrams
- Department of Medicine, Gastroenterology & Liver Center, University of South Carolina SOM - Greenville, Prisma Health- Upstate, Greenville, SC, 29605, USA
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Mohammadzadeh N, Nilforoushan N, Ashouri M. A case report of primary gastroesophageal melanoma: Presentation, diagnosis, and surgical approach. Ann Med Surg (Lond) 2022; 80:104195. [PMID: 36045864 PMCID: PMC9422219 DOI: 10.1016/j.amsu.2022.104195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/10/2022] [Accepted: 07/10/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction & importance Gastrointestinal tract is an uncommon site for primary melanoma and its annual incidence is reported 0.47 cases in million. Thus, limited information is available about its medical or surgical treatment, long-term complications of melanoma, and survival rates of each therapeutic method. Case presentation A 47-year-old male was admitted to the emergency department with massive rectorrhagia. with not notable medical history except recent episodes of dyspepsia, melena, malaise and weight loss. Melena and weight loss in a 47-year-old patient is considered as suspicious signs for malignancy and should be investigated. The patient was finally diagnosed with primary gastrointestinal melanoma (PGIM). He underwent trans-hiatal total esophagectomy and proximal gastrectomy with gastric pull-up and lymph node dissection. Immunotherapy with Interferon-α was chosen as adjuvant therapy for this patient. After 10 months, CT scan of abdomen with intravenous and oral contrast revealed multiple foci in liver and spleen consistent with metastasis without any evidence of recurrence at primary tumor excision site. Clinical discussion In this article, we presented a rare case of PGIM with later metastasis in liver and spleen. Gastric pull up was preferred to colon interposition for conduit reconstruction after esophagectomy in this case. However due to the rarity of this category of tumor more information must be gathered on the amount of margin to be resected and long-term outcome of different surgical approaches. Conclusion Based on the poor prognosis of PGIM, less invasive surgical procedure which provides the radical resection and adequate onco-surgical dissection should be considered. Primary gastrointestinal melanoma is very rare subtype of melanoma. Management of primary gastrointestinal melanoma is challenging due to the poor prognosis of this malignant tumor. Less invasive surgical procedure which provides the radical resection and adequate onco-surgical dissection should be considered.
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Affiliation(s)
- Narjes Mohammadzadeh
- Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Nilforoushan
- Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ashouri
- Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Imam Khomeini Hospital Complex, Dr Gharib St, Keshavarz Blvd, Tehran, Postal Code:1419733141, Iran
- Corresponding author. Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Dr Gharib St, Keshavarz Blvd, Tehran, Postal Code:1419733141, Iran.
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9
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Emerging Polymer Materials in Trackable Endovascular Embolization and Cell Delivery: From Hype to Hope. Biomimetics (Basel) 2022; 7:biomimetics7020077. [PMID: 35735593 PMCID: PMC9221114 DOI: 10.3390/biomimetics7020077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/05/2022] [Accepted: 06/08/2022] [Indexed: 02/01/2023] Open
Abstract
Minimally invasive endovascular embolization is a widely used clinical technique used for the occlusion of blood vessels to treat various diseases. Different occlusive agents ranging from gelatin foam to synthetic polymers such as poly(vinyl alcohol) (PVA) have been commercially used for embolization. However, these agents have some drawbacks, such as undesired toxicity and unintended and uncontrolled occlusion. To overcome these issues, several polymer-based embolic systems are under investigation including biocompatible and biodegradable microspheres, gelling liquid embolic with controlled occlusive features, and trackable microspheres with enhanced safety profiles. This review aims to summarize recent advances in current and emerging polymeric materials as embolization agents with varying material architectures. Furthermore, this review also explores the potential of combining injectable embolic agents and cell therapy to achieve more effective embolization with the promise of outstanding results in treating various devastating diseases. Finally, limitations and challenges in developing next-generation multifunctional embolic agents are discussed to promote advancement in this emerging field.
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10
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Seetharaman J, Yadav RR, Srivastava A, Sarma MS, Kumar S, Poddar U, Yachha SK. Gastrointestinal bleeding due to pseudoaneurysms in children. Eur J Pediatr 2022; 181:235-243. [PMID: 34263405 DOI: 10.1007/s00431-021-04201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/04/2021] [Accepted: 07/07/2021] [Indexed: 11/28/2022]
Abstract
Radiological embolization is the treatment of choice in adults with visceral artery pseudoaneurysm (PSA) and gastrointestinal bleeding, but pediatric data is scanty. We analyzed the etiology, clinical presentation, and outcome of radiological intervention in children with PSA of celiac (CA) or superior mesenteric artery (SMA) branches. Electronic records of children with PSA of CA or SMA branches were reviewed and data on clinical and laboratory profile, radiological intervention, and outcome was recorded. Eleven children with PSA (5 boys, 11 [7-17] years) were studied. Etiology was liver abscess (n 4), abdominal trauma (n 3), pancreatitis (n 3), and indeterminate in 1 case. Ten (91%) patients were symptomatic: abdominal pain (10, 91%), hematemesis/melena (9, 81%), and Quincke's triad (1, 9%). One child with pancreatic pseudocyst was diagnosed incidentally on imaging. Doppler ultrasound identified PSA only in 3 cases, while computed tomography angiography (CTA) picked all cases. Children with liver abscess, trauma, and unknown etiology had PSA from CA (right hepatic artery 7, left hepatic artery 1). Of the 3 pancreatitis cases, 2 had PSA from SMA (inferior pancreatico-duodenal artery and ileal branch) and 1 from CA (left gastric artery). Radiological embolization was done in 9 (81%) cases (coil 6, glue 2, both 1), without any complications or failure. One case resolved spontaneously and 1 died pre-intervention. Nine intervened cases were asymptomatic in follow-up [6 (1-24) months].Conclusion: Liver abscess, trauma, and pancreatitis are causes of PSA of CA and SMA branches in children. A majority present with gastrointestinal bleeding and are identified on CTA. Radiological embolization was safe with 100% success. What is Known: • Pseudoaneurysm of visceral artery is an uncommon cause of gastrointestinal bleeding. • Endoluminal intervention is an established and efficacious treatment modality in adults and preferred over surgery. What is New: • Liver abscess, abdominal trauma and pancreatitis are common causes of celiac artery and superior mesenteric artery branch pseudoaneurysm in children and computed tomography angiography has high sensitivity in identifying these pseudoaneurysms. • Minimally invasive radiological angio-embolization, in the hands of trained radiologists, is a safe and successful modality of treatment in children.
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Affiliation(s)
- Jayendra Seetharaman
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, 226014, Uttar Pradesh, India
| | - Rajanikant R Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, 226014, Uttar Pradesh, India.
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, 226014, Uttar Pradesh, India
| | - Sheo Kumar
- Department of Radiodiagnosis, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, 226014, Uttar Pradesh, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, 226014, Uttar Pradesh, India
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Reitano E, de'Angelis N, Bianchi G, Laera L, Spiliopoulos S, Calbi R, Memeo R, Inchingolo R. Current trends and perspectives in interventional radiology for gastrointestinal cancers. World J Radiol 2021; 13:314-326. [PMID: 34786187 PMCID: PMC8567440 DOI: 10.4329/wjr.v13.i10.314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/12/2021] [Accepted: 10/15/2021] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal (GI) cancers often require a multidisciplinary approach involving surgeons, endoscopists, oncologists, and interventional radiologists to diagnose and treat primitive cancers, metastases, and related complications. In this context, interventional radiology (IR) represents a useful minimally-invasive tool allowing to reach lesions that are not easily approachable with other techniques. In the last years, through the development of new devices, IR has become increasingly relevant in the context of a more comprehensive management of the oncologic patient. Arterial embolization, ablative techniques, and gene therapy represent useful and innovative IR tools in GI cancer treatment. Moreover, IR can be useful for the management of GI cancer-related complications, such as bleeding, abscesses, GI obstructions, and neurological pain. The aim of this study is to show the principal IR techniques for the diagnosis and treatment of GI cancers and related complications, as well as to describe the future perspectives of IR in this oncologic field.
