| BackgroundNon-Variceal Gastrointestinal Bleeding(NVGB) is a potentially life-threatening event as an admission diagnosis and as a complication during hospitalization.NVGB will stop approximately in 80%of patients with conservative therapy.In patients with persistent bleeding,therapeutic endoscopy can achieve hemostasis in almost 80%of cases.Surgical intervention is usually an expeditious and gratifying endeavor. Required in fewer than 5%of patients with NVGB,it typically is associated with operative mortality rates of more than 30%in patients with severe comorbidity. With the development of interventional radiology,artery embolism has become another safe and effective method in the treatment of NVGB following surgery. NVGB in critically ill patients is notable for rebleeding and a rebleeding rate approaching 40%.At present,the risk factors of rebleeding and the safety,therapeutic effect,complications and mortality after arterial embolism remains unclear.This study will attempt to define the role of angiography embolization for NVGB and to identify factors that could predict angiographic failure so as to advise clinical treatment. Chapter One The primary analysis for the reasons of peroperative gastrointestinal recurrent hemorrhage after arterial embolism.ObjectiveTo primarily analyze the reasons of peroperative gastrointestinal recurrent hemorrhage(PGRH) after arterial embolism.Materials and methodsRetrospectively analyzed sixty patients with gastrointestinal hemorrhage underwent arterial embolism between january,1996,and june,2008.There were 49 men and 11 women,with mean age 48.5±18.3 years old.Patients were diagnosed as gastric ulcer(n=7),duodenal ulcer(n=12),gastric dieulafoy lesion(n=7),duodenal dieulafoy lesion(n=4),gastric cancer(n=2),ampullary carcinoma(n=4),jejunal malignant tumor(n=3),duodenal diverticulum(n=1),gastric ulcer after suture ligation(n=2),duodenal ulcer after suture ligation(n=2),gastroenterostomy (n=12),odiss musculus sphincter discussion and duodenal suture ligation(n=1),colon carcinoma(n=1),duodenal arteriovenous malformation(n=2).All of the patients were referred after conservative therapy(medicine or endoscopic hemostasis) failure, surgery was not considered because of surgical risk or patient's refused.Patients with coagulopathy,hemobilia,autoimmune diseases,variceal or traumatic gastrointestinal tract bleeding were excluded in this study.All the patients underwent celiac,superior mesenteric and inferior mesenteric arteriography.Internal iliac arteriography was carried in one patient with rectal cancer hemorrhage.When extravasation of contrast agent was demonstrated at angiography,embolic therapy was performed as selectively as possible,with a 3-French Tracker microcatheter coaxially inserted through the 5-French catheter into the target vessel.The embolic agents were gelfoam particles,vascular coils ranging from 2 to 7mm,or combination of both.If direct entry into the bleeding artery was not possible,occlusion was attempted by means of a flow directed injection of the embolic agent.When a dual blood supply existed,contrast injection through the alternate route was performed to demonstrate extravasation by retrograde filling and embolization through the second limb was carried out until cessation of extravasation.In some patients without angiographic evidence of contrast extravasation into the gastroduodenal lumen,empirical embolization was achieved based on conclusive endoscopic identification of the source of bleeding.PGRH was seen in 24 patients after arterial embolism.The risk factors associated with PGRH were analyzed,including sex,prior gastrointestinal surgery,gastrointestinal vascular malformation,blood loss before artery embolism, prior coagulopathy,a transfusion requirement of more than 6 units of blood prior to the procedure,embolic agents,empirical embolization and duodenal hemorrhage.The blood loss before and after artery embolism were compared.ResultArteriography was performed in 60 patients with gastrointestinal hemorrhage. Positive angiographic results were showed in 37 patients,including contrast medium spilling in gastrointestinal lumen(n=20),tumor blood vessels and tumor staining(n=10),vascular malformations and aneurysms(n=6),local vascular intensive(n=1).Negative angiographic results were showed in 23 patients,and empirical embolism were performed in left gastic artery(n=5),gastroduodenal artery (n=13),or left gastic and gastroduodenal artery(n=5).Embolization was technically accomplished in 58 of 60 angiographies,with a technical success rate of 96.7%. Cessation of bleeding was accomplished in 36 of 60 patients,with a clinical success rate of 60%(36/60).The embolic materials were gelfoam particles(n=22),coils(n=7), or gelfoam particles and(or) coils(n=31).In twenty-four patients with recurrent hemorrhage,blood loss was small volume(n=7),middle volume(n=5) and large volume(12) before artery embolism.Blood loss was small volume(n=10),middle volume(n=11) and large volume(n=3) after artery embolism.After artery embolism, the volume of recurrent hemorrhage was alleviative(Z=-2.244,P=0.025), including