1
|
Kavitt RT, Gralnek IM. Ideal strategy for nonvariceal upper gastrointestinal bleeding. Curr Opin Gastroenterol 2024:00001574-990000000-00161. [PMID: 38967918 DOI: 10.1097/mog.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology. RECENT FINDINGS Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities. SUMMARY This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.
Collapse
Affiliation(s)
- Robert T Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
2
|
Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
Collapse
Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
| |
Collapse
|
3
|
Hu JN, Xu F, Hao YR, Sun CY, Wu KM, Lin Y, Zhong L, Zeng X. MH-STRALP: A scoring system for prognostication in patients with upper gastrointestinal bleeding. World J Gastrointest Surg 2024; 16:790-806. [PMID: 38577095 PMCID: PMC10989336 DOI: 10.4240/wjgs.v16.i3.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/21/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common medical emergency and early assessment of its outcomes is vital for treatment decisions. AIM To develop a new scoring system to predict its prognosis. METHODS In this retrospective study, 692 patients with UGIB were enrolled from two centers and divided into a training (n = 591) and a validation cohort (n = 101). The clinical data were collected to develop new prognostic prediction models. The endpoint was compound outcome defined as (1) demand for emergency surgery or vascular intervention, (2) being transferred to the intensive care unit, or (3) death during hospitalization. The models' predictive ability was compared with previously established scores by receiver operating characteristic (ROC) curves. RESULTS Totally 22.2% (131/591) patients in the training cohort and 22.8% (23/101) in the validation cohort presented poor outcomes. Based on the stepwise-forward Logistic regression analysis, eight predictors were integrated to determine a new post-endoscopic prognostic scoring system (MH-STRALP); a nomogram was determined to present the model. Compared with the previous scores (GBS, Rockall, ABC, AIMS65, and PNED score), MH-STRALP showed the best prognostic prediction ability with area under the ROC curves (AUROCs) of 0.899 and 0.826 in the training and validation cohorts, respectively. According to the calibration curve, decision curve analysis, and internal cross-validation, the nomogram showed good calibration ability and net clinical benefit in both cohorts. After removing the endoscopic indicators, the pre-endoscopic model (pre-MH-STRALP score) was conducted. Similarly, the pre-MH-STRALP score showed better predictive value (AUROCs of 0.868 and 0.767 in the training and validation cohorts, respectively) than the other pre-endoscopic scores. CONCLUSION The MH-STRALP score and pre-MH-STRALP score are simple, convenient, and accurate tools for prognosis prediction of UGIB, and may be applied for early decision on its management strategies.
Collapse
Affiliation(s)
- Jun-Nan Hu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Fei Xu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Ya-Rong Hao
- Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China
| | - Chun-Yan Sun
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Kai-Ming Wu
- Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China
| | - Yong Lin
- Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China
| | - Lan Zhong
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Xin Zeng
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| |
Collapse
|
4
|
Ahn JY. Meaning of Better Scoring System for the Patients with Cancer Bleeding in the Upper Gastrointestinal Tract. Gut Liver 2024; 18:195-196. [PMID: 38481276 PMCID: PMC10938145 DOI: 10.5009/gnl240091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Affiliation(s)
- Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
5
|
Allo G, Lang S, Martin A, Bürger M, Zhang X, Chon SH, Nierhoff D, Töx U, Goeser T, Kasper P. Learning curve of achieving competency in emergency endoscopy in upper gastrointestinal bleeding: how much experience is necessary? BMJ Open Gastroenterol 2024; 11:e001281. [PMID: 38458629 PMCID: PMC10921515 DOI: 10.1136/bmjgast-2023-001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/16/2024] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVES The management of upper gastrointestinal bleeding (UGIB) has seen rapid advancements with revolutionising innovations. However, insufficient data exist on the necessary number of emergency endoscopies needed to achieve competency in haemostatic interventions. DESIGN We retrospectively analysed all oesophagogastroduodenoscopies with signs of recent haemorrhage performed between 2015 and 2022 at our university hospital. A learning curve was created by plotting the number of previously performed oesophagogastroduodenoscopies with signs of recent haemorrhage against the treatment failure rate, defined as failed haemostasis, rebleeding and necessary surgical or radiological intervention. RESULTS The study population included 787 cases with a median age of 66 years. Active bleeding was detected in 576 cases (73.2%). Treatment failure occurred in 225 (28.6%) cases. The learning curve showed a marked decline in treatment failure rates after nine oesophagogastroduodenoscopies had been performed by the respective endoscopists followed by a first plateau between 20 and 50 procedures. A second decline was observed after 51 emergency procedures followed by a second plateau. Endoscopists with experience of <10 emergency procedures had higher treatment failure rates compared with endoscopists with >51 emergency oesophagogastroduodenoscopies performed (p=0.039) or consultants (p=0.041). CONCLUSIONS Our data suggest that a minimum number of 20 oesophagogastroduodenoscopies with signs of recent haemorrhage is necessary before endoscopists should be considered proficient to perform emergency procedures independently. Endoscopists might be considered as advanced-qualified experts in managing UGIB after a minimum of 50 haemostatic procedure performed. Implementing recommendations on minimum numbers of emergency endoscopies in education programmes of endoscopy trainees could improve their confidence and competency in managing acute UGIB.
Collapse
Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sonja Lang
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anna Martin
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University of Cologne, Cologne, Germany
| | - Dirk Nierhoff
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ulrich Töx
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| |
Collapse
|
6
|
Amaya-Fragoso E, Hernández-Guerrero A, de la Mora Levy JG, Ramírez-Solís ME, Alonso-Lárraga JO, Beltrán-Galindo LG. Mortality in patients with unresectable gastric cancer complicated with tumor bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:132-139. [PMID: 37170581 DOI: 10.17235/reed.2023.9508/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND gastric cancer (GC) is a gastrointestinal (GI) neoplasia which often complicates with GI bleeding. It is uncertain if bleeding worsens mortality in this group of patients. AIMS to compare 30- and 90-day mortality in patients with unresectable GC (uGC) and tumor bleeding versus patients with the same neoplasia without bleeding. METHODS a retrospective analysis of patients with uGC, with and without tumor bleeding was performed. Survival analysis for 30- and 90-days mortality was performed using Cox regression. Logistic regression was used to identify risk factors associated with mortality and first bleeding episode. RESULTS 202 patients were included in the analysis (105 cases). Mortality at 90 days was 37.14 % for cases and 20.62 % for controls (p = 0.04). There was a significant difference in hazard ratio (HR) at 90 days for cases compared to controls (HR 1.95, 95 % CI 1.14-3.34, p = 0.02). Cases without palliative chemotherapy had the highest 90-days mortality (HR 5.43, 95 % CI 2.12-13.87, p < 0.01), compared to controls treated with chemotherapy. Predictors for first tumor bleeding were clinical stage IV (OR 2.93, 95 % CI 1.04-8.26, p = 0.04), Helicobacter pylori infection (OR 2.80, 95 % CI 1.35-5.80, p < 0.01) and histologic intestinal-subtype (OR 2.14, 95 % CI 1.07-4.30, p = 0.03). CONCLUSIONS tumor bleeding increases 90-days mortality in patients with uGC. Prevention of the first bleeding episode might improve outcome in these patients and the recognition of high-risk patients might help decision-making.
Collapse
|
7
|
Kubo K, Zhang X, Tanaka I, Kimura N. Emergency Endoscopic Hemostasis Using the Endoscopic Mucosal Resection Technique for Severe Bleeding From Early Gastric Cancer: A Case Report. Cureus 2024; 16:e54429. [PMID: 38510882 PMCID: PMC10951553 DOI: 10.7759/cureus.54429] [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: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
Bleeding from gastric cancer may lead to severe anemia and hypovolemic shock, and can be a life-threatening condition in affected patients; thus, achieving hemostasis is essential to improving their clinical course. While endoscopic hemostasis is recommended as the hemostatic modality of first choice, endoscopic hemostasis involving the endoscopic mucosal resection (EMR) technique is also being used, though under-reported. An 85-year-old man diagnosed with bleeding from gastric cancer was raced to our hospital for hemostasis. Emergency esophagogastroduodenoscopy (EGD) revealed a 45 mm-sized elevated lesion involving the coagula due to dripping bleeding from the surface of the posterior wall of the gastric lower body. EMR was performed without any technical difficulty, and hemostasis was achieved immediately. The patient was discharged without rebleeding. This case appears to support the usefulness of EMR as an emergency endoscopic hemostatic modality for severe bleeding from early gastric cancer.