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Affiliation(s)
- Elisa Reitano
- Division of General Surgery, Department of Translational Medicine, University of Eastern Piedmont, Novara 28100, Italy
| | - Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Giorgio Bianchi
- Unit of Minimally Invasive and Robotic Digestive Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Letizia Laera
- Department of Oncology, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Athens 12461, Greece
| | - Roberto Calbi
- Department of Radiology, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70124, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreatic-Biliary Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
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Fontana F, Piacentino F, Ossola C, Coppola A, Curti M, Macchi E, De Marchi G, Floridi C, Ierardi AM, Carrafiello G, Segato S, Carcano G, Venturini M. Transcatheter Arterial Embolization in Acute Non-Variceal Gastrointestinal Bleedings: A Ten-Year Single-Center Experience in 91 Patients and Review of the Literature. J Clin Med 2021; 10:jcm10214979. [PMID: 34768505 PMCID: PMC8584454 DOI: 10.3390/jcm10214979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/12/2021] [Accepted: 10/21/2021] [Indexed: 12/13/2022] Open
Abstract
Objective: To report the safety and efficacy of trans-arterial embolization (TAE) for upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) due to different etiologies in 91 patients for ten years. Methods: A retrospective analysis of GIB treated between January 2010 and December 2020 was performed. TAE was performed using different embolic agents (coils, particles, glue, gelatin sponge, and EVOH-based agents). Technical success, secondary technical success, clinical success, and complications were evaluated. Results: Technical success was achieved in 74/91 (81.32%) patients. Seventeen patients (18.68%) required re-intervention. Secondary technical success was achieved in all cases (100.0%). Clinical success was achieved in 81/91 patients (89.01%). No major complications were recorded; overall, minor complications occurred in 20/91 patients. Conclusions: TAE is a technically feasible and safe therapeutic option for patients with GIB from a known or blind anatomic source where endoscopic therapy has failed or is deemed unfeasible.
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Affiliation(s)
- Federico Fontana
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
| | - Christian Ossola
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
- Correspondence: ; Tel.: +39-0332-393609
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
| | - Marco Curti
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
| | - Edoardo Macchi
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
| | - Giuseppe De Marchi
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
| | - Chiara Floridi
- Department of Radiology, University Hospital “Umberto I—Lancisi—Salesi”, 60100 Ancona, Italy;
| | - Anna Maria Ierardi
- Department of Radiology, Foundation IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (A.M.I.); (G.C.)
| | - Gianpaolo Carrafiello
- Department of Radiology, Foundation IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (A.M.I.); (G.C.)
| | - Sergio Segato
- Gastroenterology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy;
| | - Giulio Carcano
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
- Surgery Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
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Lambe G, Courtney M, Judge C, Donlon NE, Ravi N, Ryan M. A case report of endovascular management of delayed upper gastrointestinal bleeding after open esophagectomy for a benign esophageal stricture. Int J Surg Case Rep 2021; 85:106277. [PMID: 34388907 PMCID: PMC8355951 DOI: 10.1016/j.ijscr.2021.106277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Delayed upper gastrointestinal (GI) bleeding is a rare complication of esophagectomy and can be difficult to manage. PRESENTATION A 76-year-old female represented 17 days post open esophagectomy with an unstable upper GI bleed. When control could not be achieved endoscopically, she was transferred to the Radiology Department where a triphasic CT angiogram confirmed active contrast extravasation into the gastric tube. She proceeded to the Interventional Radiology suite where a thoracic angiogram revealed an active arterial bleed from a branch of the thyrocervical trunk. The bleeding vessel was successfully embolised with coils and haemostasis was achieved. DISCUSSION Management options for upper GI bleeding post esophagectomy include medical, endoscopic and endovascular approaches. CONCLUSION Our case represents a rare example of delayed bleeding into a gastric conduit post open esophagectomy for a benign stricture. The case reinforces.
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Affiliation(s)
- Gerard Lambe
- Radiology Department, St. James's Hospital, James's Street, Dublin 8, Ireland,Corresponding author.
| | - Michael Courtney
- Radiology Department, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - Ciaran Judge
- Gastroenterology Department, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - Noel E. Donlon
- Department of Upper GI Surgery, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - Narayanasamy Ravi
- Department of Upper GI Surgery, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - Mark Ryan
- Radiology Department, St. James's Hospital, James's Street, Dublin 8, Ireland
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Vogt K, Aryan L, Stealey S, Hall A, Pereira K, Zustiak SP. Microfluidic fabrication of imageable and resorbable polyethylene glycol microspheres for catheter embolization. J Biomed Mater Res A 2021; 110:131-142. [PMID: 34289220 DOI: 10.1002/jbm.a.37271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/17/2021] [Accepted: 07/07/2021] [Indexed: 11/11/2022]
Abstract
Radiopaque and degradable hydrogel microspheres have a range of potential uses in medicine including proper placement of embolic material during occlusion procedures, acting as inherently embolic materials, and serving as drug carriers that can be located after injection. Current methods for creating radiopaque microspheres are either unable to fully and homogeneously incorporate radiopaque material throughout the microspheres for optimal imaging capabilities, do not result in degradable or fully compressible microspheres, or require elaborate, time-consuming preparation. We used a simple one-step microfluidic method to fabricate imageable, degradable polyethylene glycol (PEG) microspheres of varying sizes with homogenous dispersion of barium sulfate-a biocompatible, high-radiopacity contrast agent. The imageability of the microspheres was characterized using optical microscopy and microcomputed tomography as a function of barium sulfate loading. Microspheres with 20% wt/vol barium sulfate had a mean CT attenuation value of 1,510 HU, similar to that of cortical bone, which should enable visualization with soft tissue. Compared with unloaded microspheres, barium sulfate-loaded ones saw an increase in gelation and degradation times and storage modulus and decrease in swelling. Imageable microspheres retained compressibility and were injectable via catheter. The developed radiopaque, degradable PEG microspheres have various potential uses for interventional radiologists and imaging laboratories.
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Affiliation(s)
- Kyle Vogt
- Biomedical Engineering, Saint Louis University, St Louis, Missouri, USA
| | - Lavanya Aryan
- Biomedical Engineering, Saint Louis University, St Louis, Missouri, USA
| | - Samuel Stealey
- Biomedical Engineering, Saint Louis University, St Louis, Missouri, USA
| | - Andrew Hall
- Biomedical Engineering, Saint Louis University, St Louis, Missouri, USA
| | - Kieth Pereira
- Vascular and Interventional Radiology, Saint Louis University Hospital, St Louis, Missouri, USA
| | - Silviya P Zustiak
- Biomedical Engineering, Saint Louis University, St Louis, Missouri, USA
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Yu Q, Liu C, Collura B, Navuluri R, Patel M, Yu Z, Ahmed O. Prophylactic transcatheter arterial embolization for high-risk ulcers following endoscopic hemostasis: a meta-analysis. World J Emerg Surg 2021; 16:29. [PMID: 34112185 PMCID: PMC8194167 DOI: 10.1186/s13017-021-00371-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
Background To conduct a meta-analysis to assess the safety and efficacy of prophylactic transcatheter arterial embolization (PTAE) for the treatment of high-risk bleeding peptic ulcers after achieving endoscopic hemostasis. Methods PubMed and Cochrane Library were queried for full-text articles published up to December 2019. The following keywords were used: “prophylactic embolization”, “supplement embolization”, “gastrointestinal bleeding”, and “ulcer bleeding”. High-risk ulcers were defined based on endoscopic findings (i.e., large ulcers, Forrest class I-IIb) and/or clinical presentation (i.e., hypotension, decreased hemoglobin during endoscopy). Only comparative studies investigating PTAE versus conservative treatment after achieving endoscopic hemostasis were included. Baseline study characteristics, rebleeding rate, need for surgery, mortality, and PTAE-related complication rates were investigated. Quantitative analyses were performed with Stata 15.1. Results Among the five included original studies, a total of 265 patients received PTAE and 617 were managed conservatively after endoscopy. The rebleeding rate (6.8% vs 14.3%, p = 0.003) and mortality (4.5% vs 8.8%, p = 0.032) of patients from the PTAE group were lower than the control group. PTAE also reduced the cumulative need for future surgical intervention (3.0% vs 14.4%, p = 0.005). The PTAE-related major and minor events were 0.75% and 14.4%, respectively. Conclusion PTAE had therapeutic potentials in reducing rebleeding risk, need for surgical intervention, and morality in high-risk peptic ulcers after achieving endoscopic hemostasis. The embolization-associated adverse events were minimal. Future studies should aim to increase the sample size and resources for performing endovascular interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00371-2.
