Clin J Gastroenterol (2014) 7:219–222 DOI 10.1007/s12328-014-0475-5
CASE REPORT
Transcatheter arterial embolization for uncontrolled bleeding during endoscopic submucosal dissection of the stomach Osamu Komatsu • Tomohito Matsushita Kyo Kishimoto • Wataru Adachi
•
Received: 28 November 2013 / Accepted: 4 March 2014 / Published online: 18 March 2014 Ó Springer Japan 2014
Abstract Bleeding during endoscopic submucosal dissection (ESD) is an important complication. Here, we report a case of early gastric cancer in which endoscopic hemostasis during ESD failed, hemostasis by transcatheter arterial embolization (TAE) was performed, and ESD was subsequently completed. ESD was scheduled for an 89-year-old male with a type IIa ? IIc lesion located on the anterior wall of the gastric antrum. During ESD, bleeding started and then increased. Hemoclips were used but the bleeding could not be controlled. ESD could not be continued because of a poor field of vision. We decided on TAE for hemostasis of the bleeding. Celiac angiography clearly showed extravasation in a branch of the right gastric artery. TAE with a microcoil and gelfoam was performed through the right gastric artery. ESD was started again directly after TAE. We were able to completely resect the lesion with a good field of vision. No complications occurred after therapy. He was alive without recurrence at 18 months after ESD. Thus, TAE is suggested to be a useful hemostatic method during ESD.
Keywords Endoscopic submucosal dissection Immediate bleeding Transcatheter arterial embolization Early gastric cancer
Introduction Bleeding during endoscopic submucosal dissection (ESD) is an important complication [1]. Although several endoscopic methods for the management of bleeding have been reported [2, 3], hemostasis may occasionally be difficult due to continuous bleeding. If the bleeding cannot be endoscopically controlled, surgery is usually conducted. On the other hand, the effectiveness of transcatheter arterial embolization (TAE) for bleeding of the gastrointestinal tract has been reported [4, 5]. Here, we report a case of early gastric cancer in which endoscopic hemostasis during ESD failed, hemostasis by TAE was performed, and ESD was subsequently completed.
Case report O. Komatsu Department of Internal Medicine, Fujimi-kogen Medical Center, Fujimi-kogen Hospital, 11100 Ochiai, Fujimi, Suwa-gun, Nagano 399-0214, Japan T. Matsushita Department of Radiology, Fujimi-kogen Medical Center, Fujimikogen Hospital, 11100 Ochiai, Fujimi, Suwa-gun, Nagano 399-0214, Japan K. Kishimoto W. Adachi (&) Department of Surgery, Fujimi-kogen Medical Center, Fujimikogen Hospital, 11100 Ochiai, Fujimi, Suwa-gun, Nagano 399-0214, Japan e-mail: [email protected]
An 89-year-old male was admitted to the hospital to undergo ESD for early gastric cancer. The tumor was a type IIa ? IIc lesion measuring approximately 2.5 cm located on the anterior wall of the gastric antrum (Fig. 1), and was microscopically confirmed as a well-differentiated tubular adenocarcinoma. At that time, the patient was under treatment for hypertension and spastic paraplegia. He had received no anticoagulant drugs. Physical examination and routine laboratory data showed no special findings. Under conscious sedation, hyaluronic acid solution was injected into the submucosal layer, and circumferential cutting was performed. After completion of the
123
220
Clin J Gastroenterol (2014) 7:219–222
Fig. 1 Endoscopy before ESD. A type IIa ? IIc lesion measuring approximately 2.5 cm is shown on the anterior wall of the gastric antrum
Fig. 3 a Endoscopy after TAE. b Endoscopy after ESD. The lesion with circumferential cutting and submucosal dissection is observed with a good field of vision (a), and the lesion has been completely removed (b)
Fig. 2 a Celiac angiography. b Selective right gastric angiography. Clear extravasation in a branch of the right gastric artery near the hemoclips is observed. Arrows indicate extravasation
circumferential cutting, submucosal dissection of the connective tissue was started using a transparent hood attached to the endoscope. During submucosal dissection, bleeding