Collapse
Affiliation(s)
- Kimitoshi Kubo
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
| | - Xinhan Zhang
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
| | - Ikko Tanaka
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
| | - Noriko Kimura
- Department of Pathology, National Hospital Organization Hakodate National Hospital, Hakodate, JPN
| |
Collapse
|
8
|
Tarasov SA, Yartsev PA, Rogal MM, Aksenova SO. [Complicated gastric cancer and modern treatment approaches]. Khirurgiia (Mosk) 2024:125-140. [PMID: 38634594 DOI: 10.17116/hirurgia2024041125] [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] [Indexed: 04/19/2024]
Abstract
Among all patients with gastric cancer, 40% admit to the hospitals due to cancer-related complications. The most common complications of gastric cancer are bleeding (22-80%), malignant gastric outlet obstruction (26-60%), and perforation (less than 5%). The main treatment methods for gastric cancer complicated by bleeding are various forms of endoscopic hemostasis, transarterial embolization and external beam radiotherapy. Surgical treatment is possible in case of ineffective management. However, surgical algorithm is not standardized. Malignant gastric outlet stenosis requires decompression: endoscopic stenting, palliative gastroenterostomy. Surgical treatment is also possible (gastrectomy, proximal or distal resection of the stomach). The main problem for patients with complicated gastric cancer is the lack of standardized algorithms and abundance of potential surgical techniques. The aim of our review is to systematize available data on the treatment of complicated gastric cancer and to standardize existing methods.
Collapse
Affiliation(s)
- S A Tarasov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - P A Yartsev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - M M Rogal
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - S O Aksenova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| |
Collapse
|
9
|
Pan HY, Wang XW, He QX, Lu YD, Zhang WY, Jin JW, Lin B. Efficacy and safety of gastroscopic hemostasis in the treatment of acute gastric hemorrhage: A meta-analysis. World J Gastrointest Oncol 2023; 15:1988-1997. [DOI: 10.4251/wjgo.v15.i11.1988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/19/2023] [Accepted: 09/27/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Gastric cancer (GC) is a malignant tumor with a high incidence and mortality rate worldwide for which acute bleeding is a common clinical complication. Gastroscopic hemostasis is an important method for treating acute bleeding in GC; however, its efficacy and safety remain controversial.
AIM To systematically analyze the efficacy and safety of gastroscopic hemostasis for the treatment of acute gastric hemorrhage.
METHODS The PUBMED, Web of Science, Wiley Library, EMBASE, Wanfang, CNKI, and VIP databases were searched for studies related to gastroscopic hemostatic treatment for acute GC published through February 20, 2023. The literature was screened according to the inclusion and exclusion criteria, data were extracted, and literature quality was evaluated. The meta-analysis was performed using RevMan software (version 5.3), while Begg’s test for publication bias was performed using Stata 13.0 software.
RESULTS Six randomized controlled trials and two retrospective analyses were retrieved. Five studies had a low, two had an uncertain, and one had a high risk of bias. Compared with the control group, the hemostatic rate of gastroscopic hemostasis was increased [relative risk (RR) = 1.24; 95% confidence interval (CI): 1.08 to 1.43; P = 0.003]; the rate of rebleeding (RR = 0.27; 95%CI: 0.09 to 0.80; P = 0.02), rate of surgery transfer (RR = 0.16; 95%CI: 0.06 to 0.43; P = 0.0003), serum C-reactive protein level [mean difference (MD) = -5.16; 95%CI: -6.11 to 4.21; P < 0.00001], interleukin-6 level (MD = -6.37; 95%CI: -10.33 to -2.42; P = 0.002), and tumor necrosis factor-α level (MD = -2.29; 95%CI: -4.06 to -0.52; P = 0.01) were decreased; and the quality of life improvement rate was increased (RR = 1.95; 95%C I= 1.41-2.71; P < 0.0001). Begg’s test revealed no significant publication bias.
CONCLUSION The efficacy and safety of endoscopic hemostasis were higher than those of the control group, suggesting that it is an effective treatment for acute GC hemorrhage.
Collapse
Affiliation(s)
- Hai-Yan Pan
- Department of Emergency Medicine, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang Province, China
| | - Xiao-Wei Wang
- Department of Cardiopulmonary Rehabilitation, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang Province, China
| | - Qiong-Xiao He
- Department of Emergency Medicine, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang Province, China
| | - Yi-Dan Lu
- Department of Ultrasound, Zhejiang Cancer Hospital, Hangzhou 310005, Zhejiang Province, China
| | - Wan-Yi Zhang
- Department of Emergency Medicine, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang Province, China
| | - Jian-Wei Jin
- Department of Oncology, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang Province, China
| | - Bin Lin
- Department of Emergency Medicine, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang Province, China
| |
Collapse
|
10
|
Kiattiweerasak A, Bongkotvirawan P, Aumpan N, Yamaoka Y, Miftahussurur M, Vilaichone RK. Predictive factors and prognosis of upper gastrointestinal bleeding in gastric cancer: A large population-based study (UGIB-GC trial). PLoS One 2023; 18:e0291926. [PMID: 37729185 PMCID: PMC10511075 DOI: 10.1371/journal.pone.0291926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 09/10/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Gastric cancer remains the fourth leading cause of cancer-related death worldwide. Significant number of gastric cancer patients presented with bleeding. OBJECTIVE This study aimed to identify risk factors and overall survival rates of bleeding gastric cancer patients. METHODS This retrospective cohort study was conducted between 2007-2022 at tertiary care center in Thailand. Clinical information, endoscopic findings and histological type were extensively reviewed and were compared between bleeders and non-bleeders. Patients were monitored for at least 5 years. RESULTS There were 20,981 patients who underwent upper gastrointestinal endoscopy during study period. Total of 201 gastric cancer patients were included in this study, 21 were excluded due to incomplete medical records. 180 gastric cancer patients were included with mean age of 60.5±14.3 years. There were 65 (36.1%) patients with gastrointestinal bleeding. Hypertension and chronic kidney disease were significantly more common in bleeders than non-bleeders (43.1% vs 23.5%, OR2.51, 95%CI 1.14.-5.52, p = 0.022; and 16.9% vs 5.2%, OR2.00, 95%CI 1.56-6.63, p = 0.025, respectively). current H. pylori infection was also significantly more common in bleeders than non-bleeders (84.6% vs. 55.7%, OR 4.39, 95%CI 1.90-10.12, p<0.001). Median overall survival of bleeders was significantly lower than non-bleeders (7±0.93 vs 10±2.10 months, p = 0.001). CONCLUSIONS Bleeding gastric cancer was not an uncommon condition. Majority of patients presented at advanced stage with grave prognosis. Male gender, hypertension, chronic kidney disease, and current H. pylori infection were reliable predictors for bleeding. Early diagnosis and prompt treatment are the key to improve clinical outcome.
Collapse
Affiliation(s)
- Anya Kiattiweerasak
- Gastroenterology and Hepatology Center, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Phubordee Bongkotvirawan
- Center of Excellence in Digestive Diseases and Gastroenterology Unit, Department of Medicine, Thammasat University, Pathumthani, Thailand
| | - Natsuda Aumpan
- Center of Excellence in Digestive Diseases and Gastroenterology Unit, Department of Medicine, Thammasat University, Pathumthani, Thailand
- Chulabhorn International College of Medicine (CICM) at Thammasat University, Pathumthani, Thailand
| | - Yoshio Yamaoka
- Department of Environmental and Preventive Medicine, Faculty of Medicine, Oita University, Yufu, Japan
- Research Center for Global and Local Infectious Diseases, Oita University, Yufu, Japan
- Department of Medicine, Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, United States of America
| | - Muhammad Miftahussurur
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ratha-korn Vilaichone
- Center of Excellence in Digestive Diseases and Gastroenterology Unit, Department of Medicine, Thammasat University, Pathumthani, Thailand
- Chulabhorn International College of Medicine (CICM) at Thammasat University, Pathumthani, Thailand
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| |
Collapse
|
11
|
Allo G, Bürger M, Chon SH, Gülcicegi D, Krämer L, Goeser T, Kütting F. Efficacy of endoscopic therapy and long-term outcomes of upper gastrointestinal tumor bleeding in patients with esophageal cancer. Scand J Gastroenterol 2023; 58:1064-1070. [PMID: 37029631 DOI: 10.1080/00365521.2023.2199439] [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: 02/04/2023] [Revised: 03/20/2023] [Accepted: 04/02/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) from malignancies is associated with a poor outcome. Only a small number of studies on gastrointestinal tumor bleeding have been published so far, focusing mainly on bleeding from gastric cancer. Since the information on patients with UGIB from esophageal cancer appears insufficient, this study aimed to present clinical and endoscopic findings, treatment options as well as clinical outcomes such as rebleeding and survival of those patients. METHODS This retrospective analysis included all patients admitted with UGIB from esophageal cancer at our university hospital during a 10-year period. RESULTS 45 patients were analyzed of whom 26 (57.8%) already had cancer stage IV at index bleeding. 22 (48.9%) patients presented with hemodynamic instability and 30 (66.7%) patients received blood transfusions. Active bleeding was present in 24 (53.3%) patients, of whom 20 (83.3%) received endoscopic therapy. Successful hemostasis was achieved in 18 (90%) of 20 patients with Argon plasma coagulation used most frequently (52.4%). Early and delayed rebleeding occurred in 5 (12.5%) and 11 (27.5%) of all inoperable patients, respectively. Intake of anticoagulation or anti-platelet drugs were risk factors for delayed rebleeding and the median overall survival after index bleeding was 1.2 months. CONCLUSION UGIB from esophageal cancer occurred most frequently in advanced tumor stages and was associated with significant blood loss. Even though initial endoscopic therapy was effective, rebleeding occurred in a significant number of patients. Those taking anticoagulants or anti-platelet drugs should be closely monitored for rebleeding. The overall survival after index bleeding was poor.