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Affiliation(s)
- Qian Yu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan City, Shandong Province, China.,Department of General Surgery, Cleveland Clinic Florida, Florida, USA
| | - Chenyu Liu
- School of Medicine, George Washington University, Washington DC, USA
| | | | - Rakesh Navuluri
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Mikin Patel
- Department of Radiology, University of Arizona Medical Center, Tucson, AZ, USA
| | - Zhiyong Yu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan City, Shandong Province, China.
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
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Chevallier O, Comby PO, Guillen K, Pellegrinelli J, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Glélé S, Loffroy R. Efficacy, safety and outcomes of transcatheter arterial embolization with N-butyl cyanoacrylate glue for non-variceal gastrointestinal bleeding: A systematic review and meta-analysis. Diagn Interv Imaging 2021; 102:479-487. [PMID: 33893060 DOI: 10.1016/j.diii.2021.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To perform a systematic review and meta-analysis to determine the safety, efficacy, and outcomes of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) as the single embolic agent for the management of non-variceal upper and lower gastrointestinal bleeding (GIB). MATERIALS AND METHODS A literature search using MEDLINE/PubMed, EMBASE, and SCOPUS databases was performed for studies published from January 1980 to December 2019. Data from eligible studies were extracted and evaluated by two independent reviewers. Exclusion criteria were sample size <5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. Technical success, clinical success, 30-day rebleeding, 30-day overall and major complications, and 30-day mortality were evaluated. The estimated overall rates were calculated with their 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. Heterogeneity across studies was assessed using the Q test and I2 statistic. RESULTS Fifteen studies with 574 patients were included. For upper GIB (331 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (328 of 331 patients) and 88.0% (237 of 300 patients), and 12.5% (69 of 314 patients) and 15.9% (68 of 331 patients), respectively. Thirty-day overall and major complications occurred in 14.3% (28 of 331 patients) and 2.7% (7 of 331 patients) of patients, respectively. For lower GIB (243 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (78 of 78 patients) and 78.0% (145 of 189 patients), and 15.7% (33 of 218 patients) and 12.7% (14 of 78 patients), respectively. Thirty-day overall and major complications occurred in 13.0% (25 of 228 patients) and 8.6% (19 of 228 patients) of patients, respectively. CONCLUSION TAE with NBCA is safe and effective for treating non-variceal GIB, with high clinical success and very low major complication rates.
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Affiliation(s)
- Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Pierre-Olivier Comby
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Kevin Guillen
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Julie Pellegrinelli
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Serge Aho-Glélé
- Department of Epidemiology and Biostatistics, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France.
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Razavilar N, Taleshi JM. Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:477-485. [PMID: 33840425 DOI: 10.1016/j.jval.2020.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.
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Affiliation(s)
- Negin Razavilar
- RAZN Health Decision Modelling LTD, University of Alberta Health Accelerator, Edmonton, Canada; Faculty of Sciences, University of Alberta, Edmonton, Canada.
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Lan T, Tong H, Qian S, Wei B, Huang Z, Wu H, Tan Q, Gao J, Bai S, Gong H, Jiang T, Yang J, Zhang Q, Hu B, Tang C. Prophylactic transcatheter angiographic embolization reduces Forrest IIa ulcer rebleeding: A retrospective study. Medicine (Baltimore) 2021; 100:e23855. [PMID: 33725926 PMCID: PMC7982249 DOI: 10.1097/md.0000000000023855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2020] [Indexed: 02/07/2023] Open
Abstract
The application of transcatheter angiographic embolization (TAE) is controversial in the treatment of ulcer bleeding. This study aims to determine rebleeding risk factors and evaluate the efficacy of prophylactic TAE (p-TAE) following endoscopic hemostasis in rebleeding prevention of Forrest lla ulcers.The medical records of Forrest lla ulcer patients who underwent endoscopic hemostasis (E group) and endoscopic hemostasis plus p-TAE (E + p-TAE group) in West China Hospital from May 2009 to May 2018 were retrospectively reviewed. Baseline characteristics, clinical efficacy, and rebleeding risk factors were analyzed.As a result, a total of 102 patients were included, with 75 and 27 patients in E and E + p-TAE group, respectively. Most of the baseline data in E and E + p-TAE group were similar except for the proportion of protruded non-bleeding visible vessel (NBVV) (E group vs E + p-TAE group, 50.7% vs 74.1%, P = .035). The rebleeding rate of E + p-TAE group (3.7%) was significantly lower than E group (24.0%) (P = .02). The protruded NBVV (OR: 6.896, 95% confidence interval [CI]: 1.532-30.642, P = .01) and employment of p-TAE (OR: 0.038, 95% CI: 0.003-0.448, P = .009) were identified as independent risk factors for Forrest IIa ulcer rebleeding. Additionally, log-rank test indicated the rebleeding occurrence was greatly reduced by p-TAE in patients with protruded NBVVs (P = .006).In conclusion, the protruded NBVV and employment of p-TAE were the independent risk factors tightly associated with rebleeding of Forrest IIa ulcer. P-TAE following endoscopic hemostasis could effectively prevent Forrest IIa ulcer from rebleeding.
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Affiliation(s)
- Tian Lan
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | - Shuaijie Qian
- West China School of Medicine, Sichuan University, Chengdu
| | - Bo Wei
- Department of Gastroenterology
| | | | - Hao Wu
- Department of Gastroenterology
| | | | - Jinhang Gao
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | | | - Ting Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinhui Yang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | | | - Bing Hu
- Department of Gastroenterology
| | - Chengwei Tang
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
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Morgan TG, Carlsson T, Loveday E, Collin N, Collin G, Mezes P, Pullyblank AM. Needle or knife? The role of interventional radiology in managing uncontrolled gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thomas G. Morgan
- Dpeartment of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Eric Loveday
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Neil Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Graham Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Peter Mezes
- Departments of Radiology, Southmead Hospital, Bristol, UK
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Loffroy R, Mouillot T, Bardou M, Chevallier O. Current role of cyanoacrylate glue transcatheter embolization in the treatment of acute nonvariceal gastrointestinal bleeding. Expert Rev Gastroenterol Hepatol 2020; 14:975-984. [PMID: 32602758 DOI: 10.1080/17474124.2020.1790355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal gastrointestinal bleeding (NVGIB) that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer liquid embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the treatment of acute NVGIB. Many embolic agents have been used successfully. However, no guidelines exist about the choice of the best embolic agent which is still controversial. Cyanoacrylate glue has gained acceptance over time. This article aims to address the current role of TAE using cyanoacrylate glue for the treatment of acute NVGIB. AREAS COVERED The authors undertook a literature review of the current evidence on the use of cyanoacrylate glue in treating patients with acute NVGIB. EXPERT OPINION The evidence shows that cyanoacrylate glue is the most clinically useful embolic agent in treating patients with acute NVGIB, despite the need for learning curve, especially in case of coagulopathy. At present, research is ongoing to assess liquid embolic agents in the treatment of patients presenting with acute NVGIB. More research is needed but cyanoacrylate glue show promise for the future.