alleviativer(n=11),aggravater(n=4) and no significant changes(n=9). There were five risk factors were found to be the independent predictors of PGRH by binary logistic regression,including prior gastrointestinal surgery(χ~2= 4.356,P=0.037),malignant tumor with gastrointestinal bleeding(χ~2=0.192,P=0.039), a transfusion requirement of more than 6 units of blood prior to the procedure (χ~2=5.432,P=0.020),more blood loss before artery embolism(χ~2=7.086,P=0.029),and longer time to angiography(χ~2=5.243,P=0.022).There was no predictive value for sex, gastrointestinal vascular malformation,prior coagulopathy,embolic agents,empirical embolizaton and duodenal bleeding(p＞0.05).ConclusionThere were five risk factors of PGRH in the patients with artery embolism, including malignant tumor with gastrointestinal bleeding,prior gastrointestinal surgery,a transfusion requirement of more than 6 units of blood prior to the procedure,more blood loss before artery embolism,and longer time to angiography, arterial embolism could release blood loss. Chapter Two The analysis for the effect in treatment of peroperative gastrointestinal recurrent hemorrhage after arterial embolism.ObjectiveTo analyze the effect in treatment of peroperative gastrointestinal recurrent hemorrhage(PGRH) after arterial embolism.Materials and methodsBetween january,1996,and june,2008.Twenty-four patients with recurrent gastrointestinal hemorrhage after arterial embolism were retrospectively analyzed. There were 21 men and 3 women,with mean age 52.2±17.9 years old.10 patients underwent conservative therapy(medicine or endoscopic hemostasis), 5 re-embolization and 9 surgery.Conservative therapy included medicine,fluid infusion and blood transfusion.When conservative therapy was ineffective, endoscopic examination was performed to search bleeding location and diagnose the reasons of the bleeding.Hemoclip and(or) hemostatic injection were used in active bleeding,hemostatic injection or electrocoagulation was used in inactive bleeding and spraying thrombin hemostasis was used in diffuse gastric hemorrhage.The method of re-embolization was similar to the chapter one.Patients underwent celiac,superior mesenteric and inferior mesenteric arteriography.When extravasation of contrast agent was demonstrated at angiography,embolic therapy was performed as selectively as possible.In some patients without angiographic evidence of contrast extravasation into the gastroduodenal lumen,empirical embolization was performed based on conclusive endoscopic identification of the source of bleeding.Surgical procedures were carried out after blood pressure above 90 / 60mmHg."Ulcer suture ligation" or "subtotal gastrectomy + gastric jejunal anastomosis(BillrothⅡ)", "wedge resection of gastric lesions","palliative resection of gastric cancer ","total gastrectomy,esophagus and jejunum anastomosis","Exploratory laparotomy" was performed in ulcer bleeding,gastric dieulafoy bleeding,gastric cancer bleeding, multiple gastric ulcer bleeding,pancreatic cancer,respectively.Patients' information was gathered by telephone interviews and case files.For each patient,the following variables were recorded,including age,sex,comorbidities,transfusion requirements, etiology of PGRH,angiographic or endoscopic identification of bleeding site, complications,short and long-term recurrence of bleeding,and mortality.The effect of conservative therapy(medicine or endoscopic hemostasis),surgery and re-embolization were compared.ResultsCessation of bleeding was accomplished in 9 of 24 patients(37.5%). Conservative therapy was successful in 1 patient,with a clinical success rate of 10%. Surgery and re-embolization were successful in 8 patents,with a clinical success rate of 57.1%.In 14 surgery or re-embolization patients,re-embolization was successful in 2 patients,with a clinical success rate of 40%,surgery was successful in 4 patients, with a success rate of 44%,combination therapy(re-embolization and surgery) was successful in 2 patients,with a success rate of 66.7%.The clinical success rate of re-embolization and surgery was higher than conservative therapy(P=0.033).7 patients experienced surgical complications in surgery group,with a complication rate of 77.7%.There were recurrent bleeding(n=3),intestinal fistula(n=1),pneumonia and anastomotic fistula(n=1),pneumonia and hypoxic-ischemic cerebral(n=1) and skin incision infection(n=1),respectively.2 patients experienced recurrent hemorrhage in re-embolization group,with a complication rate of 40%.2 patients experienced intestinal fistula in combination therapy,with a complication rate of 66.7%,the 2 patients both underwent re-embolization after gastrointestinal surgery. The mean hospital days in conservative therapy,re-embolization,surgery and combination therapy were 3.0±0d,6.0±1.4d,16.0±5.6d,42.0±7.0d,respectively.ConclusionThe effect of re-embolization and surgery were superior to conservative therapy in patient with PGRH after artery embolism.The effect of re-embolization was similar to surgery,but with a low rate of complications. |
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