Collapse
Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Dilan Gülcicegi
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Laurenz Krämer
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Fabian Kütting
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| |
Collapse
|
12
|
Andreone M, Megna B, McDonald N, Sunjaya D, Hanson B, Bilal M. Use of Endoscopic Suturing for the Treatment of Malignant Gastric Ulcer-Related Hemorrhage. ACG Case Rep J 2023; 10:e01047. [PMID: 37180465 PMCID: PMC10171711 DOI: 10.14309/crj.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Gastrointestinal bleeding secondary to malignancy can be difficult to manage with traditional endoscopic therapies. Endoscopic suturing is a relatively new technology with limited data available regarding its use for bleeding related to peptic ulcer disease. We describe a case where endoscopic suturing was successfully used to control gastrointestinal hemorrhage from a previously known malignant ulceration that was refractory to traditional interventions.
Collapse
Affiliation(s)
- Michael Andreone
- Department of Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Bryant Megna
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN
| | - Nicholas McDonald
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN
| | - Dharma Sunjaya
- Department of Gastroenterology and Hepatology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN
| | - Brian Hanson
- Department of Gastroenterology and Hepatology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN
| | - Mohammad Bilal
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN
- Department of Gastroenterology and Hepatology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN
| |
Collapse
|
13
|
Katano A, Yamashita H. Usefulness of palliative radiotherapy in reducing the frequency of red blood cell transfusion in patients with malignant tumor bleeding. J Cancer Res Ther 2023; 19:753-756. [PMID: 37470605 DOI: 10.4103/jcrt.jcrt_2090_21] [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] [Indexed: 11/04/2022]
Abstract
Objective We aimed to evaluate the usefulness of palliative radiotherapy in reducing the frequency of red blood cell (RBC) transfusions in patients with malignant tumor bleeding as a quantitative value to evaluate the hemostatic effect. Materials and Methods In this study, we conducted a retrospective review of patients visiting our department between June 2013 and April 2021. All patients underwent RBC transfusions for 30 days before the initiation of radiotherapy. We determined the overall survival (OS) time and RBC transfusion-free (RBCTF) time using statistical tests. Results In total, 21 patients were enrolled in our study, including 13 women and 8 men; the median patient age was 63 years (range: 32-82 years). After radiotherapy, 19 of the 21 patients had a decreased frequency of requirement for RBC transfusion compared to that before radiotherapy. Fourteen patients had achieved an RBCTF state 1 month after radiotherapy. The estimated 1-year OS and RBCTF rates were 36.3% (95% confidence interval [CI]: 14.2%) and 66.7% (95% CI: 42.5%-42.5%), respectively. Conclusion The present study revealed a reduction in RBC transfusion after palliative radiotherapy in patients with malignant tumor bleeding. We believe that reducing the frequency of blood transfusions in patients with terminal conditions would have significant clinical benefits.
Collapse
Affiliation(s)
- Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideomi Yamashita
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
14
|
Khorobrykh TV, Abdulkhakimov NM, Agadzhanov VG, Aghayan DL, Kazaryan AM. Laparoscopic versus open surgery for locally advanced and metastatic gastric cancer complicated with bleeding and/or stenosis: short- and long-term outcomes. World J Surg Oncol 2022; 20:216. [PMID: 35752852 PMCID: PMC9233806 DOI: 10.1186/s12957-022-02674-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Laparoscopic surgery has justified its efficacy in the treatment of early gastric cancer. There are limited data indicating the eligibility of laparoscopic interventions in locally advanced gastric cancer. Publications describing the safety of laparoscopic techniques in the treatment of local and metastatic gastric cancer complicated by bleeding and stenosis are scarce. Methods The study included patients with histologically confirmed locally advanced and disseminated gastric cancer and complicated with bleeding and/or stenosis who underwent gastrectomy with vital indications between February 2012 and August 2018. Surgical and oncologic outcomes after laparoscopic surgery (laparoscopic surgery) and open surgery (OS) were compared. Results In total, 127 patients (LS, n = 52; OS, n = 75) were analyzed. Baseline characteristics were similar between the groups. Forty-four total gastrectomies with resection of the abdominal part of the esophagus, 63 distal subtotal (43 Billroth-I and 20 Billroth-II), and 19 proximal gastrectomies were performed. The median duration of surgery was significantly longer in the LS group, 253 min (interquartile range [IQR], 200–295) versus 210 min (IQR, 165–220) (p < 0.001), while median intraoperative blood loss in the LS group was significantly less, 180 ml (IQR, 146—214) versus 320 ml (IQR, 290–350), (p < 0.001). Early postoperative complications occurred in 35% in the LS group and in 45 % of patients in the OS group (p = 0.227). There was no difference in postoperative mortality rates between the groups (3 [6 %] versus 5 (7 %), p = 1.00). Median intensive care unit stay and median postoperative hospital stay were significantly shorter after laparoscopy, 2 (IQR, 1–2) versus 4 (IQR, 3–4) days, and 8 (IQR, 7–9) versus 10 (IQR, 8–12) days, both p < 0.001. After laparoscopy, patients started adjuvant chemotherapy significantly earlier than those after open surgery, 20 vs. 28 days (p < 0.001). However, overall survival rates were similar between the group. Three-year overall survival was 24% in the LS group and 27% in the OS groups. Conclusions Despite the technical complexity, in patients with complicated locally advanced and metastatic gastric cancer, laparoscopic gastrectomies were associated with longer operation time, reduced intraoperative blood loss, shorter reconvalescence, and similar morbidity, mortality rates and long-term oncologic outcomes compared to conventional open surgery.
Collapse
Affiliation(s)
- Tatyana V Khorobrykh
- Department of Faculty Surgery №2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Nuriddin M Abdulkhakimov
- Department of Faculty Surgery №2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vadim G Agadzhanov
- Department of Faculty Surgery №2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Davit L Aghayan
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
| | - Airazat M Kazaryan
- Department of Faculty Surgery №2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia. .,The Intervention Centre, Oslo University Hospital, Oslo, Norway. .,Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia. .,Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway. .,Department of Surgery, Helse Fonna Hospital Trust, Odda, Norway. .,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
| |
Collapse
|
15
|
Stilidi IS, Sigua BV, Zemlyanoy VP, Kurkov AA, Gubkov II. [Gastric cancer complicated by bleeding. (A systematic review)]. Khirurgiia (Mosk) 2022:102-115. [PMID: 35658142 DOI: 10.17116/hirurgia2022061102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bleeding as the most common complication of gastric cancer is a significant problem of modern surgery. Both oncologists and surgeons in ordinary hospitals deal with this adverse event. In addition to the well-known drugs for hemostasis, there are also generally recognized traditional methods of endoscopic hemostasis and transcatheter angiographic embolization. Surgical interventions do not lose their role too if previous hemostatic methods turned out to be ineffective. The reports devoted to radiotherapy for treatment and prevention of gastric bleeding following malignant process have been recently published. Such a wide choice of hemostatic methods prompted us to analyze the most significant recent studies regarding effectiveness of various methods and choice of the most optimal one.
Collapse
Affiliation(s)
- I S Stilidi
- Blokhin National Cancer Research Center, Moscow, Russia
| | - B V Sigua
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - V P Zemlyanoy
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - A A Kurkov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - I I Gubkov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| |
Collapse
|
16
|
Tanner S, Al Kazzi E, Aslam R, Isenberg G, Cooper G. A Case of Upper Gastrointestinal Bleeding Due to Metastatic High-Grade B-Cell Lymphoma Successfully Treated With Chemotherapy. Cureus 2022; 14:e24738. [PMID: 35676981 PMCID: PMC9166593 DOI: 10.7759/cureus.24738] [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] [Accepted: 05/03/2022] [Indexed: 12/02/2022] Open
Abstract
Upper gastrointestinal bleeding (UGIB) is a common and potentially life-threatening condition. Metastatic disease is an exceedingly rare cause of UGIB. We report the case of a 73-year-old man with high-grade B-cell lymphoma (HGBL) who presented for the initiation of chemotherapy and was found to be acutely anemic due to UGIB. An esophagogastroduodenoscopy (EGD) revealed multiple large, discrete, ulcerated, non-circumferential, and friable masses in the stomach. Biopsies were consistent with HGBL. The patient was urgently initiated on chemotherapy with the resolution of lesions on subsequent EGD. The rate of prevalence of gastric metastases is unknown, but it should be considered in patients with active malignancy who present with signs of UGIB.
