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Zetner D, Rasmussen IR, Frykman CP, Jensen LR, Jensen RJ, Possfelt-Møller E, Taudorf M, Penninga L. Risk factors for rebleeding and mortality following prophylactic transarterial embolization for patients with high-risk peptic ulcer bleeding: a single-center retrospective cohort study. Surg Endosc 2024; 38:2010-2018. [PMID: 38413471 PMCID: PMC10978705 DOI: 10.1007/s00464-024-10709-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/21/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND To investigate factors associated with risk for rebleeding and 30-day mortality following prophylactic transarterial embolization in patients with high-risk peptic ulcer bleeding. METHODS We retrospectively reviewed medical records and included all patients who had undergone prophylactic embolization of the gastroduodenal artery at Rigshospitalet, Denmark, following an endoscopy-verified and treated peptic Sulcer bleeding, from 2016 to 2021. Data were collected from electronic health records and imaging from the embolization procedures. Primary outcomes were rebleeding and 30-day mortality. We performed logistical regression analyses for both outcomes with possible risk factors. Risk factors included: active bleeding; visible hemoclips; Rockall-score; anatomical variants; standardized embolization procedure; and number of endoscopies prior to embolization. RESULTS We included 176 patients. Rebleeding occurred in 25% following embolization and 30-day mortality was 15%. Not undergoing a standardized embolization procedure increased the odds of both rebleeding (odds ratio 3.029, 95% confidence interval (CI) 1.395-6.579) and 30-day overall mortality by 3.262 (1.252-8.497). More than one endoscopy was associated with increased odds of rebleeding (odds ratio 2.369, 95% CI 1.088-5.158). High Rockall-score increased the odds of 30-day mortality (odds ratio 2.587, 95% CI 1.243-5.386). Active bleeding, visible hemoclips, and anatomical variants did not affect risk of rebleeding or 30-day mortality. Reasons for deviation from standard embolization procedure were anatomical variations, targeted treatment without embolizing the gastroduodenal artery, and technical failure. CONCLUSIONS Deviation from the standard embolization procedure increased the risk of rebleeding and 30-day mortality, more than one endoscopy prior to embolization was associated with higher odds of rebleeding, and a high Rockall-score increased the risk of 30-day mortality. We suggest that patients with these risk factors are monitored closely following embolization. Early detection of rebleeding may allow for proper and early re-intervention.
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Affiliation(s)
- Dennis Zetner
- Department of Radiology, North Zealand Hospital, Copenhagen University Hospital, Hilleroed, Denmark.
| | - Ida Roost Rasmussen
- Department of Surgery, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | | | - Lasse Rehné Jensen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ruben Juul Jensen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emma Possfelt-Møller
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikkel Taudorf
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Luit Penninga
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Alali M, Cao C, Shin JH, Jeon G, Zeng CH, Park JH, Aljerdah S, Aljohani S. Preliminary report on embolization with quick-soluble gelatin sponge particles for angiographically negative acute gastrointestinal bleeding. Sci Rep 2024; 14:6438. [PMID: 38499668 PMCID: PMC10948793 DOI: 10.1038/s41598-024-56992-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024] Open
Abstract
Prophylactic embolization is usually performed using gelatin sponge particles, which are absorbed within several weeks, for managing angiographically negative gastrointestinal bleeding. This study aimed to evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) with quick-soluble gelatin sponge particles (QS-GSP) that dissolve in less than 4 h for treating angiographically negative gastrointestinal bleeding. We included ten patients (M:F = 7:3; mean age, 64.3 years) who underwent prophylactic TAE with QS-GSP for angiographically negative acute gastrointestinal bleeding between 2021 and 2023. The technical success rate of TAE, clinical outcomes focusing on rebleeding, and procedure-related complications were evaluated. The embolized arteries were the gastroduodenal (n = 3), jejunal (n = 4), and ileal (n = 3) arteries. QS-GSP (150-350 µm or 350-560 µm) were used alone (n = 8) or in combination with a coil (n = 1). A 100% technical success rate was accomplished. In 1 patient (10%), rebleeding occurred 2 days after prophylactic TAE of the gastroduodenal artery, and this was managed by repeat TAE. There were no procedure-related complications. The use of QS-GSP for prophylactic TAE appears to be safe and effective for controlling bleeding among patients with angiographically negative gastrointestinal bleeding. There were no cases of related ischemic complications of the embolized bowels likely attributable to recanalization of the affected arteries following biodegradation of QS-GSP.