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Affiliation(s)
- Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital , Dijon, France
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, Clinical Investigation Center, François-Mitterrand University Hospital , Dijon, France
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, Clinical Investigation Center, François-Mitterrand University Hospital , Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital , Dijon, France
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Darmon I, Rebibo L, Diouf M, Chivot C, Riault C, Yzet T, Le Mouel JP, Regimbeau JM. Management of bleeding peptic duodenal ulcer refractory to endoscopic treatment: surgery or transcatheter arterial embolization as first-line therapy? A retrospective single-center study and systematic review. Eur J Trauma Emerg Surg 2020; 46:1025-1035. [PMID: 32246169 DOI: 10.1007/s00068-020-01356-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objective of this study was to compare the results of transcatheter arterial embolization (TAE) with surgery in terms of efficacy in the context of bleeding duodenal ulcer (BDU) refractory to endoscopic treatment. MATERIALS AND METHODS From January 2006 to December 2016, all patients treated for a BDU refractory to endoscopic treatment were included in this observational, comparative, retrospective, single-center study. Primary endpoint was the overall success of treatment of BDU requiring surgical and/or TAE. The secondary endpoints were pre-interventional data, recurrence rates, feasibility of secondary treatment, morbidity and mortality of surgical and radiological treatment, intensive care unit and length of stay. A systematic review of the literature was performed to compare results of surgery and TAE. RESULTS 59 out of 396 patients (14.9%) treated for BDU required embolization and/or surgery: 15 patients underwent surgery (group S) including 7 patients after embolization failure and 44 patients underwent TAE (group TAE). The overall treatment success in intention to treat (85.7% vs 67.3%), per protocol (80% vs 79.5%) and bleeding recurrence rates (20% vs 15.9%) were also identical. Mortality (14.2% vs 15.3%) was similar between the two groups. Our study data were pooled with data from eight published studies and suggest that surgery have significant increased overall success (68.3% vs. 55.4%, p < 0.005). CONCLUSION The overall success rate was in favour of surgery according our meta-analysis. Our single-center study highlights the fact that predictive factors for recurrent bleeding after TAE must be identified to select good candidates for TAE and/or surgery.
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Affiliation(s)
- Ilan Darmon
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Momar Diouf
- Biostatistics Unit, Clinical Research and Innovation Department, Amiens-Picardie University Hospital, 80054, Amiens, France
| | - Cyril Chivot
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Clémentine Riault
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Thierry Yzet
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean Philippe Le Mouel
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France.
- SSPC (Simplification of Surgical Patients Care), Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.
- Service de Chirurgie Digestive, CHU Amiens-Picardie, Site Sud, 1 Rond-Point du Professeur Christian Cabrol, 80054, Amiens Cedex 1, France.
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22
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Ket SN, Sparrow RL, McQuilten ZK, Gibson PR, Brown GJ, Wood EM. Critical peptic ulcer bleeding requiring massive blood transfusion: outcomes of 270 cases. Intern Med J 2020; 51:2042-2050. [DOI: 10.1111/imj.15009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/22/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Shara N. Ket
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Rosemary L. Sparrow
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Zoe K. McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Peter R. Gibson
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Gregor J. Brown
- Department of GastroenterologyAlfred Health Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
- Epworth Hospital Richmond Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
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23
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Yi WS, Garg G, Sava JA. Localization and Definitive Control of Lower Gastrointestinal Bleeding with Angiography and Embolization. Am Surg 2020. [DOI: 10.1177/000313481307900426] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angiography has long been a mainstay of lower gastrointestinal bleeding localization. More recently, angioembolism has been used therapeutically for bleeding control, but there are limited data on its efficacy. This study was designed to evaluate the efficacy of angiography and embolization for localizing and treating lower gastrointestinal bleeding as well evaluate the occurrence of bowel ischemia after embolization. This study is a retrospective descriptive review of all patients undergoing mesenteric angiography at a tertiary hospital over an eight-year period. Clinical data were recorded including patient demographics, causes of bleeding, procedures, and outcomes. Patients were excluded if the cause of bleeding was upper gastrointestinal bleeding or the medical record was missing data. Localization and definitive control of bleeding was the primary end point. One hundred fifty-nine angiograms were performed on 152 patients. Mean age was 72 years. Angiographic localization was successful in 23.7 per cent of patients. Although embolization after angiographic localization achieved definitive control of bleeding in 50 per cent of patients, the success rate was only 8.6 per cent of all patients who had angiography. One patient developed postembolization ischemia requiring laparotomy. Angiographic localization of lower gastrointestinal bleeding is successful in only 23.7 per cent of patients. Definitive hemostasis through embolization was successful in only 8.6 per cent of patients who underwent angiography for lower gastrointestinal bleeding.
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Affiliation(s)
| | - Gaurav Garg
- From Washington Hospital Center, Washington, DC
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24
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Outcomes of Salvage Emergency Surgery for Bleeding Peptic Ulcer. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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25
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Kudaravalli P, Saleem SA, Pendela VS, Arif MO. Rare Complication of Interventional Radiology-guided Arterial Embolization of the Gastroduodenal Artery in the Setting of Acute Gastrointestinal Bleed: Migrated Coils in the Duodenum. Cureus 2020; 12:e7365. [PMID: 32328377 PMCID: PMC7174856 DOI: 10.7759/cureus.7365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 12/30/2022] Open
Abstract
A 91-year-old male presented to the emergency room with hemodynamically significant upper gastrointestinal bleeding. The patient underwent an esophagogastroduodenoscopy (EGD), which showed frank blood in the duodenum interfering with the visualization. Hence, the patient underwent urgent interventional radiology (IR)-guided arteriogram and embolization. An EGD done 48 hours later showed a giant, non-bleeding, cratered duodenal ulcer with a visible vessel and vascular coils partially protruding into the duodenal bulb lumen. The patient had no evidence of bleeding post embolization. The patient presented three months later with abdominal pain. Computed tomography (CT) abdomen showed multiple liver abscesses. IR-guided drainage of abscesses was performed, and the culture grew Streptococcus intermedius. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and barium enema were unremarkable. The patient was treated with a prolonged course of intravenous (IV) antibiotics and recovered without any further issues. IR guided arterial embolization can be lifesaving in cases where GI bleeding cannot be controlled endoscopically, however, it can lead to serious complications, including endovascular coil migration into the gastrointestinal (GI) lumen causing infection and re-bleeding. Endovascular coil migration can occur immediately or several years later, which can result in fatal bleeding and infection. The best approach to prevent and manage migrated endovascular coils in the GI lumen remains unclear.
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Affiliation(s)
- Pujitha Kudaravalli
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Sheikh A Saleem
- Gastroenterology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | | | - Muhammad Osman Arif
- Gastroenterology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
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26
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Wang CY, Hu J, Sheth RA, Oklu R. Emerging Embolic Agents in Endovascular Embolization: An Overview. PROGRESS IN BIOMEDICAL ENGINEERING (BRISTOL, ENGLAND) 2020; 2:012003. [PMID: 34553126 PMCID: PMC8455112 DOI: 10.1088/2516-1091/ab6c7d] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Courtney Y. Wang
- The University of Texas Health Science Center at Houston, McGovern Medical School, 6431 Fannin St., Hourson, TX 77030, USA
| | - Jingjie Hu
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ 85259, USA
| | - Rahul A. Sheth
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77054, USA
| | - Rahmi Oklu
- Division of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ 85259, USA
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27
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Hu J, Albadawi H, Oklu R, Chong BW, Deipolyi AR, Sheth RA, Khademhosseini A. Advances in Biomaterials and Technologies for Vascular Embolization. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1901071. [PMID: 31168915 PMCID: PMC7014563 DOI: 10.1002/adma.201901071] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/24/2019] [Indexed: 05/03/2023]
Abstract
Minimally invasive transcatheter embolization is a common nonsurgical procedure in interventional radiology used for the deliberate occlusion of blood vessels for the treatment of diseased or injured vasculature. A wide variety of embolic agents including metallic coils, calibrated microspheres, and liquids are available for clinical practice. Additionally, advances in biomaterials, such as shape-memory foams, biodegradable polymers, and in situ gelling solutions have led to the development of novel preclinical embolic agents. The aim here is to provide a comprehensive overview of current and emerging technologies in endovascular embolization with respect to devices, materials, mechanisms, and design guidelines. Limitations and challenges in embolic materials are also discussed to promote advancement in the field.
