|
1
|
Hameed H, Hussain J, Cláudia Paiva-Santos A, Zaman M, Hamza A, Sajjad I, Asad F. Comprehensive insights on treatment modalities with conventional and herbal drugs for the treatment of duodenal ulcers. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:8211-8229. [PMID: 38837070 DOI: 10.1007/s00210-024-03178-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024]
Abstract
Areas of the body accessible to gastric secretions, such as the stomach and duodenum, are most commonly damaged by circumscribed lesions of the upper gastrointestinal tract mucosa. Peptic ulcer disease is the term for this illness (PUD). About 80% of peptic ulcers are duodenal ulcers, with stomach ulcers accounting for the remaining 20%. Duodenal ulcers are linked to the two primary results about Helicobacter pylori infection and COX inhibitor users. Additional causes might include drinking, smoking, stress, and coffee consumption. The indications and symptoms of a duodenal ulcer depend on the patient's age and the lesion's location. For duodenal ulcers, proton pump inhibitors (PPIs) are the usual course of treatment. This comprehensive study included an in-depth literature search in the literature and methods section using electronic databases such as PubMed, ScienceDirect, and Google Scholar. The search method included publications published from the inception of the relevant database to the present. Inclusion criteria included studies investigating different treatment options for duodenal ulcer disease, including traditional pharmacotherapy and naturopathic treatments. Data mining includes information on treatment techniques, treatment outcomes, and possible synergies between conventional and herbal treatments. In addition, this review critically examines the available information on the effectiveness, safety, and possible side effects of different treatments. The inclusion of conventional and herbal treatments is intended to provide a comprehensive overview of the many treatment options available for duodenal ulcer disease. A more comprehensive and personalized treatment plan can be achieved by incorporating dietary changes, lifestyle modifications, and, if necessary, herbal therapies to complement other treatments normally.
Collapse
Affiliation(s)
- Huma Hameed
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan.
| | - Jahangir Hussain
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Ana Cláudia Paiva-Santos
- Department of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, 3000-548, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, 3000-548, Portugal
| | - Muhammad Zaman
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Ali Hamza
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Irsa Sajjad
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Faria Asad
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| |
Collapse
|
|
2
|
Nagpal P, Dane B, Aghayev A, Fowler KJ, Hedgire SS, Bartel TB, Cash BD, Collins JD, Kirsch DS, Lo HS, Pietryga JA, Ripley B, Santillan CS, Kim DH, Steigner ML. ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding: 2024 Update. J Am Coll Radiol 2024; 21:S433-S447. [PMID: 39488353 DOI: 10.1016/j.jacr.2024.08.021] [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: 08/22/2024] [Accepted: 08/31/2024] [Indexed: 11/04/2024]
Abstract
This document summarizes the relevant literature for the selection of the initial imaging in five clinical scenarios in patients with suspected or known nonvariceal upper gastrointestinal bleeding (UGIB). These clinical scenarios include suspected nonvariceal UGIB without endoscopy performed; endoscopically confirmed nonvariceal UGIB with clear source but treatment not possible or continued bleeding after endoscopic treatment; endoscopically confirmed nonvariceal UGIB without a confirmed source; suspected nonvariceal UGIB with negative endoscopy; and postsurgical or post-traumatic nonvariceal UGIB when endoscopy is contraindicated. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of nonvariceal UGIB. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
- Prashant Nagpal
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Bari Dane
- NYU Grossman School of Medicine, New York, New York
| | - Ayaz Aghayev
- Panel Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Kathryn J Fowler
- Panel Chair, University of California San Diego, San Diego, California
| | - Sandeep S Hedgire
- Panel Vice-Chair, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Twyla B Bartel
- Global Advanced Imaging, PLLC, Little Rock, Arkansas; Commission on Nuclear Medicine and Molecular Imaging
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Jeremy D Collins
- Mayo Clinic, Rochester, Minnesota; Society for Cardiovascular Magnetic Resonance
| | | | - Hao S Lo
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts; Committee on Emergency Radiology-GSER
| | - Jason A Pietryga
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | | | - David H Kim
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | |
Collapse
|
|
3
|
Soriani P, Biancheri P, Bonura GF, Gabbani T, Rodriguez de Santiago E, Dioscoridi L, Andrisani G, Luigiano C, Deiana S, Rainer J, Del Buono M, Amendolara R, Marino M, Hassan C, Repici A, Manno M. Over-the-scope clip as first-line treatment of peptic ulcer bleeding: a multicenter randomized controlled trial (TOP Study). Endoscopy 2024; 56:665-673. [PMID: 38599622 DOI: 10.1055/a-2303-4824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND First-line over-the-scope (OTS) clip treatment has shown higher efficacy than standard endoscopic therapy in acute nonvariceal upper gastrointestinal bleeding (NVUGIB) from different causes. We compared OTS clips with through-the-scope (TTS) clips as first-line mechanical treatment in the specific setting of peptic ulcer bleeding. METHODS We conducted an international, multicenter randomized controlled trial on consecutive patients with suspected NVUGIB. Patients with Forrest Ia-IIb gastroduodenal peptic ulcer were randomized 1:1 to OTS clip or TTS clip treatment. The primary outcome was the rate of 30-day rebleeding after successful initial hemostasis. Secondary outcomes included the rates of successful initial hemostasis and overall clinical success, defined as the composite of successful initial hemostasis and no evidence of 30-day rebleeding. RESULTS 251 patients were screened and 112 patients were randomized to OTS (n = 61) or TTS (n = 51) clip treatment. The 30-day rebleeding rates were 1.6% (1/61) and 3.9% (2/51) in patients treated with OTS clips and TTS clips, respectively (Kaplan-Meier log-rank, P = 0.46). Successful initial hemostasis rates were 98.4% (60/61) in the OTS clip group and 78.4% (40/51) in the TTS clip group (P = 0.001). Overall clinical success rates were 96.7% (59/61) with OTS clips and 74.5% (38/51) with TTS clips (P = 0.001). CONCLUSIONS Low rates of 30-day rebleeding were observed after first-line endoscopic treatment of acute peptic ulcer bleeding with either OTS or TTS clips. However, OTS clips showed higher efficacy than TTS clips in achieving successful initial hemostasis and overall clinical success.