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Affiliation(s)
- Meshari Alali
- Department of Radiology, Majmaah University, Almajmaah, Saudi Arabia
| | - Chuanwu Cao
- Department of Radiology, The Tenth People's Hospital, Shanghai, China
| | - Ji Hoon Shin
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Gayoung Jeon
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chu Hui Zeng
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jung-Hoon Park
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Shakir Aljerdah
- Department of Radiology, Najran University, Najran, Saudi Arabia
| | - Sultan Aljohani
- Department of Radiology, King Salman Bin Abdulaziz Medical City, Medina, Saudi Arabia
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Ini' C, Distefano G, Sanfilippo F, Castiglione DG, Falsaperla D, Giurazza F, Mosconi C, Tiralongo F, Foti PV, Palmucci S, Venturini M, Basile A. Embolization for acute nonvariceal bleeding of upper and lower gastrointestinal tract: a systematic review. CVIR Endovasc 2023; 6:18. [PMID: 36988839 DOI: 10.1186/s42155-023-00360-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Acute non-variceal gastrointestinal bleedings (GIBs) are pathological conditions associated with significant morbidity and mortality. Embolization without angiographic evidence of contrast media extravasation is proposed as an effective procedure in patients with clinical and/or laboratory signs of bleeding. The purpose of this systematic review is to define common clinical practice and clinical and technical outcomes of blind and preventive embolization for upper and lower gastrointestinal bleeding. MAIN BODY Through the PubMed, Embase and Google Scholar database, an extensive search was performed in the fields of empiric and preventive embolization for the treatment of upper and lower gastrointestinal bleedings (UGIB and LGIB). Inclusion criteria were: articles in English for which it has been possible to access the entire content; adults patients treated with empiric or blind transcatheter arterial embolization (TAE) for UGIB and/or LGIB. Only studies that analysed clinical and technical success rate of blind and empiric TAE for UGIB and/or LGIB were considered for our research. Exclusion criteria were: recurrent articles from the same authors, articles written in other languages, those in which the entire content could not be accessed and that articles were not consistent to the purposes of our research. We collected pooled data on 1019 patients from 32 separate articles selected according to the inclusion and exclusion criteria. 22 studies focused on UGIB (total 773 patients), one articles focused on LGIB (total 6 patients) and 9 studies enrolled patients with both UGIB and LGIB (total 240 patients). Technical success rate varied from 62% to 100%, with a mean value of 97.7%; clinical success rate varied from 51% to 100% with a mean value of 80%. The total number of complications was 57 events out of 1019 procedures analysed. CONCLUSION TAE is an effective procedure in the treatment of UGIB patients in which angiography does not demonstrate direct sign of ongoing bleeding. The attitude in the treatment of LGIBs must be more prudent in relation to poor vascular anastomoses and the high risk of intestinal ischemia. Blind and preventive procedures cumulatively present a relatively low risk of complications, compared to a relatively high technical and clinical success.
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Affiliation(s)
- Corrado Ini'
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy.
| | - Giulio Distefano
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. 'Policlinico-Vittorio Emanuele', Catania, Italy
| | - Davide Giuseppe Castiglione
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Daniele Falsaperla
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Francesco Giurazza
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Cristina Mosconi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Francesco Tiralongo
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Pietro Valerio Foti
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Stefano Palmucci
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Circolo Hospital, Insubria University, Viale Luigi Borri 57, 21100, Varese, Italy
| | - Antonio Basile
- Department of Medical Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania -Radiology I Unit, University Hospital Policlinico "G. Rodolico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
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Prophylactic arterial embolization in patients with bleeding peptic ulcers following endoscopic control of bleeding. Hippokratia 2022. [DOI: 10.1002/14651858.cd014999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Boros E, Sipos Z, Hegyi P, Teutsch B, Frim L, Váncsa S, Kiss S, Dembrovszky F, Oštarijaš E, Shawyer A, Erőss B. Prophylactic transcatheter arterial embolization reduces rebleeding in non-variceal upper gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2021; 27:6985-6999. [PMID: 34790019 PMCID: PMC8567479 DOI: 10.3748/wjg.v27.i40.6985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/25/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite the improvement in the endoscopic hemostasis of non-variceal upper gastrointestinal bleeding (NVUGIB), rebleeding remains a major concern.
AIM To assess the role of prophylactic transcatheter arterial embolization (PTAE) added to successful hemostatic treatment among NVUGIB patients.
METHODS We searched three databases from inception through October 19th, 2020. Randomized controlled trials (RCTs) and observational cohort studies were eligible. Studies compared patients with NVUGIB receiving PTAE to those who did not get PTAE. Investigated outcomes were rebleeding, mortality, reintervention, need for surgery and transfusion, length of hospital (LOH), and intensive care unit (ICU) stay. In the quantitative synthesis, odds ratios (ORs) and weighted mean differences (WMDs) were calculated with the random-effects model and interpreted with 95% confidence intervals (CIs).