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Affiliation(s)
- Jingjie Hu
- Division of Vascular & Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Brian W Chong
- Departments of Radiology and Neurological Surgery, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Amy R. Deipolyi
- Department of Interventional Radiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, 1275 York Avenue, New York, New York 10065, USA
| | - Rahul A. Sheth
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77054, USA
| | - Ali Khademhosseini
- Department of Bioengineering, Department of Radiological Sciences, Department of Chemical and Biomolecular Engineering, Center for Minimally Invasive Therapeutics, California Nanosystems Institute, University of California, 410 Westwood Plaza, Los Angeles, California 90095, USA
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28
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Endoscopic management of nonvariceal upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101608. [PMID: 31785733 DOI: 10.1016/j.bpg.2019.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
Endoscopic therapy is the mainstay of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB). Injection plus mechanical or thermal therapy continues to be the most widely used option. New endoscopic devices such as the use of an inert powder or a new class of over-the-scope clip system have demonstrated encouraging results as a rescue therapy for difficult hemostasis. Emerging data suggest that Doppler ultrasound-guided endoscopic therapy may improve the outcome of peptic ulcer bleeding. This review sumarizes the recent advances in the management of NVUGIB. With increasing use of anti-platelet agents and anti-coagulants, the management of NVUGIB in patients on anti-thrombotic therapy is also discussed.
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29
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Muhammad A, Awais M, Sayani R, Saeed MA, Qamar S, Rehman A, Baloch NU. Empiric Transcatheter Arterial Embolization for Massive or Recurrent Gastrointestinal Bleeding: Ten-year Experience from a Single Tertiary Care Center. Cureus 2019; 11:e4228. [PMID: 31123650 PMCID: PMC6510562 DOI: 10.7759/cureus.4228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose In patients with massive or recurrent gastrointestinal bleeding (GIB) which is not amenable to endoscopic therapy, angiographic interventions are often employed. We report our ten-year experience of empiric transcatheter arterial embolization (TAE) for patients with massive or recurrent GIB. Methods All patients who had undergone empiric TAE at our hospital between March 2004 and June 2015 were identified using the institutional radiology information system. A retrospective chart review was performed using a structured pro forma. Technical success rate, 30-day clinical success rate, 30-day mortality rate, and rate of procedural complications were computed. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20. Results A total of 32 patients had undergone empiric TAE for GIB during the study period. The median age of subjects was 56 years and two-thirds of them were male (68.7%). Gastroduodenal (n=24), ileocolic (n=3), left gastric (n=2), right gastroepiploic (n=1), and branches of superior and middle rectal arteries (n=1) were embolized using microcoils (n=25), polyvinyl alcohol particles (n=25), and gelatin sponge (n=3)--either alone or in combination. Technical and 30-day clinical success rates were 96.9% (31/32) and 71.9% (23/32), respectively. The 30-day mortality rate for our cohort was 21.9% (7/32). One patient developed re-bleeding at two days after the initial procedure and required repeat embolization. Coil migration (n=3) and access site hematoma (n=1) were the observed procedural complications. Conclusion Empiric TAE can be a useful treatment option for selected patients with massive or recurrent GIB that is not amenable to endoscopic therapy.
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Affiliation(s)
| | | | - Raza Sayani
- Radiology, Aga Khan University Hospital, Karachi, PAK
| | | | - Saqib Qamar
- Radiology, Aga Khan University Hospital, Karachi, PAK
| | - Abdul Rehman
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
| | - Noor U Baloch
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
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30
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Ye T, Yang L, Wang Q, Liu J, Zhou C, Zheng C, Xiong B. Analysis of negative DSA findings in patients with acute nonvariceal gastrointestinal bleeding: A retrospective study of 133 patients. J Interv Med 2019; 2:27-30. [PMID: 34805866 PMCID: PMC8562268 DOI: 10.1016/j.jimed.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Purpose To analyze causes of acute nonvariceal gastrointestinal bleeding (GIB) with negative digital subtraction angiography (DSA) results. Materials and methods The clinical and follow-up data of 133 patients - recruited between February 2008 and November 2016 - with acute nonvariceal GIB and negative DSA results were included in this study. DSA results, diagnoses, and clinical outcomes were recorded. Results The DSA results were negative in all 133 patients. Of the total, 55 patients (41.4%) chose to undergo surgery and 78 (58.6%) opted for conservative treatment. Within 30 days, there was no significant difference in the rebleeding or mortality rates between the two groups (P < .05). Of all 133 patients, 76 (57.1%) had upper GIB and 57 (42.9%) had lower GIB; within 30 days, the rebleeding rate in the upper GIB group (44.7%, 34/76) was significantly higher than that in the lower GIB group (26.3%, 15/57). There was no significant statistical difference (P < .05) within 30 days in the mortality rates between the two groups. Among patients with upper GIB, 26 (34.2%, 26/76) opted to undergo surgery and 50 (65.8%, 50/76) chose conservative treatment; within 30 days, the rebleeding rate in the group that chose surgery (61.5%, 16/26) was higher than that in the conservative treatment group (36%, 18/50). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups. Among the patients with lower GIB, 29 (50.9%, 29/57) chose to undergo surgery and 28 (49.1%, 28/57) opted for conservative treatment. Within 30 days, the rebleeding rate in the surgery group (13.8%, 4/29) was lower than that in conservative treatment group (39.3%, 11/28). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups. Sixteen patients underwent prophylactic arterial embolization; in 6 of these, bleeding was stopped for 30 days. DSA was then repeated in these 16 patients after a median interval of 1 day, and a positive bleeding site was found in 9 of the 16. Causes of bleeding were found in 111 patients by surgery or endoscopy, whereas the causes remained unknown in 22 patients. Conclusions Upper GIB with negative DSA results was stopped by conservative treatment, whereas lower GIB required surgery to detect the culprit bleeding site. Rare causes of GIB should be considered and appropriate management selected in a timely manner in order to detect unusual causes.
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31
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Tarasconi A, Baiocchi GL, Pattonieri V, Perrone G, Abongwa HK, Molfino S, Portolani N, Sartelli M, Di Saverio S, Heyer A, Ansaloni L, Coccolini F, Catena F. Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis. World J Emerg Surg 2019; 14:3. [PMID: 30733822 PMCID: PMC6359767 DOI: 10.1186/s13017-019-0223-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background Nowadays, very few patients with non-variceal upper gastrointestinal bleeding fail endoscopic hemostasis (refractory NVUGIB). This subset of patients poses a clinical dilemma: should they be operated on or referred to transcatheter arterial embolization (TAE)? Objectives To carry out a systematic review of the literature and to perform a meta-analysis of studies that directly compare TAE and surgery in patients with refractory NVUGIB. Materials and methods We searched PubMed, Ovid MEDLINE, and Embase. A combination of the MeSH terms “gastrointestinal bleeding”; “gastrointestinal hemorrhage”; “embolization”; “embolization, therapeutic”; and “surgery” were used ((“gastrointestinal bleeding” or “gastrointestinal hemorrhage”) and (“embolization” or “embolization, therapeutic”) and “surgery”)). The search was performed in June 2018. Studies were retrieved and relevant studies were identified after reading the study title and abstract. Bibliographies of the selected studies were also examined. Statistical analysis was performed using RevMan software. Outcomes considered were all-cause mortality, rebleeding rate, complication rate, and the need for further intervention. Results Eight hundred fifty-six abstracts were found. Only 13 studies were included for a total of 1077 patients (TAE group 427, surgery group 650). All selected papers were non-randomized studies: ten were single-center and two were double-center retrospective comparative studies, while only one was a multicenter prospective cohort study. No comparative randomized clinical trial is reported in the literature. Mortality. Pooled data (1077 patients) showed a tendency toward improved mortality rates after TAE, but this trend was not statistically significant (OD = 0.77; 95% CI 0.50, 1.18; P = 0.05; I2 = 43% [random effects]). Significant heterogeneity was found among the studies. Rebleeding rate. Pooled data (865 patients, 211 events) showed that the incidence of rebleeding was significantly higher for patients undergoing TAE (OD = 2.44; 95% CI 1.77, 3.36; P = 0.41; I2 = 4% [fixed effects]). Complication rate. Pooling of the data (487 patients, 206 events) showed a sharp reduction of complications after TAE when compared with surgery (OD = 0.45; 95% CI 0.30, 0.47; P = 0.24; I2 = 26% [fixed effects]). Need for further intervention. Pooled data (698 patients, 165 events) revealed a significant reduction of further intervention in the surgery group (OD = 2.13; 95% CI 1.21, 3.77; P = 0.02; I2 = 56% [random effects]). A great degree of heterogeneity was found among the studies. Conclusions The present study shows that TAE is a safe and effective procedure; when compared to surgery, TAE exhibits a higher rebleeding rate, but this tendency does not affect the clinical outcome as shown by the comparison of mortality rates (slight drift toward lower mortality for patients undergoing TAE). The present study suggests that TAE could be a viable option for the first-line therapy of refractory NVUGIB and sets the foundation for the design of future randomized clinical trials. Limitations The retrospective nature of the majority of included studies leads to selection bias. Furthermore, the decision of whether to proceed with surgery or refer to TAE was made on a case-by-case basis by each attending surgeon. Thus, external validity is low. Another limitation involves the variability in etiology of the refractory bleeding. TAE techniques and surgical procedure also differ consistently between different studies. Frame time for mortality detection differs between the studies. These limitations do not impair the power of the present study that represents the largest and most recent meta-analysis currently available.