Collapse
Affiliation(s)
- Paola Soriani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | - Paolo Biancheri
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | | | - Tommaso Gabbani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Lorenzo Dioscoridi
- Digestive and Interventional Endoscopy Unit, Niguarda Hospital, ASST Niguarda, Milan, Italy
| | - Gianluca Andrisani
- Digestive Endoscopy Unit, Campus Bio-Medico, University of Rome, Rome, Italy
| | - Carmelo Luigiano
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Simona Deiana
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | - Joachim Rainer
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | | | | | - Massimiliano Marino
- Clinical Governance Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Mauro Manno
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| |
Collapse
|
|
4
|
He K, Pang K, Ying L, Yang D, Song K, Ciren Y, Yan X, Guo Z, Lyu C, Wang Q, Wu D. Meta-analysis: Over-the-scope clips in patients at high risk of re-bleeding following upper gastrointestinal tract bleeding. Aliment Pharmacol Ther 2024; 60:112-123. [PMID: 38818831 DOI: 10.1111/apt.18093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/12/2024] [Accepted: 05/16/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Acute non-variceal upper gastrointestinal bleeding (UGIB) is challenging in patients at high risk of re-bleeding in whom standard endoscopic treatment (ST) has limited effectiveness. Over-the-scope clips (OTSC) have shown promise in these patients although their precise role remains uncertain. AIMS To confirm the role of OTSC in patients with UGIB at high risk of re-bleeding. METHODS We systematically searched CENTRAL, MEDLINE and Embase from January 1st, 1970 to April 24, 2024 for randomised controlled trials (RCTs) comparing OTSC and ST in acute non-variceal UGIB with high re-bleeding risk. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. RESULTS We analysed four RCTs (319 patients); pooled risk ratio (RR) for clinical success at initial endoscopy favoured OTSC (RR = 1.30, 95% CI = 1.08-1.56, p = 0.006, I2 = 58%, moderate certainty of evidence). TSA showed the desired sample size was 410 and the cumulative Z curve crossing the trial sequential monitoring boundary. The pooled RR for re-bleeding within 30 days favoured OTSC (RR = 0.53, 95% CI = 0.30-0.94, p = 0.03, I2 = 0%, moderate certainty of evidence). There was no significant difference in 30-day mortality, or length of hospital or ICU stay. CONCLUSIONS Moderate certainty evidence supports OTSC as a superior initial treatment for acute non-variceal UGIB with high re-bleeding risk. Further large-scale studies are needed to confirm OTSCs' role by exploring other prognostic outcomes and assessing cost-effectiveness and potential complications.
Collapse
Affiliation(s)
- Kun He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Gastroenterology, The People's Hospital of Tibetan Autonomous Region, Lhasa, China
| | - Ke Pang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lujing Ying
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Daiyu Yang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Kai Song
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yangjin Ciren
- Department of Gastroenterology, The People's Hospital of Tibetan Autonomous Region, Lhasa, China
| | - Xiaxiao Yan
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ziqi Guo
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chengzhen Lyu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qiang Wang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Dong Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of Gastroenterology, The People's Hospital of Tibetan Autonomous Region, Lhasa, China
| |
Collapse
|
|
5
|
Perry IE, Staursky D, Asfari MM, Vega KJ. Recurrent Duodenal Ulcer After Gastroduodenal Artery Embolization Due to Coil Migration Successfully Removed Endoscopically Resulting in Ulcer Healing. Cureus 2024; 16:e62972. [PMID: 38919859 PMCID: PMC11198983 DOI: 10.7759/cureus.62972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2024] [Indexed: 06/27/2024] Open
Abstract
Transarterial angiographic embolization using coils is an effective, common, and safe treatment for non-variceal upper gastrointestinal bleeding (UGIB) refractory to endoscopic therapy/management. Coil migration is a complication that can lead to rebleeding. Our patient experienced UGIB due to a recurring duodenal ulcer with coil protrusion following previous embolization for a bleeding duodenal ulcer that was not responsive to endoscopic therapy. The ulceration was successfully managed with endoscopic partial coil removal and medical therapy to achieve hemostasis and ulcer healing. Endoscopists should be aware of coil embolization complications and consider endoscopic removal in the appropriate clinical setting.
Collapse
Affiliation(s)
- Isaac E Perry
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - Daniel Staursky
- Department of Medicine, Augusta University Medical College of Georgia, Augusta, USA
| | - Mohammad Maysara Asfari
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - Kenneth J Vega
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| |
Collapse
|
|
6
|
Harada K, Kojima D, Yamana I, Seike H, Fujikawa T. Damage Control Surgery for Duodenal Ulcer Bleeding With Massive Hematoma and Perforation Due to Over-the-Scope Clip (OTSC). Cureus 2024; 16:e56359. [PMID: 38633969 PMCID: PMC11022004 DOI: 10.7759/cureus.56359] [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: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Due to the advances in endoscopic technology, surgery for duodenal ulcer (DU) bleeding has decreased, although surgery is still necessary for more complicated cases. The concept of damage control surgery (DCS) has been established in the field of trauma, and a simple surgical approach may be preferable in serious cases such as uncontrolled DU bleeding. We present a successful case of bleeding with massive hematoma and perforation of the duodenum due to an over-the-scope clip that was treated by a less invasive surgical approach with consideration of the DCS.
Collapse
Affiliation(s)
- Kei Harada
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
| | - Daibo Kojima
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
- Gastroenterological Surgery, Fukuoka University, Faculty of Medicine, Fukuoka, JPN
| | - Ippei Yamana
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
| | | | | |
Collapse
|
|
7
|
Toro Tole D, Maurel A, Hedger J, Kwan S, Weber D. A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2024; 28:309-315. [PMID: 38446116 DOI: 10.1016/j.gassur.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting. METHODS This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted. RESULTS The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data. CONCLUSION Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.