RESULTS We included a total of 3 RCTs and 9 observational studies with a total of 1329 patients, with 486 in the intervention group. PTAE was associated with lower odds of rebleeding (OR = 0.48, 95%CI: 0.29–0.78). There was no difference in the 30-d mortality rates (OR = 0.82, 95%CI: 0.39–1.72) between the PTAE and control groups. Patients who underwent PTAE treatment had a lower chance for reintervention (OR = 0.48, 95%CI: 0.31–0.76) or rescue surgery (OR = 0.35, 95%CI: 0.14–0.92). The LOH and ICU stay was shorter in the PTAE group, but the difference was non-significant [WMD = -3.77, 95%CI: (-8.00)–0.45; WMD = -1.33, 95%CI: (-2.84)–0.18, respectively].
CONCLUSION PTAE is associated with lower odds of rebleeding and any reintervention in NVUGIB. However, further RCTs are needed to have a higher level of evidence.
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Affiliation(s)
- Eszter Boros
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
- First Department of Internal Medicine, St. George University Teaching Hospital of County Fejér, Székesfehérvár 8000, Hungary
| | - Zoltán Sipos
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
- Szentágothai Research Center, University of Pecs, Pécs 7624, Hungary
| | - Brigitta Teutsch
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
| | - Levente Frim
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged 6720, Hungary
| | - Fanni Dembrovszky
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
| | - Eduard Oštarijaš
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
| | - Andrew Shawyer
- Department of Interventional Radiology, University Hospitals Dorset NHS Foundation Trust, Bournemouth BH7 7DW, United Kingdom
| | - Bálint Erőss
- Institute for Translational Medicine, University of Pecs, Medical School, Pécs 7624, Hungary
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Authors' Reply: Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease. J Vasc Interv Radiol 2021; 32:1390-1391. [PMID: 34197914 DOI: 10.1016/j.jvir.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
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Yu Q, Liu C, Collura B, Navuluri R, Patel M, Yu Z, Ahmed O. Prophylactic transcatheter arterial embolization for high-risk ulcers following endoscopic hemostasis: a meta-analysis. World J Emerg Surg 2021; 16:29. [PMID: 34112185 PMCID: PMC8194167 DOI: 10.1186/s13017-021-00371-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
Background To conduct a meta-analysis to assess the safety and efficacy of prophylactic transcatheter arterial embolization (PTAE) for the treatment of high-risk bleeding peptic ulcers after achieving endoscopic hemostasis. Methods PubMed and Cochrane Library were queried for full-text articles published up to December 2019. The following keywords were used: “prophylactic embolization”, “supplement embolization”, “gastrointestinal bleeding”, and “ulcer bleeding”. High-risk ulcers were defined based on endoscopic findings (i.e., large ulcers, Forrest class I-IIb) and/or clinical presentation (i.e., hypotension, decreased hemoglobin during endoscopy). Only comparative studies investigating PTAE versus conservative treatment after achieving endoscopic hemostasis were included. Baseline study characteristics, rebleeding rate, need for surgery, mortality, and PTAE-related complication rates were investigated. Quantitative analyses were performed with Stata 15.1. Results Among the five included original studies, a total of 265 patients received PTAE and 617 were managed conservatively after endoscopy. The rebleeding rate (6.8% vs 14.3%, p = 0.003) and mortality (4.5% vs 8.8%, p = 0.032) of patients from the PTAE group were lower than the control group. PTAE also reduced the cumulative need for future surgical intervention (3.0% vs 14.4%, p = 0.005). The PTAE-related major and minor events were 0.75% and 14.4%, respectively. Conclusion PTAE had therapeutic potentials in reducing rebleeding risk, need for surgical intervention, and morality in high-risk peptic ulcers after achieving endoscopic hemostasis. The embolization-associated adverse events were minimal. Future studies should aim to increase the sample size and resources for performing endovascular interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00371-2.
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Affiliation(s)
- Qian Yu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan City, Shandong Province, China.,Department of General Surgery, Cleveland Clinic Florida, Florida, USA
| | - Chenyu Liu
- School of Medicine, George Washington University, Washington DC, USA
| | | | - Rakesh Navuluri
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Mikin Patel
- Department of Radiology, University of Arizona Medical Center, Tucson, AZ, USA
| | - Zhiyong Yu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan City, Shandong Province, China.