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Affiliation(s)
- Antonio Tarasconi
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gian Luca Baiocchi
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Vittoria Pattonieri
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gennaro Perrone
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Hariscine Keng Abongwa
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Sarah Molfino
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Nazario Portolani
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | | | - Salomone Di Saverio
- 4Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arianna Heyer
- 5Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Luca Ansaloni
- 6General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 6General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
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Anami S, Minamiguchi H, Shibata N, Koyama T, Sato H, Ikoma A, Nakai M, Yamagami T, Sonomura T. Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report. World J Clin Cases 2018; 6:1012-1017. [PMID: 30568956 PMCID: PMC6288507 DOI: 10.12998/wjcc.v6.i15.1012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.
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Affiliation(s)
- Shimpei Anami
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Hiroki Minamiguchi
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
- Department of Radiology, Kochi Medical School Kochi University, Nankokushi, Kochi 783-8505, Japan
| | - Naoaki Shibata
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Takao Koyama
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Hirotatsu Sato
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Takuji Yamagami
- Department of Radiology, Kochi Medical School Kochi University, Nankokushi, Kochi 783-8505, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
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Abstract
The management of peptic ulcer disease has radically changed over the last 40 years from primarily surgical treatment to medical therapy nearly eliminating the need for elective surgery in these patients. Although there has been a decline in patients requiring acute surgical intervention for complications of peptic ulcer disease (perforation, bleeding, and obstruction), these patients still make up a significant proportion of hospital admissions every year. The modern acute care surgeon must have significant knowledge of the multiple treatment modalities used to appropriately care for these patients.
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Lee HH, Oh JS, Park JM, Chun HJ, Kim TH, Cheung DY, Lee BI, Cho YS, Choi MG. Transcatheter embolization effectively controls acute lower gastrointestinal bleeding without localizing bleeding site prior to angiography. Scand J Gastroenterol 2018; 53:1089-1096. [PMID: 30354855 DOI: 10.1080/00365521.2018.1501512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Colonoscopy is preferred for treatment of lower gastrointestinal bleeding (LGIB). However, several conditions such as poor bowel preparation can cause endoscopic failure, leading to surgery or transcatheter therapy as alternative options. We aimed to assess the efficacy and safety of transcatheter arterial embolization (TAE) for LGIB in patients with endoscopic failure. METHODS Between January 2005 and June 2015, 93 consecutive patients with acute LGIB underwent visceral angiography at three academic hospitals. Among them, a total of 52 patients were treated with TAE for LGIB and analyzed. Technical success, complications and 30-day rebleeding and mortality after TAE were investigated retrospectively in patients with and without localization of LGIB. RESULTS Technical success of TAE was achieved in all patients. After TAE, 30-day rebleeding and mortality rate were 27% (14/52) and 29% (15/52), respectively. TAE was performed without localizing bleeding site in 32 of 52 patients (62%). Between patients with and without localized bleeding site, there were no significant differences in 30-day rebleeding rate (25% vs. 28%) and mortality rate (15% vs. 38%). Causes of death were mostly unrelated to bleeding. Only two cases of bowel infarction occurred after TAE in patients without bleeding site localization. Rebleeding could be predicted if the patient received more than six units of packed red blood cell transfusion before TAE in multivariate analysis. CONCLUSIONS TAE can be an effective treatment for LGIB even without localizing bleeding site.
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Affiliation(s)
- Han Hee Lee
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Jung Suk Oh
- c Department of Radiology , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Jae Myung Park
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Ho Jong Chun
- c Department of Radiology , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Tae Ho Kim
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Dae Young Cheung
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Bo-In Lee
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Young-Seok Cho
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Myung-Gyu Choi
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
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van Zyl TJ, Murphy PB, Allen L, Parry NG, Leslie K, Vogt KN. Beyond just the operating room: characterizing the complete caseload of a tertiary acute care surgery service. Can J Surg 2018; 61:7417. [PMID: 29806803 DOI: 10.1503/cjs.007417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case-mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions. METHODS In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured. RESULTS The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (p < 0.001). Bowel obstruction (37 patients [21.0%]) was the most common reason for admission, followed by wound/abscess (24 [13.6%), biliary disease (24 [13.6%]) and appendiceal disease (23 [13.1%]). Rates of 30-day return to the emergency department and readmission were 17.0% and 9.1%, respectively, and the in-hospital mortality rate was 1.7%. CONCLUSION Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively.
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Affiliation(s)
- Theunis J van Zyl
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Patrick B Murphy
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Laura Allen
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Neil G Parry
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Ken Leslie
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Kelly N Vogt
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
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Kuyumcu G, Latich I, Hardman RL, Fine GC, Oklu R, Quencer KB. Gastrodoudenal Embolization: Indications, Technical Pearls, and Outcomes. J Clin Med 2018; 7:jcm7050101. [PMID: 29724061 PMCID: PMC5977140 DOI: 10.3390/jcm7050101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 01/06/2023] Open
Abstract
The gastroduodenal artery (GDA) is frequently embolized in cases of upper GI bleed that has failed endoscopic therapy. Additionally, it may be done for GDA pseudoaneurysms or as an adjunctive procedure prior to Yttrim-90 (Y90) treatment of hepatic tumors. This clinical review will summarize anatomy and embryology of the GDA, indications, outcomes and complications of GDA embolization.
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Affiliation(s)
- Gokhan Kuyumcu
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale University School of Medicine, New Haven, CT 06519, USA.
| | - Igor Latich
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale University School of Medicine, New Haven, CT 06519, USA.
| | - Rulon L Hardman
- Division of Interventional Radiology, University of Utah Department of Radiology, Salt Lake City, UT 84108, USA.
| | - Gabriel C Fine
- Division of Interventional Radiology, University of Utah Department of Radiology, Salt Lake City, UT 84108, USA.
| | - Rahmi Oklu
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Keith B Quencer
- Division of Interventional Radiology, University of Utah Department of Radiology, Salt Lake City, UT 84108, USA.
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Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
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Kaminskis A, Ivanova P, Ponomarjova S, Mukans M, Boka V, Pupelis G. Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding. Gastroenterology Res 2018; 10:339-346. [PMID: 29317941 PMCID: PMC5755635 DOI: 10.14740/gr909w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/19/2017] [Indexed: 12/11/2022] Open
Abstract
Background Transarterial embolization (TAE) is an alternative procedure to repeat endoscopy or surgical intervention in the case of re-bleeding after primary endoscopic treatment. The aim of the study was to assess the Rockall score as a criterion for TAE in the case of re-bleeding after endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Methods Out of the 673 patients who underwent emergent endoscopic hemostasis due to NVUGIB, 111 had a high risk of re-bleeding having a Forrest I-IIb ulcer and the Rockall score ≥ 5. From 111 patients, 37 accepted preventive TAE (PE+ group). The control group consisted of 74 patients who underwent standard treatment (PE- group). Results There were no differences in the demographic status between both groups, nor in the main clinical data on admission. The performance of TAE resulted in a significantly lower re-bleeding rate (1 (4.8%) vs. 11 (33%), P = 0.018). No patient who underwent TAE with the Rockall score ≥ 7 required surgery, resulting in only one re-bleeding episode (P = 0.004). Mortality reached 5% and 11% in the PE+ and PE- groups accordingly. Conclusion The Rockall score ≥ 7 could be a reliable predictor of re-bleeding after primary endoscopic hemostasis as one criterion for the selection of indications for preventive TAE.