Collapse
Affiliation(s)
- David Toro Tole
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia.
| | - Amelie Maurel
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Joe Hedger
- School of Medicine, Flinders University, Darwin, Australia.
| | - Sherman Kwan
- Department of Surgery, Royal Perth Hospital, Perth, Australia
| | - Dieter Weber
- Department of Surgery, Royal Perth Hospital, Perth, Australia
| |
Collapse
|
|
8
|
Vanhoenacker C, Hufkens E, Laenen A, Bonne L, Claus E, Peluso J, Demedts I, Laleman W, Wilmer A, Maleux G. Factors influencing outcome of angiographic embolization for gastroduodenal hemorrhage related to peptic ulceration. Eur J Radiol 2023; 166:110970. [PMID: 37463549 DOI: 10.1016/j.ejrad.2023.110970] [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: 04/20/2023] [Revised: 06/19/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE Long-term outcome and prognostic factors of transcatheter embolization for gastroduodenal peptic ulcer bleeding are unknown. This study was conducted to evaluate the clinical outcome and factors associated with early recurrent bleeding and 30-day mortality of transcatheter arterial embolization (TAE) for severe, upper gastroduodenal hemorrhage associated with peptic ulcer and refractory to medical and endoscopic therapy. METHODS A monocenter, retrospective study from 2005 to 2020 including 76 consecutive patients who underwent TAE as first-line therapy for bleeding gastroduodenal peptic ulcers refractory to endoscopic therapy. Patient demographics, endoscopy findings, co-morbidities and interventional procedure findings were recorded. The outcome measures were technical and clinical success, procedure related complications, recurrent bleeding, length of hospital stay, 30-day mortality and overall survival. RESULTS The technical success rate was 96% and the clinical success rate was 65,8%. The rebleeding and 30-day mortality rate were 30,7% and 22,4% respectively. A higher international normalized ratio (INR) was a statistically significant risk factor for 30-day mortality (OR, 7.15; 95% CI, 1.67-30.70; p = 0.008). The mean overall survival was 3.76 years (1.16---5.09; 95% CI); a lower Charlson Comorbidity Index (CCI) and a lower Rockall score were significantly associated with a longer overall survival (HR, 1.24; 95% CI, 1.14-1.35; p = 0.0001; HR, 1.32; 95% CI, 1.10-1.59; p = 0.003) respectively. Early rebleeding was significantly associated with a lower overall survival (HR, 2.72; 95% CI, 1.57-4.71; p = 0.0004). CONCLUSION A higher INR was a significant risk factor with a higher 30-day mortality. A lower CCI, a lower Rockall score and the absence of early rebleeding were significantly associated with a longer overall survival.
Collapse
Affiliation(s)
- Charlotte Vanhoenacker
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Eva Hufkens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven,Herestraat 49, 3000 Leuven, Belgium.
| | - Annouschka Laenen
- Department of Public Health and Primary Care, Leuven Biostatistics and Statistical Bioinformatics Centre, Kapucijnenvoer 35, 3000 Leuven, Belgium.
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Eveline Claus
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Jo Peluso
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Ingrid Demedts
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven,Herestraat 49, 3000 Leuven, Belgium.
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven,Herestraat 49, 3000 Leuven, Belgium.
| | - Alexander Wilmer
- Department of General Internal Medicine, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| |
Collapse
|
|
9
|
Kuellmer A, Mangold T, Bettinger D, Schiemer M, Mueller J, Wannhoff A, Caca K, Wedi E, Kleemann T, Thimme R, Schmidt A. Reduced mortality for over-the-scope clips (OTSC) versus surgery for refractory peptic ulcer bleeding: a retrospective study. Surg Endosc 2023; 37:1854-1862. [PMID: 36253626 PMCID: PMC10017662 DOI: 10.1007/s00464-022-09679-9] [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: 04/13/2022] [Accepted: 09/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgery or transcatheter arterial embolization or are both considered as standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-The-Scope clips (OTSC) have shown superiority to standard endoscopic treatment but a comparison with surgery has not been performed, yet. PATIENTS AND METHODS In this retrospective, multicenter study, 103 patients treated with OTSC (n = 66) or surgery (n = 37) for refractory PUB in four tertiary care centers between 2009 and 2019 were analyzed. Primary endpoint was clinical success (successful hemostasis and no rebleeding within seven days). Secondary endpoints were adverse events, length of ICU-stay and in-hospital mortality. Univariable and multivariable regression models were performed to define predictive factors for allocation to surgical therapy and for mortality. RESULTS Age, comorbidities, anticoagulation therapy, number of pretreatments, ulcer location, and Rockall-Score were similar in both groups. In the surgical group, there were significantly more patients in shock at rebleeding (78.1% vs. 43.9%; p = 0.002), larger ulcers (18.6 ± 7.4 mm vs. 23.0 ± 9.4 mm; p = 0.017) and more FIa bleedings (64.9% vs. 19.7%; p < 0.001) were detected. Clinical success was comparable (74.2% vs. 83.8%; p = 0.329). In the surgical group, length of ICU-stay (16.2 ± 18.0 days vs. 4.7 ± 6.6 days; p < 0.001), severe adverse events (70.3% vs. 4.5%; p < 0.001) and in-hospital mortality (35.1% vs. 9.1%; p = 0.003) were significantly higher. Multivariable analysis defined shock at rebleeding as the main predictor for allocation to surgical therapy (OR 4.063, 95%CI {1.496-11.033}, p = 0.006). Postsurgical adverse events were the main reason for the in-hospital mortality (OR 5.167, 95% CI {1.311-20.363}, p = 0.019). CONCLUSION In this retrospective study, OTSC compared to surgical treatment showed comparable clinical success but was associated with shorter ICU-stay, less severe adverse events and lower in-hospital mortality.