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
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Lan T, Tong H, Qian S, Wei B, Huang Z, Wu H, Tan Q, Gao J, Bai S, Gong H, Jiang T, Yang J, Zhang Q, Hu B, Tang C. Prophylactic transcatheter angiographic embolization reduces Forrest IIa ulcer rebleeding: A retrospective study. Medicine (Baltimore) 2021; 100:e23855. [PMID: 33725926 PMCID: PMC7982249 DOI: 10.1097/md.0000000000023855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2020] [Indexed: 02/07/2023] Open
Abstract
The application of transcatheter angiographic embolization (TAE) is controversial in the treatment of ulcer bleeding. This study aims to determine rebleeding risk factors and evaluate the efficacy of prophylactic TAE (p-TAE) following endoscopic hemostasis in rebleeding prevention of Forrest lla ulcers.The medical records of Forrest lla ulcer patients who underwent endoscopic hemostasis (E group) and endoscopic hemostasis plus p-TAE (E + p-TAE group) in West China Hospital from May 2009 to May 2018 were retrospectively reviewed. Baseline characteristics, clinical efficacy, and rebleeding risk factors were analyzed.As a result, a total of 102 patients were included, with 75 and 27 patients in E and E + p-TAE group, respectively. Most of the baseline data in E and E + p-TAE group were similar except for the proportion of protruded non-bleeding visible vessel (NBVV) (E group vs E + p-TAE group, 50.7% vs 74.1%, P = .035). The rebleeding rate of E + p-TAE group (3.7%) was significantly lower than E group (24.0%) (P = .02). The protruded NBVV (OR: 6.896, 95% confidence interval [CI]: 1.532-30.642, P = .01) and employment of p-TAE (OR: 0.038, 95% CI: 0.003-0.448, P = .009) were identified as independent risk factors for Forrest IIa ulcer rebleeding. Additionally, log-rank test indicated the rebleeding occurrence was greatly reduced by p-TAE in patients with protruded NBVVs (P = .006).In conclusion, the protruded NBVV and employment of p-TAE were the independent risk factors tightly associated with rebleeding of Forrest IIa ulcer. P-TAE following endoscopic hemostasis could effectively prevent Forrest IIa ulcer from rebleeding.
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Affiliation(s)
- Tian Lan
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | - Shuaijie Qian
- West China School of Medicine, Sichuan University, Chengdu
| | - Bo Wei
- Department of Gastroenterology
| | | | - Hao Wu
- Department of Gastroenterology
| | | | - Jinhang Gao
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | | | - Ting Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinhui Yang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | | | - Bing Hu
- Department of Gastroenterology
| | - Chengwei Tang
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
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Mille M, Engelhardt T, Stier A. Bleeding Duodenal Ulcer: Strategies in High-Risk Ulcers. Visc Med 2021; 37:52-62. [PMID: 33718484 PMCID: PMC7923890 DOI: 10.1159/000513689] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute peptic ulcer bleeding is still a major reason for hospital admission. Especially the management of bleeding duodenal ulcers needs a structured therapeutic approach due to the higher morbidity and mortality compared to gastric ulcers. Patient with these bleeding ulcers are often in a high-risk situation, which requires multidisciplinary treatment. SUMMARY This review provides a structured approach to modern management of bleeding duodenal ulcers and elucidates therapeutic practice in high-risk situations. Initial management including pharmacologic therapy, risk stratification, endoscopy, surgery, and transcatheter arterial embolization are reviewed and their role in the management of bleeding duodenal ulcers is critically discussed. Additionally, a future perspective regarding prophylactic therapeutic approaches is outlined. KEY MESSAGES Beside pharmacotherapeutic and endoscopic advances, bleeding management of high-risk duodenal ulcers is still a challenge. When bleeding persists or rebleeding occurs and the gold standard endoscopy fails, surgical and radiological procedures are indicated to manage ulcer bleeding. Surgical procedures are performed to control hemorrhage, but they are still associated with a higher morbidity and a longer hospital stay. In the meantime, transcatheter arterial embolization is recommended as an alternative to surgery and more often replaces surgery in the management of failed endoscopic hemostasis. Future studies are needed to improve risk stratification and therefore enable a better selection of high-risk ulcers and optimal treatment. Additionally, the promising approach of prophylactic embolization in high-risk duodenal ulcers has to be further investigated to reduce rebleeding and improve outcomes in these patients.
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Affiliation(s)
- Markus Mille
- Department of General and Visceral Surgery, HELIOS Hospital Erfurt, Erfurt, Germany
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Chang JHE, Lye TJY, Zhu HZ, Syn NL, Tang SS, Gogna A, Chan WH, Ong HS, Tan JTH, Lim CH. Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease. J Vasc Interv Radiol 2021; 32:576-584.e5. [PMID: 33526343 DOI: 10.1016/j.jvir.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
The present systematic review determined the role of transarterial embolization (TAE) as a prophylactic treatment in bleeding peptic ulcers after initial successful endoscopic hemostasis. PubMed and Ovid Medline databases were searched from inception until July 2019 for studies that included patients deemed high-risk based on Forrest Classification, Rockall score ≥ 5, or endoscopic evaluation in addition to those who underwent prophylactic TAE after initial successful endoscopic hemostasis. Meta-analysis was performed to compare patients who underwent endoscopic therapy (ET) and TAE with those who underwent ET alone. The primary outcomes measured included rates of rebleeding, reintervention, and 30-day mortality. Secondary outcome measures evaluated length of hospitalization, technical success rates, and complications associated with TAE. Of 916 publications, 5 were eligible for inclusion; 310 patients with high-risk peptic ulcer bleeding underwent prophylactic TAE, and 255 were compared against a control group of 580 patients that underwent standard treatment with ET alone. Patients who underwent ET with TAE had lower 30-day rebleeding rates (odds ratio [OR], 0.35; 95% confidence interval [CI] 0.15-0.85; P = .02; I2 = 50%). The ET with TAE group had a lower 30-day mortality rate (OR, 0.28; 95% CI, 0.10-0.83; P = .02; I2 = 58%). There was no difference in pooled reintervention rates (OR, 0.68; 95% CI, 0.43-1.08; P = .10; I2 = 0%) and length of hospitalization (mean difference, -0.32; 95% CI, -1.88 to 1.24; P = .69; I2 = 0%). Technical success rate of prophylactic TAE was 90.5% (95% CI, 83.09-97.98; I2 = 75.9%). Pooled proportion of overall complication rate was 0.18% (95% CI, 0.00-1.28; I2 = 0%). Prophylactic TAE has lower rebleeding and mortality with a good success rate and low complications. Prophylactic TAE after primary ET may be recommended for selected patients with high-risk bleeding ulcers; however, further studies should be performed to establish this as a routine tool in patients with bleeding peptic ulcer disease.