Collapse
|
17
|
Han C, Ling X, Liu J, Lin R, Ding Z. Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments. Therap Adv Gastroenterol 2022; 15:17562848211056148. [PMID: 35126666 PMCID: PMC8808014 DOI: 10.1177/17562848211056148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/08/2021] [Indexed: 02/04/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)-guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy's lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.
Collapse
Affiliation(s)
- Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, China
| |
Collapse
|
18
|
Stilidi IS, Sigua BV, Zemlyanoy VP, Kurkov AA, Gubkov II. [Gastric cancer complicated by bleeding: a systematic review]. Khirurgiia (Mosk) 2022:101-114. [PMID: 35289556 DOI: 10.17116/hirurgia2022031101] [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] [Indexed: 06/14/2023]
Abstract
Bleeding as the most common complication of gastric cancer is a significant problem of modern surgery. Both oncologists and surgeons in ordinary hospitals deal with this adverse event. In addition to the well-known drugs for hemostasis, there are also generally recognized traditional methods of endoscopic hemostasis and transcatheter angiographic embolization. Surgical interventions do not lose their role too if previous hemostatic methods turned out to be ineffective. The reports devoted to radiotherapy for treatment and prevention of gastric bleeding following malignant process have been recently published. Such a wide choice of hemostatic methods prompted us to analyze the most significant recent studies regarding effectiveness of various methods and choice of the most optimal one.
Collapse
Affiliation(s)
- I S Stilidi
- Blokhin National Cancer Research Center, Moscow, Russia
| | - B V Sigua
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - V P Zemlyanoy
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - A A Kurkov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - I I Gubkov
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Lee J, Byun HK, Koom WS, Lee YC, Seong J. Efficacy of radiotherapy for gastric bleeding associated with advanced gastric cancer. Radiat Oncol 2021; 16:161. [PMID: 34425855 PMCID: PMC8383356 DOI: 10.1186/s13014-021-01884-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/14/2021] [Indexed: 12/24/2022] Open
Abstract
Background Gastric bleeding negatively impacts the quality of life of patients with unresectable advanced gastric cancer and is frequently lethal. We investigated the efficacy of RT for palliation of gastric bleeding from gastric cancer and identified an optimal radiotherapy (RT) strategy. Methods The study analyzed 57 patients submitted to palliative RT for gastric bleeding associated with gastric cancer between January 2009 and February 2019. Changes in hemoglobin (Hb) levels were analyzed based on measurements taken before and immediately, 1 month, and 2 months after RT. Re-bleeding after RT was identified as either Hb level dropping to < 7.0 g/dL or the administration of a blood transfusion after RT. Results The median biologically effective dose (α/β = 10) was 37.5 Gy (range 23.6–58.5). The most common regimen was 25 Gy in five fractions. The mean Hb levels before, immediately after, 1 month, and 2 months after RT (6.6, 9.7, 10.3, and 9.7 g/dL, respectively) were significantly higher than that before RT (all p < 0.001). No significant differences in re-bleeding rates were observed according to total dose, fractional dose, and fraction number. Gastric tumor response evaluated by computed tomography within 2 months after RT showed partial responses were more frequent in patients achieving bleeding control (25.0% vs. 10.8%, p = 0.023) and overall survival was significantly improved for bleeding control within 3 months after RT (median, 15.4 vs. 10.0 weeks, p = 0.048). Conclusions RT was an effective modality for gastric bleeding control in gastric cancer, which can be achieved with a short course scheme with five fractions. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01884-5.
Collapse
Affiliation(s)
- Joongyo Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea.
| |
Collapse
|
21
|
Yu J, Jung J, Park SR, Ryu MH, Park JH, Kim JH, Yoon SM. Role of palliative radiotherapy in bleeding control in patients with unresectable advanced gastric cancer. BMC Cancer 2021; 21:413. [PMID: 33858353 PMCID: PMC8048171 DOI: 10.1186/s12885-021-08145-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/05/2021] [Indexed: 12/24/2022] Open
Abstract
Background This study analyzed the clinical results of palliative radiotherapy for bleeding control in patients with unresectable advanced gastric cancer. Methods We retrospectively reviewed the medical records of patients who met the following inclusion criteria between January 2002 and June 2018: histologically proven gastric cancer, gastric tumor bleeding confirmed by upper gastrointestinal endoscopy, and palliative radiotherapy performed for hemostasis. The median radiotherapy dose was 30 Gy, with a daily dose ranging from 1.8 to 3 Gy. Results Sixty-one patients were included in this analysis. The study population was predominantly male (72.1%), with a median age of 62 years (range: 32–92). The median baseline hemoglobin level was 7.1 g/dL, and the most common presenting symptom of gastric tumor bleeding was melena (85.2%). Bleeding control was achieved in 54 (88.5%) patients. The median levels of hemoglobin at 1, 2, and 3 months after completion of radiotherapy were 10.1 g/dL, 10.2 g/dL, and 10.4 g/dL, respectively; these values were significantly different from that before radiotherapy (7.1 g/dL; p < 0.001). The median overall survival was 4.8 months. Among the 54 patients who achieved bleeding control after radiotherapy, 19 (35.2%) experienced re-bleeding during the follow-up period. The median time to re-bleeding was 6.0 months. Multivariate analysis demonstrated that a higher radiation dose (p = 0.007) and additional chemotherapy after radiotherapy (p = 0.004) were significant factors for prolonging the time to re-bleeding. Conclusions Tumor bleeding was adequately controlled by radiotherapy in patients with unresectable advanced gastric cancer.
Collapse
Affiliation(s)
- Jesang Yu
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sook Ryun Park
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min-Hee Ryu
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| |
Collapse
|
22
|
Sugita H, Sakuramoto S, Mihara Y, Matsui K, Nishibeppu K, Ebara G, Fuijta S, Fujihata S, Oya S, Miyawaki Y, Sato H, Horita Y, Hamaguchi T, Noda SE, Kato S, Hirano Y, Okamoto K, Koyama I. Verification of the Utility of Palliative Radiotherapy for Hemostasis of Gastric Cancer Bleeding: a Case Control Study. J Gastrointest Cancer 2021; 53:420-426. [PMID: 33754255 DOI: 10.1007/s12029-021-00632-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Bleeding from unresectable gastric cancer is a localized condition that adversely affects quality of life. Radiotherapy can be used to treat gastric cancer bleeding when surgery, endoscopic treatment, and intravascular embolization are ineffective. This study evaluated the utility of radiotherapy for unresectable hemorrhagic gastric cancer. METHODS We retrospectively analyzed data from 33 patients with gastric cancer bleeding who underwent palliative radiotherapy in our hospital between April 2013 and May 2020. In this study, successful hemostasis was defined as > 1 month after starting radiotherapy with the patient alive and showing no need for blood transfusion, no drop in hemoglobin, and no evidence of melena or hematemesis. RESULTS Patients comprised 26 men (79%) and 7 women (21%), with a median age of 71 years (range, 41-78 years). Hemostasis was achieved in 24 patients (73%). Thirty-two patients (94%) have been discharged home or transferred to the hospice. Patients with successful hemostasis from radiotherapy showed significantly longer overall survival than patients with unsuccessful hemostasis (p = 0.0026). No toxicities of grade 2 or more were encountered. CONCLUSIONS This retrospective study found that palliative radiotherapy for gastric cancer bleeding was useful and safe and can improve remaining quality of life in patients with poor prognosis.
Collapse
Affiliation(s)
- Hirofumi Sugita
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan.
| | - Shinichi Sakuramoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Yoshiaki Mihara
- Department of Gastroenterological Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Kazuaki Matsui
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Keiji Nishibeppu
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Gen Ebara
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shohei Fuijta
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shiro Fujihata
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shuichiro Oya
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Yutaka Miyawaki
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Hiroshi Sato
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Yosuke Horita
- Department of Gastroenterological Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Tetsuya Hamaguchi
- Department of Gastroenterological Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shin-Ei Noda
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Yasumitsu Hirano
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Isamu Koyama
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| |
Collapse
|
23
|
Shin J, Cha B, Park JS, Ko W, Kwon KS, Lee JW, Kim HK, Shin YW. Efficacy of a novel hemostatic adhesive powder in patients with upper gastrointestinal tumor bleeding. BMC Gastroenterol 2021; 21:40. [PMID: 33509102 PMCID: PMC7842074 DOI: 10.1186/s12876-021-01611-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/13/2021] [Indexed: 01/06/2023] Open
Abstract
Background Gastrointestinal tumor bleeding remains a clinical challenge because it is difficult to treat with conventional endoscopic hemostatic options. Recently, an endoscopic hemostatic powder (UI-EWD) was developed and reported to provide effective control of upper gastrointestinal bleeding. The aim of current study was to evaluate the feasibility and efficacy of this novel hemostatic powder in tumor bleeding.