Collapse
Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Tobias Mangold
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Moritz Schiemer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Julius Mueller
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Andreas Wannhoff
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Medizinische Klinik II / IV, Sana Klinikum Offenbach, Offenbach, Germany
| | - Tobias Kleemann
- Medinische Klinik IV, Carl-Thiem-Klinikum Cottbus, Cottbus, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| |
Collapse
|
|
10
|
Bapaye J, Chandan S, Naing LY, Shehadah A, Deliwala S, Bhalla V, Chathuranga D, Okolo PI. Safety and efficacy of over-the-scope clips versus standard therapy for high-risk nonvariceal upper GI bleeding: systematic review and meta-analysis. Gastrointest Endosc 2022; 96:712-720.e7. [PMID: 35803307 DOI: 10.1016/j.gie.2022.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Upper GI bleeding (UGIB) is a common condition associated with significant morbidity and mortality. Endoscopic hemostasis remains the mainstay of therapy and is mainly aimed at effective hemostasis and prevention of rebleeding. Lesions with high-risk stigmata can have rebleeding rates of as high as 26.3%. Rebleeding is associated with increased mortality and reduced success rates of endoscopic retreatment. The over-the-scope-clip (OTSC) is a device with widespread endoscopic indications including hemostasis for nonvariceal UGIB (NVUGIB). The current study presents a systematic review and meta-analysis comparing OTSCs versus standard therapy (STD) for NVUGIB. METHODS Multiple databases were searched through April 2022 for studies comparing OTSCs and STD for NVUGIBs. Primary outcomes were clinical success rates, rebleeding rates, and procedure times, and secondary outcomes were mortality rates and length of hospitalization. Meta-analysis was performed to determine pooled odds ratios to compare outcomes between the OTSC and STD groups. RESULTS Ten studies, including 4 randomized controlled trials, with 914 patients were included in the final analysis. Of patients with NVUGIB, 431 were treated with OTSCs and 483 with STD. Patients treated with OTSCs had an overall lower risk of 7-day (risk ratio [RR], .41; 95% confidence interval [CI], .24-.68; I2 = 0%) and 30-day rebleeding (RR, .46; 95% CI, .31-.65; I2 = 0%). Clinical success rates were higher with OTSCs compared with STD (RR, 1.36; 95% CI, 1.06-1.75). Mean procedure time was shorter in the OTSC group by 6.62 minutes (95% CI, 2.58-10.67) versus the STD group (I2 = 84%). There was no statistically significant difference in terms of mortality between the OTSC and STD groups (RR, .55; 95% CI, .24-1.24; I2 = 0%). Length of hospitalization was comparable between both groups, with a pooled mean difference for OTSCs versus STD of .87 days (95% CI, -1.62 to 3.36 days; I2 = 71%). CONCLUSIONS Although our study was limited to high-risk NVUGIB, our analysis showed that hemostasis with OTSCs is associated with a lower 7-day and 30-day rebleeding rates, higher clinical success rates, and shorter procedure time with similar mortality rates and length of hospital stay as compared with STD.
Collapse
Affiliation(s)
- Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Saurabh Chandan
- Division of Gastroenterology, CHI Health Creighton University Medical Center, Omaha, Nebraska, USA
| | - Le Yu Naing
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Ahmed Shehadah
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Smit Deliwala
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, Michigan, USA
| | - Varun Bhalla
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Dileepa Chathuranga
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Patrick I Okolo
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| |
Collapse
|
|
11
|
Caragher S, Wang D, Moonsamy P, Fagenholz P. Hepatic arterial haemorrhage caused by duodenal ulcer. BMJ Case Rep 2022; 15:e249523. [PMID: 36316056 PMCID: PMC9628537 DOI: 10.1136/bcr-2022-249523] [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] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
A man in his late 60s with prior Hartman's procedure underwent colostomy takedown and complex ventral hernia repair. He subsequently developed gastrointestinal (GI) bleeding from a duodenal bulb ulcer. Despite five endoscopic procedures aimed at achieving haemostasis, including placement of an over-the-scope clip, and four endovascular embolisations (inferior and superior pancreaticoduodenal, right gastroepiploic and gastroduodenal arteries), the patient continued to experience episodic, haemodynamically significant bleeding. He eventually required emergency exploratory laparotomy, where the proper hepatic artery was identified as the source (a previously unreported phenomenon). He underwent antrectomy and proper hepatic artery ligation. This case highlights the need to interrogate all portions of the hepatic vasculature in the treatment of refractory GI bleeding.
Collapse
Affiliation(s)
| | - Danny Wang
- General Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Philicia Moonsamy
- General Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
|
12
|
Meier B, Wannhoff A, Denzer U, Stathopoulos P, Schumacher B, Albers D, Hoffmeister A, Feisthammel J, Walter B, Meining A, Wedi E, Zachäus M, Pickartz T, Küllmer A, Schmidt A, Caca K. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut 2022; 71:1251-1258. [PMID: 35321938 DOI: 10.1136/gutjnl-2021-325300] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/26/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is managed by standard endoscopic combination therapy, but a few cases remain difficult and carry a high risk of persistent or recurrent bleeding. The aim of our study was to compare first-line over-the-scope-clips (OTSC) therapy with standard endoscopic treatment in these selected patients. DESIGN We conducted a prospective, randomised, controlled, multicentre study (NCT03331224). Patients with endoscopic evidence of acute NVUGIB and high risk of rebleeding (defined as complete Rockall Score ≥7) were included. Primary endpoint was clinical success defined as successful endoscopic haemostasis without evidence of recurrent bleeding. RESULTS 246 patients were screened and 100 patients were finally randomised (mean of 5 cases/centre and year; 70% male, 30% female, mean age 78 years; OTSC group n=48, standard group n=52). All but one case in the standard group were treated with conventional clips. Clinical success was 91.7% (n=44) in the OTSC group compared with 73.1% (n=38) in the ST group (p=0.019), with persistent bleeding occurring in 0 vs 6 in the OTSC versus standard group (p=0.027), all of the latter being successfully managed by rescue therapy with OTSC. Recurrent bleeding was observed in four patients (8.3%) in the OTSC group and in eight patients (15.4%) in the standard group (p=0.362). CONCLUSION OTSC therapy appears to be superior to standard treatment with clips when used by trained physicians for selected cases of primary therapy of NVUGIB with high risk of rebleeding. Further studies are necessary with regards to patient selection to identify subgroups benefiting most from OTSC haemostasis. TRIAL REGISTRATION NUMBER NCT03331224.