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Affiliation(s)
- Aleksejs Kaminskis
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Patricija Ivanova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Sanita Ponomarjova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradins University, Riga, Latvia
| | | | - Guntars Pupelis
- Surgical Department, Riga East University Hospital, Riga, Latvia
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Transcatheter arterial embolization for upper gastrointestinal tract bleeding. Wideochir Inne Tech Maloinwazyjne 2017; 12:385-393. [PMID: 29362654 PMCID: PMC5776486 DOI: 10.5114/wiitm.2017.72319] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/15/2017] [Indexed: 12/27/2022] Open
Abstract
Introduction Transcatheter arterial embolization is a possible treatment for patients with recurrent bleeding from the upper gastrointestinal tract after failed endoscopic management and is also an alternative to surgical treatment. Aim To analyze the outcomes of transcatheter arterial embolization and identify the clinical and technical factors that influenced the rates of morbidity and mortality. Material and methods A retrospective analysis was carried out, based on the data of 36 patients who underwent transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding in 2013 to 2015 in our center. An analysis was performed between early rebleeding rates, mortality and the following factors: patient sex, age, number of units of packed red blood cells and packed plasma administered to the patients, length of hospital stay, therapeutic or prophylactic embolization. Results The technical success rate of the embolization procedure was 100%. There were 15 (41.70%) therapeutic embolizations and 21 (58.3%) prophylactic embolizations. There was a 77.8% clinical success rate. Following embolization, 10 (27.80%) patients had repeated bleeding and 9 (25.0%) patients died. Significant associations were found between rebleeding and prophylactic embolization (OR = 10.53; p = 0.04) and between mortality and prophylactic embolization (OR = 10.53; p = 0.04) and units of packed red blood cells (OR = 1.25; p < 0.01). Conclusions In our experience, transcatheter arterial embolization is a safe treatment method for acute nonvariceal upper gastrointestinal bleeding and a possible alternative to surgery for high-risk patients.
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Werner DJ, Manner H, Nguyen-Tat M, Kloeckner R, Kiesslich R, Abusalim N, Rey JW. Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature. United European Gastroenterol J 2017; 6:337-342. [PMID: 29774146 DOI: 10.1177/2050640617746299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022] Open
Abstract
Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.
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Affiliation(s)
- David J Werner
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Hendrik Manner
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Marc Nguyen-Tat
- First Department of Internal Medicine, University Medical Center, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz, Germany
| | - Ralf Kiesslich
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Nael Abusalim
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Johannes W Rey
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
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Hur S, Jae HJ, Lee H, Lee M, Kim HC, Chung JW. Superselective Embolization for Arterial Upper Gastrointestinal Bleeding Using N-Butyl Cyanoacrylate: A Single-Center Experience in 152 Patients. J Vasc Interv Radiol 2017; 28:1673-1680. [PMID: 28935474 DOI: 10.1016/j.jvir.2017.07.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/11/2017] [Accepted: 07/24/2017] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To evaluate 30-day safety and efficacy of superselective embolization for arterial upper gastrointestinal bleeding (UGIB) using N-butyl cyanoacrylate (NBCA). MATERIALS AND METHODS This single-center retrospective 10-year study included 152 consecutive patients with UGIB (gastric, n = 74; duodenal, n = 78) who underwent embolization with NBCA for angiographically positive arterial bleeding. The primary endpoint was clinical success rate defined as achievement of hemostasis without rebleeding or UGIB-related mortality within 30 days after embolization. Mean systolic blood pressure and heart rate were 121.2 mm Hg ± 27.4 and 97.9 beats/minute ± 22.5; 31.1% of patients needed intravenous inotropes, and 36.6% had coagulopathy. The etiology of bleeding was ulcer (80.3%) or iatrogenic injury (19.7%). Statistical analysis was performed to identify predictive factors for outcomes. RESULTS Technical success rate was 100%. Clinical success, 1-month mortality, and major complication rates were 70.4%, 22.4%, and 0.7%. There were significant differences in the clinical success rates between gastric and duodenal bleeding (79.4% vs 62.2%; P = .025). The need for intravenous inotropes at the time of embolization was a significant negative predictive factor in both gastric (odds ratio [OR] = 0.091, P = .004) and duodenal (OR = 0.156, P = .002) bleeding. The use of a microcatheter with a smaller tip (2 F) was associated with better outcomes in duodenal bleeding (OR = 7.389, P = .005). CONCLUSIONS Superselective embolization using NBCA is safe and effective for angiographically positive arterial UGIB.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, Korea.
| | - Hyukjoon Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, Korea
| | - Myungsu Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, Korea
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Han Q, Qian C, Gabriel G, Krohmer S, Raissi D. Gastrointestinal bleeding from supraduodenal artery with aberrant origin. Radiol Case Rep 2017; 12:526-528. [PMID: 28828118 PMCID: PMC5551961 DOI: 10.1016/j.radcr.2017.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/18/2017] [Indexed: 11/26/2022] Open
Abstract
Angiography and endovascular embolization play an important role in controlling acute arterial upper gastrointestinal hemorrhage, particularly when endoscopic intervention fails to do so. In our case, the patient presented with recurrent life-threatening bleed in spite of multiple prior endoscopic interventions and gastroduodenal artery embolization. Our teaching points focus on the role of angiography in acute upper gastrointestinal bleed and when to conduct empiric embolization, while reviewing the supraduodenal artery as an atypical but important potential culprit for refractory upper gastrointestinal bleed.
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ACR Appropriateness Criteria ® Nonvariceal Upper Gastrointestinal Bleeding. J Am Coll Radiol 2017; 14:S177-S188. [PMID: 28473074 DOI: 10.1016/j.jacr.2017.02.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 12/18/2022]
Abstract
Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Nykänen T, Peltola E, Kylänpää L, Udd M. Bleeding gastric and duodenal ulcers: case-control study comparing angioembolization and surgery. Scand J Gastroenterol 2017; 52:523-530. [PMID: 28270041 DOI: 10.1080/00365521.2017.1288756] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To compare the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) and surgery in the treatment of bleeding gastric and duodenal ulcers (BGDUs). MATERIALS AND METHODS The study group comprised patients receiving TAE or surgery for BGDUs after failed endoscopic hemostasis in Helsinki University Hospital (HUH) during 2000-2015. Hospital medical records provided study data. 30-d mortality and rebleeding rates were the primary outcomes. Postoperative complications, blood transfusion rate, and the durations of intensive care and hospital admissions were the secondary outcomes. RESULTS During the study period, BGDUs lead to 1583 hospital admissions. TAE or surgery was necessary on 85 (5.4%) patients, 43 receiving surgery and 42 TAE. Out of 42, 16 received prophylactic TAE. Two underwent angiography and TAE to localize the bleeding. The remaining 24 received TAE for active or recurrent bleeding after endoscopy. The comparison of TAE (n = 24) and surgery (n = 43) included only patients with active or recurrent bleeding. Mortality rate was 12.5% after TAE and 25.6% after surgery (p = 0.347). Rebleeding rate was 25% after TAE and 16.3% after surgery (p = 0.641). Postprocedural complications were less frequent after TAE than surgery (37.5 vs. 67.4%, p = 0.018). Other secondary outcomes did not differ. Out of 85 procedures, 14 (16.5%) took place between midnight and 8 a.m., all nighttime interventions being surgeries. CONCLUSIONS Mortality and rebleeding rates did not differ between TAE and surgery. With less postoperative complications, TAE should be the preferred hemostatic method when endoscopy fails.
