Superselective microcoil embolization for endoscopically uncontrollable bleeding after endoscopic submucosal dissection

Superselective arterial microcoil embolization for delayed bleeding after peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) has been shown to be an effective treatment for achalasia and with few adverse events. Only a few cases of delayed bleeding have been described. This current case report describes a patient with delayed bleeding in the submucosal tunnel on the eighth day after POEM. The patient was a 21-year-old woman with a 4-month history of dysphagia, vomiting and excessive weight loss. Achalasia was diagnosed according to her symptoms, barium oesophagogram, oesophageal manometry and endoscopy examination. POEM was performed by an experienced operator. On the eighth day after POEM, the patient suddenly developed continuous haematemesis presented with vomiting of fresh blood and melena. An emergency exploratory esophagogastroduodenoscopy was performed. A large number of blood clots were found at the wound and a long haematoma was found along the lining of the submucosal tunnel. Re-entry into the submucosal tunnel and exposure of the haemorrhagic site was attempted but failed because of severe submucosal tissue adhesion. An emergency angiography was undertaken and haemostasis was achieved with superselective arterial microcoil embolization.

Transarterial embolisation for gastroduodenal bleeding following endoscopic resection

OBJECTIVES

Transcatheter arterial embolisation (TAE) is widely used to treat gastrointestinal bleeding. This paper reports the safety and efficacy of TAE for bleeding following endoscopic resection, including endoscopic mucosal resection and endoscopic submucosal dissection.

METHODS

Fifteen consecutive patients (13 males, two females; mean age 62.2 years) from two tertiary medical centres who underwent TAE for gastroduodenal bleeding after endoscopic resection from November 2001 to December 2020 were included. Patient demographics, clinical presentations, angiographic findings, and TAE details were retrospectively reviewed.

RESULTS

Immediate bleeding during endoscopic resection was noted in four patients. Delayed bleeding 1-30 days after endoscopic resection in nine patients presented with haematochezia (n = 4), haematemesis (n = 6) and melaena (n = 1). Endoscopic haemostasis was attempted in 11 patients (73.3%) but failed due to continued bleeding despite haemostasis (n = 6), failure to secure endoscopic field (n = 3) and unstable vital signs (n = 2). Eleven patients had positive angiographic findings for bleeding, and all bleeding arteries were embolised except one owing to failed superselection of the bleeder. In the other four patients with negative angiographic findings, the left gastric artery with/without the right gastric artery or the accessory left gastric artery was empirically embolised using gelatin sponge particles. Both technical and clinical success rates were 93.3% (14/15). No procedure-related complications occurred during follow-up.

CONCLUSIONS

TAE is safe and effective in the treatment of immediate and delayed bleeding after endoscopic resection procedures.

ADVANCES IN KNOWLEDGE

This is the first and largest 20-year bicentric study published in English on this topic. Empirical TAE for angiographically negative bleeding sites was also effective without significant complications.

A case of gastric pseudoaneurysm following endoscopic submucosal dissection of early gastric cancer

A woman in her 80s underwent endoscopic submucosal dissection (ESD) for a 20-mm-sized early gastric cancer lesion in the posterior wall of the upper gastric body. The lesion was resected en bloc with no adverse events. However, bleeding was observed in a post-ESD mucosal defect the day after ESD, so endoscopic hemostasis was performed. Moreover, hematemesis occurred 4 days after ESD, when the bleeding site showed a sign of pulsatile aneurysm. Therefore, endoscopic hemostasis was considered difficult, and angiographic treatment was chosen. Since angiography revealed a pseudoaneurysm in a portion of a branch of the left gastric artery, embolization with microcoils was performed. Thereafter, no bleeding occurred. To the best of our knowledge, there is no case report about the formation of a pseudoaneurysm in a post-gastric ESD mucosal defect. Thus, this case is being reported to document valuable information.

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.