Collapse
Affiliation(s)
- Benjamin Meier
- Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Ulrike Denzer
- Gastroenterology, University of Marburg, Marburg, Germany
| | | | | | - David Albers
- Gastroenterology, Elisabeth-Krankenhaus-Essen, Essen, Germany
| | | | | | | | - Alexander Meining
- Gastroenterology, University of Ulm, Ulm, Germany.,Gastroenterology, University of Würzburg, Würzburg, Germany
| | - Edris Wedi
- Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany.,Gastroenterology, University of Göttingen, Göttingen, Germany
| | - Markus Zachäus
- Gastroenterology, Helios Park-Klinikum Leipzig, Leipzig, Germany
| | - Tilman Pickartz
- Gastroenterology, University of Greifswald, Greifswald, Germany
| | - Armin Küllmer
- Gastroenterology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Arthur Schmidt
- Gastroenterology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Karel Caca
- Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| |
Collapse
|
|
13
|
Romstad KK, Detlie TE, Søberg T, Thomas O, Ricanek P, Jahnsen ME, Lerang F, Jahnsen J. Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions - (BLUE study). Scand J Gastroenterol 2022; 57:8-15. [PMID: 34663154 DOI: 10.1080/00365521.2021.1988701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients. MATERIALS AND METHODS A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled. RESULTS Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients. CONCLUSIONS Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.
Collapse
Affiliation(s)
- Katrine Kauczynska Romstad
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trond Espen Detlie
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Taran Søberg
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Owen Thomas
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Petr Ricanek
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Marte Eide Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Frode Lerang
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
|
14
|
Kuellmer A, Mangold T, Bettinger D, Maruschke L, Wannhoff A, Caca K, Wedi E, Hosseini ASA, Kleemann T, Schulz T, Jung C, Thimme R, Schmidt A. Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis. United European Gastroenterol J 2021; 9:1048-1056. [PMID: 34432392 PMCID: PMC8598957 DOI: 10.1002/ueg2.12135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/02/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment. OBJECTIVE To compare OTSC treatment to TAE in refractory peptic ulcer bleeding. PATIENTS AND METHODS In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics. RESULTS Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant. CONCLUSIONS OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.
Collapse
Affiliation(s)
- Armin Kuellmer
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tobias Mangold
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Dominik Bettinger
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
- Berta‐Ottenstein‐ProgrammeUniversity of FreiburgFreiburgGermany
| | - Lars Maruschke
- Department of RadiologySt.‐Josef HospitalRkK‐KlinikumFreiburgGermany
| | - Andreas Wannhoff
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Karel Caca
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Edris Wedi
- Medizinische Klinik II / IVSana Klinikum OffenbachOffenbachGermany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional RadiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Tobias Kleemann
- Medinische Klinik IVCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Thomas Schulz
- Institut für RadiologieCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy UnitForlì‐Cesena HospitalsAUSL RomagnaForlì‐CesenaItaly
| | - Robert Thimme
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Arthur Schmidt
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| |
Collapse
|
|
15
|
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: 5] [Impact Index Per Article: 1.3] [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.
Collapse
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
| |
Collapse
|
|
16
|
Darmon I, Rebibo L, Diouf M, Chivot C, Riault C, Yzet T, Le Mouel JP, Regimbeau JM. Management of bleeding peptic duodenal ulcer refractory to endoscopic treatment: surgery or transcatheter arterial embolization as first-line therapy? A retrospective single-center study and systematic review. Eur J Trauma Emerg Surg 2020; 46:1025-1035. [PMID: 32246169 DOI: 10.1007/s00068-020-01356-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objective of this study was to compare the results of transcatheter arterial embolization (TAE) with surgery in terms of efficacy in the context of bleeding duodenal ulcer (BDU) refractory to endoscopic treatment. MATERIALS AND METHODS From January 2006 to December 2016, all patients treated for a BDU refractory to endoscopic treatment were included in this observational, comparative, retrospective, single-center study. Primary endpoint was the overall success of treatment of BDU requiring surgical and/or TAE. The secondary endpoints were pre-interventional data, recurrence rates, feasibility of secondary treatment, morbidity and mortality of surgical and radiological treatment, intensive care unit and length of stay. A systematic review of the literature was performed to compare results of surgery and TAE. RESULTS 59 out of 396 patients (14.9%) treated for BDU required embolization and/or surgery: 15 patients underwent surgery (group S) including 7 patients after embolization failure and 44 patients underwent TAE (group TAE). The overall treatment success in intention to treat (85.7% vs 67.3%), per protocol (80% vs 79.5%) and bleeding recurrence rates (20% vs 15.9%) were also identical. Mortality (14.2% vs 15.3%) was similar between the two groups. Our study data were pooled with data from eight published studies and suggest that surgery have significant increased overall success (68.3% vs. 55.4%, p < 0.005). CONCLUSION The overall success rate was in favour of surgery according our meta-analysis. Our single-center study highlights the fact that predictive factors for recurrent bleeding after TAE must be identified to select good candidates for TAE and/or surgery.
Collapse
Affiliation(s)
- Ilan Darmon
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Momar Diouf
- Biostatistics Unit, Clinical Research and Innovation Department, Amiens-Picardie University Hospital, 80054, Amiens, France
| | - Cyril Chivot
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Clémentine Riault
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Thierry Yzet
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean Philippe Le Mouel
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France.
- SSPC (Simplification of Surgical Patients Care), Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.