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Affiliation(s)
- Jasmine H E Chang
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital
| | - Tiffany J Y Lye
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital.
| | - Hong Zhi Zhu
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Nicholas L Syn
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Sarah S Tang
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital
| | - Weng Hoong Chan
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital
| | - Hock Soo Ong
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital
| | - Jeremy Tian Hui Tan
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital
| | - Chin Hong Lim
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital
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Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 2020; 15:3. [PMID: 31921329 PMCID: PMC6947898 DOI: 10.1186/s13017-019-0283-9] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Dieter G. Weber
- Royal Perth Hospital, Perth, Australia & The University of Western Australia, Crawley, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fabio C. Campanile
- Division of Surgery, ASL VT - Ospedale “Andosilla”, Civita Castellana, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Michael D. Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Andrew Peitzman
- University of Pittsburgh, School of Medicine, UPMC – Presbyterian, Pittsburgh, PA USA
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Marco Ceresoli
- Department of General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Michael Sugrue
- Letterkenny University Hospital, Donegal Clinical Research Academy Centre for Personalized Medicine, Donegal, Ireland
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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12
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Kaminskis A, Ivanova P, Kratovska A, Ponomarjova S, Ptašņuka M, Demičevs J, Demičeva R, Boka V, Pupelis G. Endoscopic hemostasis followed by preventive transarterial embolization in high-risk patients with bleeding peptic ulcer: 5-year experience. World J Emerg Surg 2019; 14:45. [PMID: 31516544 PMCID: PMC6734378 DOI: 10.1186/s13017-019-0264-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease is one of the leading causes of death in patients with non-variceal bleeding, resulting in up to 10% mortality rate, and the patient group at high risk of rebleeding (Forrest IA, IB, and IIA) often requires additional therapy after endoscopic hemostasis. Preventive transarterial embolization (P-TAE) after endoscopic hemostasis was introduced in our institution in 2014. The aim of the study is an assessment of the intermediate results of P-TAE following primary endoscopic hemostasis in patients with serious comorbid conditions and high risk of rebleeding. Methods During the period from 2014 to 2018, a total of 399 patients referred to our institution with a bleeding peptic ulcer, classified as type Forrest IA, IB, or IIA with the Rockall score ≥ 5, after endoscopic hemostasis was prospectively included in two groups—P-TAE group and control group, where endoscopy alone (EA) was performed. The P-TAE patients underwent flow-reducing left gastric artery or gastroduodenal artery embolization according to the ulcer type. The rebleeding rate, complications, frequency of surgical interventions, transfused packed red blood cells (PRBC), amount of fresh frozen plasma (FFP), and mortality rate were analyzed. Results From 738 patients with a bleeding peptic ulcer, 399 were at high risk for rebleeding after endoscopic hemostasis. From this cohort, 58 patients underwent P-TAE, and 341 were allocated to the EA. A significantly lower rebleeding rate was observed in the P-TAE group, 3.4% vs. 16.2% in the EA group; p = 0.005. The need for surgical intervention reached 10.3% vs. 20.6% in the P-TAE and EA groups accordingly; p = 0.065. Patients that underwent P-TAE required less FFP, 1.3 unit vs. 2.6 units in EA; p = 0.0001. The mortality rate was similar in groups with a tendency to decrease in the P-TAE group, 5.7% vs. 8.5% in EA; p = 0.417. Conclusion P-TAE is a feasible and safe procedure, and it may reduce the rebleeding rate and the need for surgical intervention in patients with a bleeding peptic ulcer when the rebleeding risk remains high after primary endoscopic hemostasis.
