Patients with ulcer bleeding who have failed endoscopic hemostasis gain relief from transarterial embolization (TAE). The procedure leads to fewer surgeries, has fewer associated complications, and does not increase overall mortality, according to a study published in the May issue of Gastrointestinal Endoscopy.
Patients with bleeding peptic ulcers are generally recommended for surgery if endoscopic hemostasis does not work, but surgical procedures carry a high risk for morbidity and mortality, explain lead author Tiffany Cho-Lam Wong, MRCSEd, from the Institute of Digestive Disease, Chinese University Hong Kong, and colleagues.
TAE has been recommended as an alternative, but it has not been well studied. The researchers designed a retrospective study to compare the outcomes of TAE and salvage surgery in patients with peptic ulcers who had failed endoscopic hemostasis. They determined rates of all-cause mortality, rebleeding, reintervention, and complications.
Thirty-two patients were included in the TAE group: 25 patients had bleeding in the gastroduodenal artery, 4 had bleeding in the left gastric artery, 2 had bleeding in the right gastric artery, and 1 had bleeding in the splenic artery. Fifteen patients (46.9%) had active extravasation, 26 patients underwent embolization, and the procedure was successful in 23 patients (88.5%).
There were 11 cases of bleeding recurrence (34.4%) in the TAE group compared with 7 (12.5%) of the 56 patients who underwent surgery (P = .01). There was a higher rate of complications in the surgery group (67.9%) than the TAE group (40.6%; P = .01). Thirty-day mortality rates were not significantly different between the groups (25% for TAE vs 30.4% for surgery; P = .77). Likewise, no difference was seen in mean length of hospital stay (17.3 days for TAE vs 21.6 days for surgery; P = .09) or need for transfusion (15.6 units for TAE vs 14.2 units for surgery; P = .60).
An accompanying editorial welcomed the finding. "There will always be selected patients in whom endoscopic hemostasis therapy fails, who may not be candidates for embolization therapy or in whom it fails, or who may not have access to interventional radiology hemostasis techniques. But the role of the surgeon in this clinical sphere is certainly diminishing and will continue to diminish in ensuing years," the editorialist, Ian M. Gralnek, MD, MSHS, FASGE, from the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, and the Department of Gastroenterology, Rambam Health Care Medical Center, Haifa, Israel, wrote.
The authors and editorialist have disclosed no relevant financial relationships.
根據一項發表於5月胃腸內視鏡期刊(Gastrointestinal Endoscopy)的研究，無法使用內視鏡止血的潰瘍出血病患可以藉由「經動脈血管栓塞術(transarterial embolization，TAE)」獲得緩解，這個方式可減少手術、相關併發症以及不會增加整體死亡率。
香港中文大學消化道疾病研究中心的Tiffany Cho-Lam Wong等人解釋，當內視鏡止血無效時，一般會建議出血性胃潰瘍病患接受手術，但是手術在發病率及死亡率方面有高風險。
曾建議以TAE作為替代方式，但是未被充分研究。研究者設計了一個回溯研究，研究對象是內視鏡止血失敗的胃潰瘍病患，比較TAE和挽救手術的結果；分析各種原因死亡率、再度出血率、再度介入率以及併發症。
納入TAE組的有32名病患，其中25人的胃十二指腸動脈出血，4人的左胃動脈出血、2人的右胃動脈出血、1人的脾動脈出血；15名病患(46.9%)有急性出血，26名病患進行血管栓塞術，有23名病患手術成功(88.5%)。
TAE組有11個出血復發案例(34.4%)，手術組的56名病患則是有7人(12.5%)復發出血(P = .01)。手術組的併發症比率(67.9%)高於TAE組(40.6%；P = .01)。兩組之間的30天死亡率沒有顯著差異(TAE組為25%、手術組為30.4%；P = .77)。此外，平均住院天數也沒有差異(TAE組為17.3天、手術組為21.6；P = .09)，需輸血量也無差異(TAE組為15.6單位、手術組為14.2 單位；P = .60)。
編輯評論對研究結果抱持肯定。以色列海法Rambam健康照護醫學中心胃腸科、Technion-Israel科技研究中心、醫學院的Ian M. Gralnek醫師寫道，總是有一些特定病患的內視鏡止血治療失敗，這些可能不適用栓塞治療或曾失敗、或者無法獲得介入性放射線止血技術進行治療。但是，在這臨床方面，醫師的角色逐漸減少，且未來也將繼續減少。
資料來源：http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=6536&x_classno=0
Gastrointestinal Endoscopy Volume 73, Issue 5 , Pages 900-908, May 2011 摘要：
A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers
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