- Service de Chirurgie Digestive, CHU Amiens-Picardie, Site Sud, 1 Rond-Point du Professeur Christian Cabrol, 80054, Amiens Cedex 1, France.
| |
Collapse
|
|
17
|
Lai HY, Wu KT, Liu Y, Zeng ZF, Zhang B. Angiography and transcatheter arterial embolization for non-variceal gastrointestinal bleeding. Scand J Gastroenterol 2020; 55:931-940. [PMID: 32650690 DOI: 10.1080/00365521.2020.1790650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND GOALS Acute non-variceal gastrointestinal bleeding (NVGIB) is one of the most common medical emergencies, leading to significant morbidity and mortality without proper management. This study was to analyze the causes of NVGIB and to evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) for the treatment of NVGIB. STUDY From November 2012 to October 2018, 158 patients with NVGIB underwent digital subtraction angiography, and TAE was performed for confirmed gastrointestinal bleeding. Patient characteristics, cause of bleeding, angiographic findings, technical and clinical success rates, complication rates, and outcomes were retrospectively analyzed. RESULTS Bleeding was confirmed in 71.5% (113/158) of performed angiographies, and 68 patients had visible contrast extravasation on angiography, with the other 45 patients having indirect signs of bleeding. Among the 113 patients with confirmed gastrointestinal bleeding, TAE was technically successful in 111 patients (98.2%). The mean procedure time required for TAE was 116 ± 44 min (ranging from 50 to 225 min). The primary total clinical success rate of TAE was 84.7% (94/111). The primary clinical success rates of TAE for vascular abnormality, neoplastic disease, and iatrogenic condition were 84.5% (49/58), 84.1% (37/44), and 88.9% (8/9), respectively. Intestinal necrosis and perforation were found in two patients after TAE. CONCLUSIONS The causes of NVGIB are complex and the onset, location, risk, and clinical presentations are variable. NVGIB can be generally divided into three types: vascular abnormality, neoplastic disease, and iatrogenic condition. TAE is a safe, effective, and fast procedure in the management of gastrointestinal bleeding.
Collapse
Affiliation(s)
- Hai-Yang Lai
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ke-Tong Wu
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yang Liu
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhao-Fei Zeng
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bo Zhang
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
|
18
|
Over-The-Scope Clip system as a first-line therapy for high-risk bleeding peptic ulcers: a retrospective study. Surg Endosc 2020; 35:2198-2205. [PMID: 32394167 DOI: 10.1007/s00464-020-07625-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Effective hemostasis is essential to prevent rebleeding. We evaluated the efficacy and feasibility of the Over-The-Scope Clip (OTSC) system compared to combined therapy (through-the-scope clips with epinephrine injection) as a first-line endoscopic treatment for high-risk bleeding peptic ulcers. METHODS We retrospectively analyzed data of 95 patients from a single, tertiary center and underwent either OTSC (n = 46) or combined therapy (n = 49). The primary outcome of the present study was the efficacy of the OTSC system as a first-line therapy in patients with high-risk bleeding peptic ulcers compared to combined therapy with TTS clips and epinephrine injection. The secondary outcomes included the rebleeding rate, perforation rate, mean procedure time, reintervention rate, mean procedure cost and days of hospitalization in the two study groups within 30 days of the index procedure. RESULTS All patients achieved hemostasis within the procedure; two patients in the OTSC group and four patients in the combined therapy group developed rebleeding (p = 0.444). No patients experienced gastrointestinal perforation. OTSC had a shorter median procedure time than combined therapy (11 min versus 20 min; p < 0.001). The procedure cost was superior for OTSC compared to combined therapy ($102,000 versus $101,000; p < 0.001). We found no significant difference in the rebleeding prevention rate (95.6% versus 91.8%, p = 0.678), hospitalization days (3 days versus 4 days; p = 0.215), and hospitalization costs ($108,000 versus $240,000, p = 0.215) of the OTSC group compared to the combined therapy group. CONCLUSION OTSC treatment is an effective and feasible first-line therapy for high-risk bleeding peptic ulcers. OTSC confers comparable costs and patient outcomes as combined treatments, with a shorter procedure time.
Collapse
|
|
19
|
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: 154] [Impact Index Per Article: 30.8] [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.
Collapse
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
| |
Collapse
|
|
20
|
Abstract
The over-the-scope clip is a novel endoscopic tool developed for tissue compression in the gastrointestinal tract. It has already revolutionized the management of acute perforations and leaks. In the past decade, it has also increasingly been used for treatment of severe and/or refractory gastrointestinal hemorrhage. Available studies report high rates of primary hemostasis and rebleeding. This article provides an overview on available literature, potential indications, and technical aspects of hemostasis with over-the-scope clip.
Collapse
|
|
21
|
Kuellmer A, Behn J, Meier B, Wannhoff A, Bettinger D, Thimme R, Caca K, Schmidt A. Over-the-scope clips are cost-effective in recurrent peptic ulcer bleeding. United European Gastroenterol J 2019; 7:1226-1233. [PMID: 31700635 DOI: 10.1177/2050640619871754] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/31/2019] [Indexed: 12/31/2022] Open
Abstract
Background A recent prospective randomised controlled trial ('STING') showed superiority of over-the-scope clips compared to standard treatment in recurrent peptic ulcer bleeding. Cost-effectiveness studies on haemostasis with over-the-scope clips have not been reported so far. Objective The aim of this study was to investigate whether the higher efficacy of the over-the-scope clips treatment outweighs the higher costs of the device compared to standard clips. Methods For the analysis, the study population of the STING trial was used. Costs for the hospital stay in total as well as treatment-related costs were obtained. The average cost-effectiveness ratio, representing the mean costs per designated outcome, and the incremental cost-effectiveness ratio, expressing the additional costs of a new treatment strategy per difference in outcome were calculated. The designated outcome was defined as successful haemostasis without rebleeding within seven days, which was the primary endpoint of the STING trial. Average cost-effectiveness ratio and incremental cost-effectiveness ratio were calculated for total costs of the hospital stay as well as the haemostasis treatment alone. The cost-effectiveness analysis is taken from the perspective of the care provider.Results: Total costs and treatment-related costs per patient were 13,007.07 € in the standard group vs 12,808.56 € in the over-the-scope clip group (p = 0.812) and 2084.98 € vs 1984.71 € respectively (p = 0.663). The difference was not statistically significant. Total costs per successful haemostasis (average cost-effectiveness ratio) were 30,677.05 € vs 15,104.43 € and 4917.41 € vs 2340.46 € for the haemostasis treatment. The additional costs per successful haemostasis with over-the-scope clip treatment (incremental cost-effectiveness ratio) is -468.18 € for the whole treatment and -236.49€ for the haemostasis treatment. Conclusions Over-the-scope clip treatment is cost-effective in recurrent peptic ulcer bleeding.