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Affiliation(s)
| | | | - Aina Kratovska
- 1Riga East University Hospital, University of Latvia, Riga, Latvia
| | | | | | | | | | | | - Guntars Pupelis
- 1Riga East University Hospital, University of Latvia, Riga, Latvia.,2Riga Stradins University, Riga, Latvia
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13
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Park M, Kim JW, Shin JH. Endovascular hemostasis for endoscopic procedure-related gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Minho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Lau JYW, Pittayanon R, Wong KT, Pinjaroen N, Chiu PWY, Rerknimitr R, Holster IL, Kuipers EJ, Wu KC, Au KWL, Chan FKL, Sung JJY. Prophylactic angiographic embolisation after endoscopic control of bleeding to high-risk peptic ulcers: a randomised controlled trial. Gut 2019; 68:796-803. [PMID: 29802172 DOI: 10.1136/gutjnl-2018-316074] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In the management of patients with bleeding peptic ulcers, recurrent bleeding is associated with high mortality. We investigated if added angiographic embolisation after endoscopic haemostasis to high-risk ulcers could reduce recurrent bleeding. DESIGN After endoscopic haemostasis to their bleeding gastroduodenal ulcers, we randomised patients with at least one of these criteria (ulcers≥20 mm in size, spurting bleeding, hypotensive shock or haemoglobin<9 g/dL) to receive added angiographic embolisation or standard treatment. Our primary endpoint was recurrent bleeding within 30 days. RESULTS Between January 2010 and July 2014, 241 patients were randomised (added angiographic embolisation n=118, standard treatment n=123); 22 of 118 patients (18.6%) randomised to angiography did not receive embolisation. In an intention-to-treat analysis, 12 (10.2%) in the embolisation and 14 (11.4%) in the standard treatment group reached the primary endpoint (HR 1.14, 95% CI 0.53 to 2.46; p=0.745). The rate of reinterventions (13 vs 17; p=0.510) and deaths (3 vs 5, p=0.519) were similar. In a per-protocol analysis, 6 of 96 (6.2%) rebled after embolisation compared with 14 of 123 (11.4%) in the standard treatment group (HR 1.89, 95% CI 0.73 to 4.92; p=0.192). None of 96 patients died after embolisation compared with 5 (4.1%) deaths in the standard treatment group (p=0.108). In a posthoc analysis, embolisation reduced recurrent bleeding only in patients with ulcers≥15 mm in size (2 (4.5%) vs 12 (23.1%); p=0.027). CONCLUSIONS After endoscopic haemostasis, added embolisation does not reduce recurrent bleeding. TRIAL REGISTRATION NUMBER NCT01142180.
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Affiliation(s)
- James Y W Lau
- Institute of Digestive Disease, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Rapat Pittayanon
- Department of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ka-Tak Wong
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Hong Kong, China
| | - Nutcha Pinjaroen
- Department of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Philip Wai Yan Chiu
- Institute of Digestive Disease, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Rungsun Rerknimitr
- Department of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ingrid Lisanne Holster
- Department of Gastroenterology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Kai-Chun Wu
- Institute of Digestive Disease, Xijing Hospital, Xian, China
| | - Kim W L Au
- Institute of Digestive Disease, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Francis K L Chan
- Institute of Digestive Disease, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Joseph J Y Sung
- Institute of Digestive Disease, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong, China
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15
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Sung JJY, Chiu PCY, Chan FKL, Lau JYW, Goh KL, Ho LHY, Jung HY, Sollano JD, Gotoda T, Reddy N, Singh R, Sugano K, Wu KC, Wu CY, Bjorkman DJ, Jensen DM, Kuipers EJ, Lanas A. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 2018; 67:1757-1768. [PMID: 29691276 PMCID: PMC6145289 DOI: 10.1136/gutjnl-2018-316276] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the 'gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.
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Affiliation(s)
- Joseph JY Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Philip CY Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James YW Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Khean-lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
| | - Lawrence HY Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jose D Sollano
- UST Hospital, University of Santo Tomas, Manila, Philippines
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Asian Healthcare Foundation, Hyderabad, India
| | - Rajvinder Singh
- Department of Medicine, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical School, Shimotsuke, Japan
| | - Kai-chun Wu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Xi’an, China
| | | | | | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angel Lanas
- Department of Gastroenterology, University Hospital, Zaragoza, Spain
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16
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Wang Y, Jia P. The role of metallic clips in transcatheter intravascular embolization for non-variceal upper gastrointestinal bleeding cases receiving unmanageable endoscopic therapy: A retrospective cohort study. Int J Surg 2018; 58:26-30. [PMID: 30144580 DOI: 10.1016/j.ijsu.2018.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/14/2018] [Accepted: 08/18/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION This study aims to explore whether metallic clips could be a kind of localizer and guider in transcatheter arterial embolization for patients with non-variceal upper gastrointestinal bleeding, who received an unmanageable endoscopic therapy. METHODS A total of 18 patients with non-variceal hemorrhage of the upper gastrointestinal tract, who received an unmanageable endoscopic therapy at *** Hospital of **** Province from July 2010 to December 2016, were included into this study. One or two metallic clips were placed on the margin of the bleeding point to be a mark during the endoscopic therapy. Then, all patients were immediately transferred to have an emergent upper gastrointestinal angiography. Bleeding vessels were embolized when found according to the guidance of the metallic clips. After the procedure, any changes of the patient's condition were closely observed and recorded. RESULTS The average transcatheter arterial embolization therapy time was 31 min, 17 patients immediately had a successful result, and the success rate of the arterial embolization therapy was 94.44%. However, the bleeding could not be stopped in one patient. This patient was transferred and underwent a surgical operation to stop the bleeding. CONCLUSION Metallic clips could play an important role in accurately locating the bleeding vessel during the trans catheter arterial embolization therapy. Furthermore, it could also improve the success rate of stopping the bleeding during intravascular embolization therapy, and shorten the time of intravascular embolization therapy.