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Affiliation(s)
- Taina Nykänen
- a Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Erno Peltola
- b Department of Radiology, Helsinki Medical Imaging Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Leena Kylänpää
- c Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Marianne Udd
- d Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Transcatheter Arterial Embolization of Gastrointestinal Bleeding with N-Butyl Cyanoacrylate: A Systematic Review and Meta-Analysis of Safety and Efficacy. J Vasc Interv Radiol 2017; 28:522-531.e5. [PMID: 28256302 DOI: 10.1016/j.jvir.2016.12.1220] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for the treatment of gastrointestinal (GI) bleeding via a meta-analysis of published studies. MATERIALS AND METHODS The MEDLINE/PubMed and EMBASE databases were searched for English-language studies from January 1990 to March 2016 that included patients with nonvariceal GI bleeding treated with transcatheter arterial embolization with NBCA with or without other embolic agents. The exclusion criteria were a sample size of < 5, no extractable data, or data included in subsequent articles or duplicate reports. RESULTS The cases of 440 patients (mean age, 63.8 y ± 14.3; 319 men [72.5%] and 121 women [27.5%]) from 15 studies were evaluated. Of these patients, 261 (59.3%) had upper GI bleeding (UGIB) and 179 (40.7%) had lower GI bleeding (LGIB). Technical success was achieved in 99.2% of patients with UGIB (259 of 261) and 97.8% of those with LGIB (175 of 179). The pooled clinical success and major complication rates in the 259 patients with UGIB in whom technical success was achieved were 82.1% (95% confidence interval [CI], 73.0%-88.6%; P = 0.058; I2 = 42.7%) and 5.4% (95% CI, 2.8%-10.0%; P = 0.427; I2 = 0.0%), respectively, and those in the 175 patients with LGIB in whom technical success was achieved were 86.1% (95% CI, 79.9%-90.6%; P = 0.454; I2 = 0.0%) and 6.1% (95% CI, 3.1%-11.6%; P = 0.382; I2 = 4.4%), respectively. CONCLUSIONS Transcatheter arterial embolization with NBCA is safe and effective for the treatment of GI bleeding.
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Relevance of surgery in patients with non-variceal upper gastrointestinal bleeding. Langenbecks Arch Surg 2017; 402:509-519. [DOI: 10.1007/s00423-017-1552-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
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Preventive transarterial embolization in upper nonvariceal gastrointestinal bleeding. World J Emerg Surg 2017; 12:3. [PMID: 28101125 PMCID: PMC5237324 DOI: 10.1186/s13017-016-0114-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/27/2016] [Indexed: 12/19/2022] Open
Abstract
Background Transarterial embolization (TAE) is a therapeutic option for patients with a high risk of recurrent bleeding after endoscopic haemostasis. The aim of our prospective study was a preliminary assessment of the safety, efficacy, and clinical outcomes following preventive TAE in patients with non-variceal acute upper gastrointestinal bleeding (NVUGIB) with a high risk of recurrent bleeding after endoscopic haemostasis. Methods Preventive visceral angiography and TAE were performed after endoscopic haemostasis on patients with NVUGIB who were at a high risk of recurrent bleeding (PE+ group). The comparison group consisted of similar patients who only underwent endoscopic haemostasis, without preventive TAE (PE− group). The technical success of preventive TAE, the completeness of haemostasis, the incidence of rebleeding and the need for surgical intervention and the main outcomes were compared between the groups. Results The PE+ group consisted of 25 patients, and the PE− group of 50 patients, similar in age (median age 66 vs. 63 years), gender and comorbid conditions. The ulcer size at endoscopy was not significantly different (median of 152 mm vs. 127 mm). The most frequent were Forest II type ulcers, 44% in both groups. The distribution of the Forest grade was even. The median haemoglobin on admission was 8, 2 g/dl vs. 8,7 g/dl, p = 0,482, erythrocyte count was 2,7 × 1012/L vs. 2,9 × 1012/L, p = 0,727. The shock index and Rockall scores were similar, as well as and transfusion – on average, four units of packed red blood cells for the majority of patients in both groups, however, significantly more fresh frozen plasma was transfused in the PE− group, p = 0,013. The rebleeding rate was similar, while surgical treatment was needed notably more often in the PE- group, 8% vs. 35% accordingly, p = 0,012. The median ICU stay was 3 days, hospital stay – 6 days vs. 9 days, p = 0.079. The overall mortality reached 20%; in the PE+ group it was 4%, not reaching a statistically significant difference. Conclusion Preventive TAE is a feasible, safe and effective minimally invasive type of haemostasis decreasing the risk of repeated bleeding and preparing the patient for the definitive surgical intervention when indicated.
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MDCT angiography and transcatheter embolization in management of acute gastrointestinal bleeding. ALEXANDRIA JOURNAL OF MEDICINE 2016. [DOI: 10.1016/j.ajme.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Roy A, Kim M, Hawes R, Varadarajulu S. The clinical and cost implications of failed endoscopic hemostasis in gastroduodenal ulcer bleeding. United European Gastroenterol J 2016; 5:359-364. [PMID: 28507747 DOI: 10.1177/2050640616663570] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/19/2016] [Indexed: 11/16/2022] Open
Abstract
AIM The aim of this article is to evaluate the clinical and cost implications of failed endoscopic hemostasis in patients with gastroduodenal ulcer bleeding. METHODS A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) file was conducted to identify all hospitalizations for gastroduodenal ulcer bleeding in the year 2012. The main outcome measures were to compare all-cause mortality, total length of hospital stay (LOS), hospital costs and payment between patients managed with one upper gastrointestinal (UGI) endoscopy versus more than one UGI endoscopy or requiring interventional radiology-guided hemostasis (IRH) or surgery after failed endoscopic attempt. RESULTS The MedPAR claims data evaluated 13,501 hospitalizations, of which 12,242 (90.6%) reported one UGI endoscopy, 817 (6.05%) reported >1 UGI endoscopy, 303 (2.24%) reported IRH after failed endoscopy and 139 (1.03%) reported surgeries after failed endoscopy. All cause-mortality was significantly lower for patients who underwent only one UGI endoscopy (3%) compared to patients requiring >1 endoscopy (6%), IRH (9%) or surgery (14%), p < 0.0001. The median LOS was significantly lower for patients who underwent only one UGI endoscopy (four days) compared to patients requiring >1 endoscopy (eight days), IRH (nine days) or surgery (15 days), p < 0.0001. The median hospital costs were significantly lower for patients who underwent one UGI endoscopy ($10,518) compared to patients requiring >1 endoscopy ($20,055), IRH ($34,730) or surgery ($47,589), p < 0.0001. CONCLUSIONS Failure to achieve hemostasis at the index endoscopy has significant clinical and cost implications. When feasible, a repeat endoscopy must be attempted followed by IRH. Surgery should preferably be reserved as a last resort for patients who fail other treatment measures.
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Affiliation(s)
- Ann Roy
- Health Economics and Reimbursement, Boston Scientific Corporation, Natick, MA, USA
| | - Micheline Kim
- Health Economics and Reimbursement, Boston Scientific Corporation, Natick, MA, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA
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Evaluation of Superselective Transcatheter Arterial Embolization with n-Butyl Cyanoacrylate in Treating Lower Gastrointestinal Bleeding: A Retrospective Study on Seven Cases. Gastroenterol Res Pract 2016; 2016:8384349. [PMID: 27528867 PMCID: PMC4978829 DOI: 10.1155/2016/8384349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/19/2016] [Indexed: 12/20/2022] Open
Abstract
Background. To investigate the safety and efficacy of superselective transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate (NBCA) in treating lower gastrointestinal bleeding caused by angiodysplasia. Methods. A retrospective study was performed to evaluate the clinical data of the patients with lower gastrointestinal bleeding caused by angiodysplasia. The patients were treated with superselective TAE with NBCA between September 2013 and March 2015. Angiography was performed after the embolization. The clinical signs including melena, anemia, and blood transfusion treatment were evaluated. The complications including abdominal pain and intestinal ischemia necrosis were recorded. The patients were followed up to evaluate the efficacy in the long run. Results. Seven cases (2 males, 5 females; age of 69.55 ± 2.25) were evaluated in the study. The embolization was successfully performed in all cases. About 0.2-0.8 mL (mean 0.48 ± 0.19 mL) NCBA was used. Immediate angiography after the embolization operation showed that the abnormal symptoms disappeared. The patients were followed up for a range of 2-19 months and six patients did not reoccur. No serious complications, such as femoral artery puncture point anomaly, vascular injury, and intestinal necrosis perforation were observed. Conclusion. For the patients with refractory and repeated lower gastrointestinal hemorrhage due to angiodysplasia, superselective TAE with NBCA seem to be a safe and effective alternative therapy when endoscopy examination and treatment do not work.
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