Collapse
Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juliane Behn
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Benjamin Meier
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
|
22
|
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: 1.5] [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.
Collapse
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
| |
Collapse
|
|
23
|
Tarasconi A, Baiocchi GL, Pattonieri V, Perrone G, Abongwa HK, Molfino S, Portolani N, Sartelli M, Di Saverio S, Heyer A, Ansaloni L, Coccolini F, Catena F. Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis. World J Emerg Surg 2019; 14:3. [PMID: 30733822 PMCID: PMC6359767 DOI: 10.1186/s13017-019-0223-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/22/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nowadays, very few patients with non-variceal upper gastrointestinal bleeding fail endoscopic hemostasis (refractory NVUGIB). This subset of patients poses a clinical dilemma: should they be operated on or referred to transcatheter arterial embolization (TAE)? OBJECTIVES To carry out a systematic review of the literature and to perform a meta-analysis of studies that directly compare TAE and surgery in patients with refractory NVUGIB. MATERIALS AND METHODS We searched PubMed, Ovid MEDLINE, and Embase. A combination of the MeSH terms "gastrointestinal bleeding"; "gastrointestinal hemorrhage"; "embolization"; "embolization, therapeutic"; and "surgery" were used (("gastrointestinal bleeding" or "gastrointestinal hemorrhage") and ("embolization" or "embolization, therapeutic") and "surgery")). The search was performed in June 2018. Studies were retrieved and relevant studies were identified after reading the study title and abstract. Bibliographies of the selected studies were also examined. Statistical analysis was performed using RevMan software. Outcomes considered were all-cause mortality, rebleeding rate, complication rate, and the need for further intervention. RESULTS Eight hundred fifty-six abstracts were found. Only 13 studies were included for a total of 1077 patients (TAE group 427, surgery group 650). All selected papers were non-randomized studies: ten were single-center and two were double-center retrospective comparative studies, while only one was a multicenter prospective cohort study. No comparative randomized clinical trial is reported in the literature.Mortality. Pooled data (1077 patients) showed a tendency toward improved mortality rates after TAE, but this trend was not statistically significant (OD = 0.77; 95% CI 0.50, 1.18; P = 0.05; I 2 = 43% [random effects]). Significant heterogeneity was found among the studies.Rebleeding rate. Pooled data (865 patients, 211 events) showed that the incidence of rebleeding was significantly higher for patients undergoing TAE (OD = 2.44; 95% CI 1.77, 3.36; P = 0.41; I 2 = 4% [fixed effects]).Complication rate. Pooling of the data (487 patients, 206 events) showed a sharp reduction of complications after TAE when compared with surgery (OD = 0.45; 95% CI 0.30, 0.47; P = 0.24; I 2 = 26% [fixed effects]).Need for further intervention. Pooled data (698 patients, 165 events) revealed a significant reduction of further intervention in the surgery group (OD = 2.13; 95% CI 1.21, 3.77; P = 0.02; I 2 = 56% [random effects]). A great degree of heterogeneity was found among the studies. CONCLUSIONS The present study shows that TAE is a safe and effective procedure; when compared to surgery, TAE exhibits a higher rebleeding rate, but this tendency does not affect the clinical outcome as shown by the comparison of mortality rates (slight drift toward lower mortality for patients undergoing TAE). The present study suggests that TAE could be a viable option for the first-line therapy of refractory NVUGIB and sets the foundation for the design of future randomized clinical trials. LIMITATIONS The retrospective nature of the majority of included studies leads to selection bias. Furthermore, the decision of whether to proceed with surgery or refer to TAE was made on a case-by-case basis by each attending surgeon. Thus, external validity is low. Another limitation involves the variability in etiology of the refractory bleeding. TAE techniques and surgical procedure also differ consistently between different studies. Frame time for mortality detection differs between the studies. These limitations do not impair the power of the present study that represents the largest and most recent meta-analysis currently available.
Collapse
Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gian Luca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Vittoria Pattonieri
- Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gennaro Perrone
- Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Hariscine Keng Abongwa
- Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Sarah Molfino
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Nazario Portolani
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | | | - Salomone Di Saverio
- Department of Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arianna Heyer
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| |
Collapse
|
|
24
|
Schmidt A, Gölder S, Goetz M, Meining A, Lau J, von Delius S, Escher M, Hoffmann A, Wiest R, Messmann H, Kratt T, Walter B, Bettinger D, Caca K. Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers. Gastroenterology 2018; 155:674-686.e6. [PMID: 29803838 DOI: 10.1053/j.gastro.2018.05.037] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding. METHODS We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n = 31) or thermal therapy plus injection with diluted adrenaline (n = 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy. RESULTS Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P = .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P = .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6-63.2; P = .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P = .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P = .672). There were no significant differences in the other secondary endpoints. CONCLUSIONS In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900.