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Affiliation(s)
- Yang Wang
- Department of Gastroenterology, Affiliated Huangyan Hospital of Wenzhou Medical University, Taizhou No 1 People's Hospital, Huangyan, 318020, Zhejiang province, China
| | - Peng Jia
- Department of Intervention, Affiliated Huangyan Hospital of Wenzhou Medical University, Taizhou No 1 People's Hospital, Huangyan, 318020, China.
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17
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Orron DE, Bloom AI, Neeman Z. The Role of Transcatheter Arterial Embolization in the Management of Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:331-349. [PMID: 29933779 DOI: 10.1016/j.giec.2018.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nearly 50 years ago, catheter angiography was introduced as a means of both diagnosing and treating nonvariceal upper gastrointestinal bleeding. Technological advances and innovations have resulted in the introduction of microcatheters that, using a coaxial technique, are capable of selecting third-order arterial branches and of delivering a wide array of embolic agents. This article reviews the imaging diagnosis of nonvariceal upper gastrointestinal bleeding, the techniques of diagnostic and therapeutic angiography, the angiographic appearance of the various etiologies of nonvariceal upper gastrointestinal bleeding, the rationale behind case-specific selection of embolic agents as well as the anticipated outcome of transcatheter arterial embolization.
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Affiliation(s)
- Dan E Orron
- Department of Radiology, Carmel Medical Center, Michal Street, Haifa 34362, Israel
| | - Allan I Bloom
- Department of Radiology, Hadassah University Medical Center, Ein Karem, Jerusalem 91120, Israel
| | - Ziv Neeman
- Medical Imaging Institute, Haemek Medical Center, Izhak Rabin Boulevard, Afula 1834111, Israel.
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18
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Ray DM, Srinivasan I, Tang SJ, Vilmann AS, Vilmann P, McCowan TC, Patel AM. Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology. World J Radiol 2017; 9:97-111. [PMID: 28396724 PMCID: PMC5368632 DOI: 10.4329/wjr.v9.i3.97] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/12/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.
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Preventive transarterial embolization in upper nonvariceal gastrointestinal bleeding. World J Emerg Surg 2017; 12:3. [PMID: 28101125 PMCID: PMC5237324 DOI: 10.1186/s13017-016-0114-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/27/2016] [Indexed: 12/19/2022] Open
Abstract
Background Transarterial embolization (TAE) is a therapeutic option for patients with a high risk of recurrent bleeding after endoscopic haemostasis. The aim of our prospective study was a preliminary assessment of the safety, efficacy, and clinical outcomes following preventive TAE in patients with non-variceal acute upper gastrointestinal bleeding (NVUGIB) with a high risk of recurrent bleeding after endoscopic haemostasis. Methods Preventive visceral angiography and TAE were performed after endoscopic haemostasis on patients with NVUGIB who were at a high risk of recurrent bleeding (PE+ group). The comparison group consisted of similar patients who only underwent endoscopic haemostasis, without preventive TAE (PE− group). The technical success of preventive TAE, the completeness of haemostasis, the incidence of rebleeding and the need for surgical intervention and the main outcomes were compared between the groups. Results The PE+ group consisted of 25 patients, and the PE− group of 50 patients, similar in age (median age 66 vs. 63 years), gender and comorbid conditions. The ulcer size at endoscopy was not significantly different (median of 152 mm vs. 127 mm). The most frequent were Forest II type ulcers, 44% in both groups. The distribution of the Forest grade was even. The median haemoglobin on admission was 8, 2 g/dl vs. 8,7 g/dl, p = 0,482, erythrocyte count was 2,7 × 1012/L vs. 2,9 × 1012/L, p = 0,727. The shock index and Rockall scores were similar, as well as and transfusion – on average, four units of packed red blood cells for the majority of patients in both groups, however, significantly more fresh frozen plasma was transfused in the PE− group, p = 0,013. The rebleeding rate was similar, while surgical treatment was needed notably more often in the PE- group, 8% vs. 35% accordingly, p = 0,012. The median ICU stay was 3 days, hospital stay – 6 days vs. 9 days, p = 0.079. The overall mortality reached 20%; in the PE+ group it was 4%, not reaching a statistically significant difference. Conclusion Preventive TAE is a feasible, safe and effective minimally invasive type of haemostasis decreasing the risk of repeated bleeding and preparing the patient for the definitive surgical intervention when indicated.