Methods A total of 41 consecutive patients with upper gastrointestinal tumor bleeding were included. UI-EWD was applied in all patients as an auxiliary hemostatic method as a salvage therapy or monotherapy during endoscopic treatment. Hemostasis success rates, adverse event related to UI-EWD, and rates of re-bleeding were evaluated. Results In all cases, UI-EWD application was successful at tumor bleeding sites. Immediate hemostasis occurred in 40/41 (97.5%) patients, and re-bleeding within 28 days occurred in 10 of 40 (22.5%) patients that achieved initial hemostasis. The success rate of immediate hemostasis for UI-EWD monotherapy was 100% (23/23). The re-bleeding rate at 28 days after UI-EWD monotherapy was 26.1% (6/23). No adverse events associated with UI-EWD application were encountered. Conclusions The success rate of UI-EWD for immediate hemostasis in cases of GI tumor bleeding was excellent and UI-EWD produced promising results with respect to the prevention of re-bleeding. Based on these results, we suggest that UI-EWD be considered an effective salvage therapy or even monotherapy for GI tumor bleeding.
Collapse
Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Boram Cha
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea.
| | - Weonjin Ko
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Kye Sook Kwon
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Jin-Woo Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Hyung Kil Kim
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| | - Yong Woon Shin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea
| |
Collapse
|
24
|
Tanaka O, Sugiyama A, Omatsu T, Tawada M, Makita C, Matsuo M. Hemostatic radiotherapy for inoperable gastric cancer: a pilot study. Br J Radiol 2020; 93:20190958. [PMID: 32356453 DOI: 10.1259/bjr.20190958] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Standard treatment for progressive gastric cancer with bleeding includes hemostatic radiotherapy (RT); however, the only prospective study using a fixed dose with fractions during hemostatic RT did not introduce re-irradiation. Therefore, we determined the utility of RT including re-irradiation for gastric cancer. METHODS In this study, 31 patients with gastric cancer and bleeding were treated with an initial dose of 20 Gy/5 fractions for the whole stomach and a salvage dose of 15 Gy/5 fractions for the partial stomach. Patients achieving hemostasis, defined as a stable hemoglobin level within 30 days following irradiation, were considered responders, whereas those with no cessation of bleeding and those with re-bleeding within 30 days of irradiation were considered non-responders. We evaluated response rate, disease-free survival, overall survival (OS), re-irradiation, and adverse events (AEs). RESULTS The response rate of initial RT was 80% (25/31). 6 of the 25 patients underwent re-irradiation, and all 6 were responders (100%). The median OS was significantly different among the entire cohort and one-time irradiation and re-irradiation groups (91, 76, and 112 days, respectively). No AEs of grade ≥3 were observed. Initial low-dose RT followed by reirradiation was effective in reducing AEs and did not cause any further AEs. CONCLUSION Hemostatic RT was an effective approach with low toxicity, and re-irradiation was effective and tolerable, with no patients developing severe AEs. Further, randomized controlled studies are warranted to determine the ideal dose and number of fractions for initial RT in patients with gastric cancer and bleeding. ADVANCES IN KNOWLEDGE In this prospective study on hemostatic radiotherapy for gastric cancer, the response rate was 80% using a fixed dose of 20 Gy/5 fractions and the salvage dose of 15 Gy for re-bleeding was effective. Future comparative studies should include other doses with 20 Gy as a control.
Collapse
Affiliation(s)
- Osamu Tanaka
- Department of Radiation Oncology, Asahi University Hospital, Mizuho, Japan
| | - Akihiko Sugiyama
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Tatsushi Omatsu
- Department of Gastroenterology, Asahi University Hospital, Mizuho, Japan
| | - Masahiro Tawada
- Department of Surgery, Asahi University Hospital, Mizuho, Japan
| | - Chiyoko Makita
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| |
Collapse
|
25
|
Cho SB, Hur S, Kim HC, Jae HJ, Lee M, Kim M, Kim JE, Lee JH, Chung JW. Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients. Medicine (Baltimore) 2020; 99:e19630. [PMID: 32282712 PMCID: PMC7220502 DOI: 10.1097/md.0000000000019630] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Soo Buem Cho
- Department of Radiology, College of Medicine, Ewha Womans University, 25, Magokdong-ro 2-gil, Gangseo-gu
| | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul
| | - Myungsu Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul
| | - Minuk Kim
- Department of Radiology, College of Medicine, Ewha Womans University, 25, Magokdong-ro 2-gil, Gangseo-gu
| | - Jeong-Eun Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang-si
| | - Jae Hwan Lee
- Department of Radiology, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul
| |
Collapse
|
26
|
Pih GY, Ahn JY, Choi JY, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience. Surg Endosc 2020; 35:1190-1201. [PMID: 32170563 DOI: 10.1007/s00464-020-07486-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 03/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Duodenal gastrointestinal stromal tumors (GISTs) are rare, and reports on duodenal GIST bleeding are few. We analyzed the risk factors and clinical outcomes of hemorrhagic duodenal GISTs and compared them with those of gastric GISTs. METHODS Primary duodenal GISTs surgically diagnosed between January 1998 and December 2017 were retrospectively reviewed. Furthermore, patients with duodenal GIST were compared with those with primary gastric GIST histopathologically diagnosed between January 1998 and May 2015 using previously published data. RESULTS Of the 170 total patients with duodenal GISTs, 48 (28.2%) exhibited tumor bleeding. Endoscopic intervention, embolization, and non-interventional conservative treatment were performed for initial hemostasis in 17, 1, and 30 patients, respectively. The 5-year survival rate was 81.9% in the bleeding group and 89.4% in the non-bleeding group (P = 0.495). Multivariate analysis showed that p53 positivity was a significant risk factor for duodenal GIST bleeding (hazard ratio [HR] 2.781, P = 0.012), and age ≥ 60 years (HR 3.163, P = 0.027), a large maximum diameter (comparing four groups: < 2, 2-5, 5-10, and ≥ 10 cm), and mitotic count ≥ 5/high-power field (HPF) (HR 3.265, P = 0.032) were risk factors for overall survival. The incidence of bleeding was significantly higher in duodenal GISTs than in gastric GISTs (28.2% vs. 6.6%, P < 0.001), and the re-bleeding rate after endoscopic hemostasis was also higher in duodenal GISTs than in gastric GISTs (41.2% vs. 13.3%, P = 0.118). CONCLUSION In patients with duodenal GIST with old age, large tumor diameter, and mitotic count ≥ 5/HPF, a treatment plan should be established in consideration of the poor prognosis, although tumor bleeding does not adversely affect the prognosis. Duodenal GISTs have a higher incidence of tumor bleeding and re-bleeding rate after endoscopic hemostasis than gastric GISTs.
Collapse
Affiliation(s)
- Gyu Young Pih
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Ji Young Choi
- Health Promotion Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| |
Collapse
|
27
|
Chan SM, Lau JYW. Is hemospray the ultimate answer to malignant GI bleeding? Gastrointest Endosc 2020; 91:329-331. [PMID: 32036940 DOI: 10.1016/j.gie.2019.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - James Yun Wong Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| |
Collapse
|
28
|
|
29
|
Management of Bleeding from Unresectable Gastric Cancer. Biomedicines 2019; 7:biomedicines7030054. [PMID: 31344824 PMCID: PMC6784219 DOI: 10.3390/biomedicines7030054] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Bleeding from unresectable gastric cancer (URGC) is not a rare complication. Two major ways in which the management of this issue differs from the management of benign lesions are the high rate of rebleeding after successful hemostasis and that not only endoscopic therapy (ET) and transcatheter arterial embolization (TAE) but palliative radiotherapy (PRT) can be applied in the clinical setting. However, there are no specific guidelines concerning the management of URGC with bleeding. We herein discuss strategies for managing bleeding from URGC. A high rate of initial hemostasis for active bleeding is expected when using various ET modalities properly. If ET fails in patients with hemostatic instability, emergent TAE is considered in order to avoid a life-threating condition due to massive bleeding. Early PRT, especially, regimens with a high biologically effective dose (BED) of ≥39 Gy should be considered not only for patients with hemostatic failure but also for those with successful hemostasis and inactive hemorrhage, as longer duration of response with few complications can be expected. Further prospective, comparative studies considering not only the hemostatic efficacy of these modalities but the patients' quality of life are needed in order to establish treatment strategies for bleeding from URGC.
