Climate of confrontation. Health groups urge Congress: let EPA oversee greenhouse gases. Presse Med. 2010;40:6-7, 1. [PMID: 21033003 DOI: 10.1016/j.lpm.2010.09.011]

Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.

The successful endoscopic hemostasis factors in bleeding from advanced gastric cancer

BACKGROUND

When patients with advanced gastric cancer experience active bleeding, gastroenterologists normally choose between two treatment modalities, endoscopic hemostasis and transarterial embolization (TAE). In patients with advanced gastric cancer with bleeding, the predictive factors for endoscopic hemostatic failure are still unknown. Thus, the purpose of this study was to evaluate predictive factors for endoscopic hemostasis failure and to differentiate which hemostasis procedure is more effective for advanced gastric cancer with bleeding.

METHODS

We reviewed the medical records of patients who were diagnosed with advanced gastric cancer and acute non-variceal gastric bleeding from January 2006 to August 2011. Forty-five patients were enrolled in this study and they were divided into a group of 14 patients who had experienced successful endoscopic hemostasis and a group of 31 patients who had had unsuccessful hemostasis with the first endoscopy and then underwent TAE.

RESULTS

Lesion size and bleeding condition of Forrest class 1a or 1b were statistically significant predictive factors for endoscopic hemostatic failure (P = 0.023 and P = 0.017, respectively). On multivariate logistic regression analysis, size (lesion >2 cm) was a significant predictive factor for endoscopic hemostatic failure [adjusted odds ratio (aOR) 8.056; 95% confidence interval (CI) 1.329-48.846].

CONCLUSIONS

We determined that small bleeding lesions (<2 cm) and exposed vessels in the bleeding site with gastric cancer indicated that endoscopic hemostasis would be an effective hemostatic modality to choose. Particularly, in the opposite condition, the presence of large bleeding lesions (>2 cm) and non-exposed vessel bleeding with a tumor, endoscopic hemostasis failure is predicted and TAE could be recommended.

Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding

Acute nonvariceal upper gastrointestinal bleeding (UGIB) is a major medical emergency problem associated with significant morbidity and mortality. Endoscopy is considered the first method of choice to detect and treat UGIB. Endoscopic therapy usually achieves primary hemostasis, but 10%-30% of these patients have repeat bleeding. In patients in whom hemostasis is not achieved with endoscopic techniques, treatment with transcatheter angiographic embolization (TAE) or surgery is needed. Surgical intervention is usually an expeditious and gratifying endeavor, but it can be associated with high operative mortality rates. A large number of studies support the use of TAE as salvage therapy as an alternative to surgery. However, few studies have compared the results of TAE with that of emergency surgery in terms of efficiency, the frequency of repeat bleeding, and complications. Recently, Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment. There were no significant differences in 30 d mortality, complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery. In this commentary, we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB. We also attempt to define the exact role of TAE for acute nonvariceal UGIB.