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Prophylactic Transcatheter Arterial Embolization After Successful Endoscopic Hemostasis in the Management of Bleeding Duodenal Ulcer. J Clin Gastroenterol 2015; 49:738-45. [PMID: 25319738 DOI: 10.1097/mcg.0000000000000259] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
GOALS The aim of this study was to demonstrate the new strategy of prophylactic transcatheter arterial embolization (TAE) of the gastroduodenal artery after endoscopic hemostasis of bleeding duodenal ulcers. BACKGROUND TAE is a well-established method for the treatment of recurrent or refractory ulcer bleeding resistant to endoscopic intervention, which increasingly replaces surgical procedures. A new approach for improving outcome and reducing rebleeding episodes is the supplemental and prophylactic TAE after successful endoscopic hemostasis. STUDY This retrospective study included all patients (n=117) treated from 2008 to 2012 for duodenal ulcer bleeding. After initial endoscopic hemostasis, patients were assessed regarding their individual rebleeding risk. Patients with a low rebleeding risk (n=47) were conservatively treated, patients with a high risk for rebleeding (n=55) had prophylactic TAE of the gastroduodenal artery, and patients with endoscopically refractory ulcer bleeding received immediate TAE. RESULTS The technical success of prophylactic TAE was 98% and the clinical success was 87% of cases. Rebleeding occurred in 11% of patients with prophylactic TAE and was successfully treated with repeated TAE or endoscopy. The major complication rate was 4%. Surgery was necessary in only 1 prophylactic TAE patient (0.9%) during the whole study period. Mortality associated with ulcer bleeding was 4% in patients with prophylactic TAE. CONCLUSIONS Prophylactic TAE in patients with duodenal ulcers at high risk for rebleeding was feasible, effective at preventing the need for surgery, and had low major complication rates. Given these promising outcomes, prophylactic TAE should be further evaluated as a preventative therapy in high-risk patients.
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Abstract
PURPOSE OF REVIEW Acute, nonvariceal upper gastrointestinal bleeding (UGIB) is a common medical emergency encountered worldwide. Despite medical and technological advances, it remains associated with significant morbidity and mortality. RECENT FINDINGS Rapid patient assessment and management are paramount. When indicated, upper endoscopy in patients presenting with acute UGIB is effective for both diagnosis of the bleeding site and provision of endoscopic hemostasis. Endoscopic hemostasis significantly reduces rebleeding rates, blood transfusion requirements, length of hospital stay, surgery, and mortality. Furthermore, early upper endoscopy, defined as being performed within 24 h of patient presentation, improves patient outcomes. SUMMARY A structured approach to the patient with acute UGIB that includes early hemodynamic resuscitation and stabilization, preendoscopic risk stratification using validated instruments, pharmacologic and endoscopic intervention, and postendoscopy therapy is important to optimize patient outcome and assure efficient use of medical resources.
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Loffroy R, Favelier S, Pottecher P, Estivalet L, Genson P, Gehin S, Cercueil J, Krausé D. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96:731-44. [DOI: 10.1016/j.diii.2015.05.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 05/06/2015] [Indexed: 02/08/2023]
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23
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Prophylactic arterial embolization as the possible new gold standard for high-risk peptic ulcer bleeding after achieved endoscopic hemostasis. J Clin Gastroenterol 2015; 49:448. [PMID: 25551208 DOI: 10.1097/mcg.0000000000000282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Loffroy R. Prophylactic arterial embolization in high-risk peptic ulcer bleeding after endoscopic hemostasis is achieved: a new step. Scand J Gastroenterol 2014; 49:772-3. [PMID: 24730373 DOI: 10.3109/00365521.2014.898785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Romaric Loffroy
- Department of Vascular, Oncologic and Interventional Radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital , 14 Rue Paul Gaffarel, BP77908, 21079 Dijon Cedex , France
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Laursen SB, Møller Hansen J, Andersen PE, de Muckadell OBS. Prophylactic arterial embolization in high-risk peptic ulcer bleeding after endoscopic hemostasis is achieved: a new step - authors' reply. Scand J Gastroenterol 2014; 49:774. [PMID: 24689745 DOI: 10.3109/00365521.2014.904398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Stig Borbjerg Laursen
- Department of Medical Gastroenterology, Odense University Hospital , Søndre Boulevard 29, 5000 Odense C , Denmark
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