Collapse
|
30
|
Ofosu A, Ramai D, Latson W, Adler DG. Endoscopic management of bleeding gastrointestinal tumors. Ann Gastroenterol 2019; 32:346-351. [PMID: 31263356 PMCID: PMC6595926 DOI: 10.20524/aog.2019.0391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023] Open
Abstract
Bleeding due to primary or metastatic gastrointestinal (GI) tumors remains clinically challenging. Bleeding is further complicated in the setting of underlying friable neovascularization of tumors and coagulopathy. Endoscopic hemostatic therapeutic options have traditionally involved the use of thermal/mechanical therapy in conjunction with injection therapy. This review looks at the role of endoscopy in managing tumor-related GI bleeding, specifically contact and non-contact thermal therapy, radiofrequency ablation, endoloops, epinephrine and ethanol injection, and, most recently, Hemospray. Overall, current data show that endoscopic therapy is limited, with high rebleeding rates and a failure to improve overall outcomes. Larger clinical trials are needed to determine the efficacy of current techniques and establish therapeutic algorithms, with the goal of achieving primary hemostasis and reducing rebleeding rates.
Collapse
Affiliation(s)
- Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Will Latson)
| | - Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, NY (Daryl Ramai)
| | - Will Latson
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Will Latson)
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Douglas G. Adler), USA
| |
Collapse
|
31
|
Clinical outcomes of upper gastrointestinal bleeding in patients with gastric gastrointestinal stromal tumor. Surg Endosc 2019; 34:696-706. [PMID: 31062158 DOI: 10.1007/s00464-019-06816-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is one of the major manifestations of gastrointestinal stromal tumor (GIST) of the stomach. Several studies have reported that GIST bleeding is associated with poor prognosis. However, only case reports have reported hemostasis modalities for treating hemorrhagic gastric GIST. To identify clinical outcome of gastric GIST bleeding, we analyzed risk factors and prognosis of hemorrhagic GIST evaluating hemostasis methods. METHODS Total 697 patients histopathologically diagnosed with primary gastric GIST between January 1998 and May 2015 were enrolled to the study, retrospectively. RESULTS Of 697 total patients, 46 (6.6%) patients had UGIB. Endoscopic intervention, transarterial embolization, or surgical intervention was performed for initial hemostasis in 15, 2, and 1, respectively. Over a median of 68 months of follow-up, 16 patients in bleeding group and 88 patients in non-bleeding group died; the 5-year survival rate was 79.4% in bleeding group and 91.8% in non-bleeding group (p = 0.004). Multivariate analysis showed that significant risk factors for gastric GIST bleeding included the maximal tumor diameter > 5 cm and Ki-67 positivity. Age ≥ 60 [hazard ratio (HR) = 8.124, p = 0.048], necrosis (HR = 5.093, p = 0.027), and bleeding (HR 5.743, p = 0.034) were significant factors for overall survival of gastric GIST patients. CONCLUSIONS Bleeding risk of gastric GIST was higher when tumor had diameter > 5 cm or Ki-67 positivity. In addition, tumor bleeding, necrosis, and age ≥ 60 years were associated with poor overall survival. Endoscopic intervention can be considered as an effective method for initial hemostasis of hemorrhagic gastric GIST.
Collapse
|
32
|
Vitali F, Naegel A, Atreya R, Zopf S, Neufert C, Siebler J, Neurath MF, Rath T. Comparison of Hemospray ® and Endoclot ™ for the treatment of gastrointestinal bleeding. World J Gastroenterol 2019; 25:1592-1602. [PMID: 30983819 PMCID: PMC6452236 DOI: 10.3748/wjg.v25.i13.1592] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal (GI) bleeding is a common indication for endoscopy. For refractory cases, hemostatic powders (HP) represent “touch-free” agents.
AIM To analyze short term (ST-within 72 h-) and long-term (LT-within 30 d-) success for achieving hemostasis with HP and to directly compare the two agents Hemospray (HS) and Endoclot (EC).
METHODS HP was applied in 154 consecutive patients (mean age 67 years) with GI bleeding. Patients were followed up for 1 mo (mean follow-up: 3.2 mo).
RESULTS Majority of applications were in upper GI tract (89%) with following bleeding sources: peptic ulcer disease (35%), esophageal varices (7%), tumor bleeding (11.7%), reflux esophagitis (8.7%), diffuse bleeding and erosions (15.3%). Overall ST success was achieved in 125 patients (81%) and LT success in 81 patients (67%). Re-bleeding occurred in 27% of all patients. In 72 patients (47%), HP was applied as a salvage hemostatic therapy, here ST and LT success were 81% and 64%, with re-bleeding in 32%. As a primary hemostatic therapy, ST and LT success were 82% and 69%, with re-bleeding occurring in 22%. HS was more frequently applied for upper GI bleeding (P = 0.04)
CONCLUSION Both HP allow for effective hemostasis with no differences in ST, LT success and re-bleeding.
Collapse
Affiliation(s)
- Francesco Vitali
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Andreas Naegel
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Raja Atreya
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Steffen Zopf
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Clemens Neufert
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Juergen Siebler
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Markus F Neurath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| | - Timo Rath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen 91054, Germany
| |
Collapse
|
33
|
Kim YJ, Park JC, Kim EH, Shin SK, Lee SK, Lee YC. Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy. Endosc Int Open 2018; 6:E700-E705. [PMID: 29868635 PMCID: PMC5979193 DOI: 10.1055/a-0593-5884] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Despite use of various endoscopic therapies in patients with tumor-related bleeding, various rates of successful immediate hemostasis and short-term rebleeding have been reported. We aimed to evaluate preliminary results of use of the EndoClot polysaccharide hemostatic system (PHS) in patients with acute upper gastrointestinal bleeding (UGIB) from a gastric malignancy. PATIENTS AND METHODS We retrospectively analyzed data from a prospectively collected database of 12 patients with acute UGIB from a gastric malignancy who had been treated with EndoClot PHS. The EndoClot air compressor was used to propel 2 g of absorbable modified polymer particles onto the bleeding site. We checked successful immediate hemostasis, rebleeding events and mortality within 30 days. RESULTS Twelve patients were enrolled in the study. The median patient age was 72.5 years (range, 57 - 89). The initial median hemoglobin level was 6.75 g/dL (range, 5.4 - 8.9). The median systolic blood pressure was 114 mmHg (range, 86 - 153). Eleven patients had advanced gastric cancer and one patient had a gastrointestinal stromal tumor. The lower body of the stomach was the most common tumor location (58.3 %), and the median tumor size was 40 mm (range, 15 - 100). Immediate hemostasis was achieved in all patients, and rebleeding developed in 2 of 12 patients (16 %), 3 and 5 days after treatment. There were no significant Endoclot PHS-related adverse events, and there was no all-cause mortality at 30 days after the intervention. CONCLUSIONS Endoclot PHS represents a new alternative, complementary, and promising therapy for patients with an acute UGIB from a gastric malignancy.
Collapse
Affiliation(s)
- Yeong Jin Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea,Corresponding author Jun Chul Park, MD, Associate professor Division of GastroenterologyDepartment of Internal MedicineYonsei University College of Medicine50, Yonsei-ro, Seodaemun-guSeoul,Korea+82-2-2227-7877
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
34
|
Pittayanon R, Rerknimitr R, Barkun A. Prognostic factors affecting outcomes in patients with malignant GI bleeding treated with a novel endoscopically delivered hemostatic powder. Gastrointest Endosc 2018; 87:994-1002. [PMID: 29158179 DOI: 10.1016/j.gie.2017.11.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic hemostatic techniques remain poorly effective for GI tumor bleeding. We assessed Tc-325 (Hemospray, Cook Medical, Bloomington, Ind, USA) for this indication and determined possible predictors of decreased recurrent bleeding and improved 6-month survival in affected patients. METHODS This retrospective study identified 99 patients with active malignant GI bleeding (primary or metastatic) treated with Tc-325. Eleven patients were excluded because of incomplete data. Data on patient characteristics and possible predictive factors of early (72-hour) and delayed (7-, 14-, and 30-day) recurrent bleeding, as well as 6-month survival, were collected. RESULTS Overall, 70.5% were male (age, 65 ± 14 years). Half had a high Eastern Cooperative Oncology Group (ECOG) score (3 or 4). An upper GI cancer was found in 56.8%, and 72.7% cancers were stage 4. Of those affected, 51.6% received at least 1 non-endoscopic additional definitive hemostatic treatment after Tc-325. Immediate hemostasis with Tc-325 was 97.7%, with recurrent bleeding noted in 15% (early) and 17% (delayed). Six-month survival was 53.4%. On multivariable analysis, no predictive factor for recurrent bleeding was identified, whereas ECOG score 0 to 2 (P = .001; hazard ratio [HR], 0.14; 95% confidence interval [CI], 0.04-0.47), cancer stage 1 to 3 (P = .04; HR, 0.31; 95% CI, 0.10-0.96), and receiving definite hemostatic treatment alone or in any combination with surgery, chemotherapy, radiotherapy, or radiologic embolization (P = .002; HR, 0.24; 95% CI, 0.09-0.59) were significant prognosticators of 6-month survival after adjusting for comorbidity, type of cancer bleeding, and presence of a coagulopathy. CONCLUSION Before definitive therapy can be offered, Tc-325 provides effective initial hemostasis of tumoral GI bleeding. Good performance status, non-end-stage cancer, and receiving definite hemostatic treatment are independent predictors of 6-month survival. (Clinical trial registration number: NCT03066700.).