Collapse
Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany; Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Gölder
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Goetz
- Interdisciplinary Endoscopy, University of Tübingen, Tübingen, Germany
| | | | - James Lau
- Department of Surgery, University of Hong Kong, Hong Kong
| | - Stefan von Delius
- Department of Gastroenterology, Klinikum Rechts der Isar, TU München, München, Germany
| | - Markus Escher
- Department of Gastroenterology, Robert Bosch Krankenhaus Stuttgart, Stuttgart, Germany
| | - Arthur Hoffmann
- Department of Gastroenterology, Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Reiner Wiest
- Department of Gastroenterology, Inselspital Bern, Bern, Switzerland
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Thomas Kratt
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Benjamin Walter
- Department of Gastroenterology, University of Ulm, Ulm, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany.
| |
Collapse
|
|
25
|
Byrne BE, Bassett M, Rogers CA, Anderson ID, Beckingham I, Blazeby JM. Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study. BMJ Open 2018; 8:e023721. [PMID: 30127054 PMCID: PMC6104767 DOI: 10.1136/bmjopen-2018-023721] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also planned to explore factors associated with fatal outcome after surgery for perforated ulcers. These analyses were designed to provide a thorough understanding of current practice and identify potentially modifiable factors associated with outcome as targets for future quality improvement. DESIGN National cohort study using National Emergency Laparotomy Audit (NELA) data. SETTING English and Welsh hospitals within the National Health Service. PARTICIPANTS Adult patients admitted as an emergency with perforated or bleeding PUD between December 2013 and November 2015. INTERVENTIONS Laparotomy for bleeding or perforated peptic ulcer. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was 60-day in-hospital mortality. Secondary outcomes included length of postoperative stay, readmission and reoperation rate. RESULTS 2444 and 382 procedures were performed for perforated and bleeding ulcers, respectively. In-hospital 60-day mortality rates were 287/2444 (11.7%, 95% CI 10.5% to 13.1%) for perforations, and 68/382 (17.8%, 95% CI 14.1% to 22.0%) for bleeding. Median (IQR) 2-year institutional volume was 12 (7-17) and 2 (1-3) for perforation and bleeding, respectively. In the exploratory analysis, age, American Society of Anesthesiology score and preoperative systolic blood pressure were associated with mortality, with no association with time from admission to operation, surgeon grade or operative approach. CONCLUSIONS Patients undergoing surgery for complicated PUD face a high 60-day mortality risk. Exploratory analyses suggested fatal outcome was primarily associated with patient rather than provider care factors. Therefore, it may be challenging to reduce mortality rates further. NELA data provide important benchmarking for patient consent and has highlighted low institutional volume and high mortality rates after surgery for bleeding peptic ulcers as a target for future research and improvement.
Collapse
Affiliation(s)
- Benjamin E Byrne
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Bassett
- National Emergency Laparotomy Audit, The Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Iain D Anderson
- National Emergency Laparotomy Audit, The Royal College of Anaesthetists, London, UK
- Department of Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Ian Beckingham
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Association of Upper Gastrointestinal Surgeons, Royal College of Surgeons of England, London, UK
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
|
26
|
Kaminskis A, Ivanova P, Ponomarjova S, Mukans M, Boka V, Pupelis G. Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding. Gastroenterology Res 2018; 10:339-346. [PMID: 29317941 PMCID: PMC5755635 DOI: 10.14740/gr909w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/19/2017] [Indexed: 12/11/2022] Open
Abstract
Background Transarterial embolization (TAE) is an alternative procedure to repeat endoscopy or surgical intervention in the case of re-bleeding after primary endoscopic treatment. The aim of the study was to assess the Rockall score as a criterion for TAE in the case of re-bleeding after endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Methods Out of the 673 patients who underwent emergent endoscopic hemostasis due to NVUGIB, 111 had a high risk of re-bleeding having a Forrest I-IIb ulcer and the Rockall score ≥ 5. From 111 patients, 37 accepted preventive TAE (PE+ group). The control group consisted of 74 patients who underwent standard treatment (PE- group). Results There were no differences in the demographic status between both groups, nor in the main clinical data on admission. The performance of TAE resulted in a significantly lower re-bleeding rate (1 (4.8%) vs. 11 (33%), P = 0.018). No patient who underwent TAE with the Rockall score ≥ 7 required surgery, resulting in only one re-bleeding episode (P = 0.004). Mortality reached 5% and 11% in the PE+ and PE- groups accordingly. Conclusion The Rockall score ≥ 7 could be a reliable predictor of re-bleeding after primary endoscopic hemostasis as one criterion for the selection of indications for preventive TAE.
Collapse
Affiliation(s)
- Aleksejs Kaminskis
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Patricija Ivanova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Sanita Ponomarjova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradins University, Riga, Latvia
| | | | - Guntars Pupelis
- Surgical Department, Riga East University Hospital, Riga, Latvia
| |
Collapse
|
|
27
|
Transcatheter arterial embolization for upper gastrointestinal tract bleeding. Wideochir Inne Tech Maloinwazyjne 2017; 12:385-393. [PMID: 29362654 PMCID: PMC5776486 DOI: 10.5114/wiitm.2017.72319] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/15/2017] [Indexed: 12/27/2022] Open
Abstract
Introduction Transcatheter arterial embolization is a possible treatment for patients with recurrent bleeding from the upper gastrointestinal tract after failed endoscopic management and is also an alternative to surgical treatment. Aim To analyze the outcomes of transcatheter arterial embolization and identify the clinical and technical factors that influenced the rates of morbidity and mortality. Material and methods A retrospective analysis was carried out, based on the data of 36 patients who underwent transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding in 2013 to 2015 in our center. An analysis was performed between early rebleeding rates, mortality and the following factors: patient sex, age, number of units of packed red blood cells and packed plasma administered to the patients, length of hospital stay, therapeutic or prophylactic embolization. Results The technical success rate of the embolization procedure was 100%. There were 15 (41.70%) therapeutic embolizations and 21 (58.3%) prophylactic embolizations. There was a 77.8% clinical success rate. Following embolization, 10 (27.80%) patients had repeated bleeding and 9 (25.0%) patients died. Significant associations were found between rebleeding and prophylactic embolization (OR = 10.53; p = 0.04) and between mortality and prophylactic embolization (OR = 10.53; p = 0.04) and units of packed red blood cells (OR = 1.25; p < 0.01). Conclusions In our experience, transcatheter arterial embolization is a safe treatment method for acute nonvariceal upper gastrointestinal bleeding and a possible alternative to surgery for high-risk patients.
Collapse
|