Collapse
Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital of the Thai Red Cross, Bangkok, Thailand; Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Canada
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital of the Thai Red Cross, Bangkok, Thailand
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Canada
| |
Collapse
|
35
|
Using Hemospray Improves the Cost-effectiveness Ratio in the Management of Upper Gastrointestinal Nonvariceal Bleeding. J Clin Gastroenterol 2018; 52:36-44. [PMID: 27749635 DOI: 10.1097/mcg.0000000000000709] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
GOALS We compared the cost-effectiveness of traditional recommended endoscopic hemostatic therapies and Hemospray alone or in combination when treating nonvariceal upper gastrointestinal bleeding (NVUGIB). BACKGROUND Hemospray (TC-325) is a novel endoscopic hemostatic powder, achieving hemostasis through adherence to actively bleeding biological surfaces. STUDY A decision tree of patients with NVUGIB assessed 4 possible treatment strategies: traditional therapy alone (T), Hemospray alone (H), traditional therapy completed by Hemospray if needed (T+H), or Hemospray completed by traditional therapy if needed (H+T). Using published probabilities, effectiveness was the likelihood of avoiding rebleeding over 30 days. Costs in 2014 US$ were based on the US National Inpatient Sample. A third-party payer perspective was adopted. Sensitivity and subgroup analyses were performed. RESULTS For all patients, T+H was more efficacious (97% avoiding rebleeding) and less expensive (average cost per patient of US$9150) than all other approaches. The second most cost-effective approach was H+T (5.57% less effective and US$635 more per patient). Sensitivity analyses showed T+H followed by a strategy of H+T remained more cost-effective than H or T alone when varying all probability assumptions across plausible ranges. Subgroup analysis showed that the inclusion of H (especially alone) was least adapted for ulcers and was more cost-effective when treating lesions at low risk of delayed rebleeding. CONCLUSIONS Hemospray improves the effectiveness of traditional hemostasis, being less costly in most NVUGIB patient populations. A Hemospray first approach is most cost-effective for nonulcer bleeding lesions at low risk of delayed hemorrhage.
Collapse
|
36
|
Song IJ, Kim HJ, Lee JA, Park JC, Shin SK, Lee SK, Lee YC, Chung H. Clinical Outcomes of Endoscopic Hemostasis for Bleeding in Patients with Unresectable Advanced Gastric Cancer. J Gastric Cancer 2017; 17:374-383. [PMID: 29302377 PMCID: PMC5746658 DOI: 10.5230/jgc.2017.17.e42] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/16/2022] Open
Abstract
Purpose Bleeding is one of the most serious complications of advanced gastric cancer (AGC) and is associated with a poor prognosis. This study aimed to evaluate the clinical outcomes of endoscopic hemostasis for bleeding in patients with unresectable AGC. Materials and Methods This study included 106 patients with bleeding associated with gastric cancer who had undergone endoscopic hemostasis between January 2010 and December 2013. Clinical characteristics, treatment outcomes, including rates of successful endoscopic hemostasis and rebleeding, risk factors for rebleeding, and overall survival (OS) were investigated. Results Successful initial hemostasis was achieved in 83% of patients. Rebleeding occurred in 28.3% of patients within 30 days. The median OS after initial hemostasis was lower in patients with rebleeding than in those without rebleeding (2.7 and 3.9 months, respectively, P=0.02). There were no significant differences in disease status and rebleeding rates among patients with partial response or stable disease (n=4), progressive disease (n=64), and first diagnosis of disease (n=38). Univariate and multivariate analyses (P=0.038 and 0.034, respectively) revealed that transfusion of ≥5 units of RBCs was a significant risk factor for rebleeding. Conclusions Despite favorable success rates of endoscopic hemostasis for bleeding associated with gastric cancer, the 30-day rebleeding rate was 28.3% and the median OS was significantly lower in patients with rebleeding than in those without rebleeding. Massive transfusion (≥5 units of RBCs) was the only significant risk factor for rebleeding. Patients with bleeding associated with AGC who have undergone massive transfusion should be observed closely following endoscopic hemostasis. Further research on approaches to reduce rebleeding rate and prevent death is needed.
Collapse
Affiliation(s)
- In Ji Song
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ju Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Departtment of Medicine, Yonsei University Graduate School, Seoul, Korea
| | - Ji Ae Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Departtment of Medicine, Yonsei University Graduate School, Seoul, Korea
| |
Collapse
|
37
|
Cahyadi O, Bauder M, Meier B, Caca K, Schmidt A. Effectiveness of TC-325 (Hemospray) for treatment of diffuse or refractory upper gastrointestinal bleeding - a single center experience. Endosc Int Open 2017; 5:E1159-E1164. [PMID: 29124127 PMCID: PMC5677459 DOI: 10.1055/s-0043-118794] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS TC-325 (Hemospray, Cook Medical) is a powder agent for endoscopic hemostasis in patients with upper gastrointestinal bleeding (UGIB). Although most publications are based on case-reports and retrospective studies, data on efficacy are promising. Here we report our experience with TC-325 for diffuse or refractory UGIB. PATIENTS AND METHODS Data on patients receiving TC-325 for endoscopic hemostasis from November 2013 to February 2017 at our center were analyzed retrospectively. Primary endpoints were technical success (successful immediate hemostasis) and clinical success (effective hemostasis and no recurrent bleeding). Secondary endpoints were recurrent bleeding within 3 and 7 days, hospital mortality and TC-325 associated complications. TC-325 was used for bleeding not amenable to standard endoscopic treatment (e. g. diffuse bleeding) or as salvage therapy after failure of conventional methods. RESULTS Fifty-two patients received TC-325 treatment. Most of the patients were treated for peptic ulcer bleeding (18/52 patients, 34.6 %) and post-interventional bleeding (13/52 patients, 25 %). Hemospray was used in 23/52 (44.2 %) patients as monotherapy and in 29/52 (55.8 %) patients as a salvage therapy. Application of the powder on the bleeding source was successful in all patients with no therapy-related adverse events (AEs). Immediate hemostasis was achieved in 51/52 (98.1 %) patients. Recurrent bleeding within 3 and 7 days was observed in 22/51 and 25/51 patients respectively (43.1 % and 49 %). The overall clinical success was 56.9 % on day 3 and 51 % on day 7. Total mortality was 15.4 % (8 patients), bleeding associated mortality was 3.8 % (2 patients). There were no therapy-related AEs. CONCLUSIONS TC-325 showed a high technical success rate as monotherapy for bleeding sources not amenable to standard methods or as an "add-on" therapy after unsuccessful hemostasis. However, rebleeding was frequent in this cohort and further studies are warranted to exactly define a treatment algorithm for TC-325 use.
Collapse
Affiliation(s)
- Oscar Cahyadi
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Markus Bauder
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Benjamin Meier
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Arthur Schmidt
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
- Department of Medicine II, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| |
Collapse
|
38
|
Park H, Ahn JY, Jung HY, Chun JH, Nam K, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Kim JH. Can Endoscopic Bleeding Control Improve the Prognosis of Advanced Gastric Cancer Patients?: A Retrospective Case-Control Study. J Clin Gastroenterol 2017; 51:599-606. [PMID: 27775963 DOI: 10.1097/mcg.0000000000000717] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastric bleeding is not rare and difficult to treat in gastric cancer patients. We investigated whether this affects survival and if successful bleeding control improves the prognosis. PATIENTS/MATERIAL AND METHODS We retrospectively reviewed medical records for 64 subjects who underwent endoscopic therapy for gastric cancer bleeding at Asan Medical Center from January 2012 to December 2014 (bleeding group). Each subject was matched 1:2 by age, sex, and American Joint Committee on Cancer staging with 128 randomly selected patients treated for stomach cancer during the same period (control group). Median survival, bleeding treatment methods, successful bleeding control, and rebleeding rate were investigated. RESULTS The median age was 58.5 years, the male to female ratio 4.3:1. The initial hemostasis rate was 73.4%. Most patients were treated with a single method (37 patients, 57.8%); the coagrasper (32/95 cases, 33.7%) was the most frequently used treatment. Among the 47 patients in which successful bleeding control was achieved, 17 (36.2%) experienced rebleeding after 3 days. The median survival was longer in the control than in the bleeding group (18.5 vs. 6.5 mo), and in the successful bleeding control than in the failed bleeding control group (8.5 vs. 1.8 mo). However, the successful bleeding control group had lower survival than the control group (18.5 vs. 8.5 mo). Multivariate analysis showed that the risk of bleeding was lower in Borrmann type II, IV cancer, but was higher in the patients using antiplatelet or anticoagulant. CONCLUSIONS Successful bleeding control is essential for improving survival in bleeding gastric cancer patients.
Collapse
Affiliation(s)
- Hyungchul Park
- Departments of *Internal Medicine †Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Kim YI, Kim MJ, Park SR, Kim HK, Cho SJ, Lee JY, Kim CG, Kim GH, Park MI, Nam BH, Park YI, Choi IJ. Effect of a Proton Pump Inhibitor on Tumor Bleeding Prevention in Unresectable Gastric Cancer Patients: a Double-Blind, Randomized, Placebo-Controlled Trial. J Gastric Cancer 2017; 17:120-131. [PMID: 28680717 PMCID: PMC5489541 DOI: 10.5230/jgc.2017.17.e15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/06/2017] [Accepted: 05/08/2017] [Indexed: 12/26/2022] Open
Abstract
Purpose Tumor bleeding is a major complication in inoperable gastric cancer. The study aim was to investigate the effects of proton pump inhibitor (PPI) treatment for the prevention of gastric tumor bleeding. Materials and Methods This study was a prospective double-blind, randomized, placebo-controlled trial. Patients with inoperable gastric cancer were randomly assigned to receive oral lansoprazole (30 mg) or placebo daily. The primary endpoint was the occurrence of tumor bleeding, and the secondary endpoints were transfusion requirement and overall survival (OS). Results This study initially planned to enroll 394 patients, but prematurely ended due to low recruitment rate. Overall, 127 patients were included in the analyses: 64 in the lansoprazole group and 63 in the placebo group. During the median follow-up of 6.4 months, tumor bleeding rates were 7.8% and 9.5%, in the lansoprazole and placebo groups, respectively, with the cumulative bleeding incidence not statistically different between the groups (P=0.515, Gray's test). However, during the initial 4 months, 4 placebo-treated patients developed tumor bleeding, whereas there were no bleeding events in the lansoprazole-treated patients (P=0.041, Gray's test). There was no difference in the proportion of patients who required transfusion between the groups. The OS between the lansoprazole (11.7 months) and the placebo (11.0 months) groups was not statistically different (P=0.610). Study drug-related serious adverse event or bleeding-related death did not occur. Conclusions Treating patients with inoperable gastric cancer with lansoprazole did not significantly reduce the incidence of tumor bleeding. However, further studies are needed to evaluate whether lansoprazole can prevent tumor bleeding during earlier phases of chemotherapy (ClinicalTrial.gov, identifier No. NCT02150447).
Collapse
Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Mi-Jung Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Sook Ryun Park
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea.,Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hark Kyun Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Soo-Jeong Cho
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Jong Yeul Lee
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Byung-Ho Nam
- Biometric Research Branch, Research Institute for National Cancer Control & Evaluation, National Cancer Center, Goyang, Korea
| | - Young Iee Park
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| |
Collapse
|
40
|
Park S, Shin JH, Gwon DI, Kim HJ, Sung KB, Yoon HK, Ko GY, Ko HK. Transcatheter Arterial Embolization for Gastrointestinal Bleeding Associated with Gastric Carcinoma: Prognostic Factors Predicting Successful Hemostasis and Survival. J Vasc Interv Radiol 2017; 28:1012-1021. [PMID: 28483303 DOI: 10.1016/j.jvir.2017.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To evaluate outcomes of transcatheter arterial embolization (TAE) for gastric cancer-related gastrointestinal (GI) bleeding and factors associated with successful TAE and improved survival after TAE. MATERIALS AND METHODS This retrospective study included 43 patients (34 men; age 60.6 y ± 13.6) with gastric cancer-related GI bleeding undergoing angiography between January 2000 and December 2015. Clinical course, laboratory findings, and TAE characteristics were reviewed. Technical success of TAE was defined as target area devascularization, and clinical success was defined as bleeding cessation with hemodynamic stability during 72 hours after TAE. Student t test was used for comparison of continuous variables, and Fisher exact test was used for categorical variables. Univariate and multivariate analysis were performed to identify predictors of successful TAE and 30-day survival after TAE. RESULTS TAE was performed in 40 patients. Technical and clinical success rates of TAE were 85.0% and 65.0%, respectively. Splenic infarction occurred in 2 patients as a minor complication. Rebleeding after TAE occurred in 7 patients. Death related to bleeding occurred in 5 patients. Active bleeding (P = .044) and higher transfusion requirement (3.3 U ± 2.6 vs 1.8 U ± 1.7; P = .039) were associated with TAE failure. Successful TAE predicted improved 30-day survival after TAE on univariate and multivariate analysis (P = .018 and P = .022; odds ratio, 0.132). CONCLUSION TAE for gastric cancer-associated GI bleeding may be a lifesaving procedure. Severe bleeding with a higher transfusion requirement and active bleeding on angiography predicted TAE failure.
Collapse
Affiliation(s)
- Sangik Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea.
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Heung Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul 138-736, Korea
| |
Collapse
|
41
|
Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy: Natural History, Management, and Outcomes. Dig Dis Sci 2017; 62:491-501. [PMID: 28032204 DOI: 10.1007/s10620-016-4368-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/27/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal (GI) tumor bleeding can vary from occult bleeding to massive hemorrhage and can be the presenting sign of malignancy. AIMS Our primary aims were to: (1) characterize the natural history, treatment, and outcomes in patients with GI tumor bleeding and (2) compare and contrast bleeding in upper GI (UGI)/small bowel (SB) and lower GI malignancies. METHODS Patients with endoscopically confirmed tumor bleeding were identified through search of consecutive electronic medical records: Bleeding was determined by the presence of melena, hematochezia, hematemesis, or fecal occult blood. Comprehensive clinical and management data were abstracted. RESULTS A total of 354 patients with GI tumors were identified: 71 had tumor bleeding (42 UGI/SB and 29 colonic). GI bleeding was the initial presenting symptom of malignancy in 55/71 (77%) of patients; 26/71 patients had widely metastatic disease at presentation. Further, 15 of 26 patients with metastatic disease presented with GI bleeding. Visible bleeding was present in 14/42 (33%) and 4/29 (14%) of UGI/SB and colonic tumors, respectively. Endoscopic hemostasis was attempted in 10 patients, and although initial control was successful in all, bleeding recurred in all of these patients. The most common endoscopic lesion was clean-based tumor ulceration. Overall mortality at 1 year was 57% for esophageal/gastric, 14% for SB, and 33% for colonic tumors. CONCLUSIONS When patients with GI malignancy present with GI bleeding, it is often the index symptom. Initial endoscopic hemostasis is often successful, but rebleeding is typical. Esophageal and gastric tumors carry the poorest prognosis, with a high 1-year mortality rate.
Collapse
|
42
|
Xavier S, Magalhães J, Rosa B, Cotter J. Hemospray use in upper gastrointestinal bleeding from tumor: Is it the answer? Endosc Int Open 2016; 4:E1331-E1332. [PMID: 27995200 PMCID: PMC5161129 DOI: 10.1055/s-0042-121800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sofia Xavier
- Corresponding author Sofia
Xavier Hospital Senhora da
OliveiraGastroenterology dos
CutileirosCreixomil
GuimarãesGuimarães
4835-044Portugal+351-253-540330
+253513592
| | | | | | | |
Collapse
|
43
|
Abstract
Recent studies could demonstrate that neoadjuvant chemotherapy and radiochemotherapy for esophageal and gastric cancer do not significantly increase the risk of postoperative morbidity and mortality as compared to surgery alone. With respect to patient safety and effectiveness of neoadjuvant concepts, quality assured performance of each treatment modality and close interdisciplinary cooperation play an important role. The majority of potential side effects and complications, which might occur during neoadjuvant therapy can be adequately controlled by correct prophylaxis and professional medical complication management. Complications before, during and after neoadjuvant therapy of upper gastrointestinal tract tumors can also be caused by the tumor itself or by medicinal therapy. These comprise bleeding, fistulas, perforations and stenoses. Modern endoscopic techniques are the therapy of choice in these situations. Preoperative conditioning during the period of neoadjuvant therapy opens the possibility of reduced postoperative complications to patients with tumors of the upper gastrointestinal tract.
Collapse
|
44
|
Folkert IW, Roses RE. Value in palliative cancer surgery: A critical assessment. J Surg Oncol 2016; 114:311-5. [PMID: 27393738 DOI: 10.1002/jso.24303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/22/2016] [Indexed: 12/11/2022]
Abstract
Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Ian W Folkert
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
45
|
Kim YI, Choi IJ. Endoscopic management of tumor bleeding from inoperable gastric cancer. Clin Endosc 2015; 48:121-7. [PMID: 25844339 PMCID: PMC4381138 DOI: 10.5946/ce.2015.48.2.121] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 01/10/2023] Open
Abstract
Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated.
Collapse
Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| |
Collapse
|