123
started and then increased. The bleeding was pulsating and oozing from multiple points. Hemoclips were used, but the bleeding could not be controlled. ESD could not be continued because of a poor field of vision. At this point, the general condition of the patient was stable. We decided on TAE for hemostasis of the bleeding. Celiac angiography clearly showed extravasation in a branch of the right gastric artery near the hemoclips (Fig. 2). TAE with a microcoil and gelfoam was performed through the right gastric artery, superselectively catheterized using a coaxial system. After TAE, hemostasis was angiographically confirmed. ESD was started again with a good field of vision directly after TAE (Fig. 3a). ESD was continued using a water-jet system, transparent hood attachment, and
Clin J Gastroenterol (2014) 7:219–222
221
Table 1 Laboratory data before and after ESD Before ESD
1 day after ESD
RBC (9104/ll)
425
380
HGB (g/dl)
13.0
11.6
HCT (%)
39.7
34.9
PLT (9104/ll)
16.4
18.8
WBC (/ll)
5,500
12,600
TP (g/dl)
6.7
6.1
Alb (g/dl)
3.4
3.2
AST (IU/l)
26
21
ALT (IU/l)
19
15
T.Bil (mg/dl)
0.2
0.2
BUN (mg/dl) Creat (mg/dl)
36 1.02
35 1.06
CRP (mg/dl)
0.77
3.6
electrocautery with hemostatic forceps. Submucosal dissection was not possible because the tumor had an ulcer scar in the submucosal layer. Hyaluronic acid solution injection did not clearly separate the submucosal layer. We performed snearing of the tumor before submucosal dissection was performed. The tumor could not be resected en bloc, but was resected completely without blood transfusion (Fig. 3b). Laboratory data before and after ESD are shown in Table 1. TAE did not create any difficulties for performing ESD. No complications occurred after therapy. Pathological examination of the resected specimens revealed a well-differentiated tubular adenocarcinoma in the mucosal layer and an ulcer scar in the submucosal layer. The vertical margin of the tumor was negative. He was alive without recurrence at 18 months after ESD.
Discussion Therapeutic endoscopy plays an important role in the management of gastric neoplasia. Although endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique, the EMR technique is not suitable for large lesions. Due to developments in therapeutic endoscopy, direct dissection of the submucosa has become possible, and the ESD technique has been established. ESD can be used to resect large lesions; however, it is still associated with a higher incidence of complications than standard EMR procedures, and it requires a high level of endoscopic skill [1]. Gastric ESD is associated with various complications, most importantly involving bleeding and perforation. Bleeding is divided into immediate (intraoperative) bleeding occurring during the procedure and delayed bleeding after the procedure [2]. Immediate bleeding is
common with ESD, and rates of immediate bleeding during ESD were reported to be 2.9 % [6], 12.0 % [7], and 22.6 % [8]. Park and Lee [9] reported that immediate bleeding is difficult to avoid and occurs in almost all ESDs. Reported immediate bleeding rates varied. This discrepancy is due to the definition of bleeding which ranges from minor bleeding that stops spontaneously to massive bleeding that requires transfusion. Massive bleeding interferes with the subsequent endoscopic procedure because of a poor field of vision. Therefore, the management of immediate bleeding plays a critical role in the successful completion of ESD. Several endoscopic hemostatic methods have been reported. When bleeding occurs during ESD, bleeding points can be rapidly identified by washing out the blood with a water-jet system using a transparent hood attachment [3]. Electrocautery using a cutting device can control minor oozing, and electrocautery using hemostatic forceps is suitable for arterial bleeding [2]. When hemostasis by electrocautery cannot be achieved, hemostasis using endoscopic hemoclips is necessary [3]. In this case, we used a water-jet system, transparent hood attachment, electrocautery with hemostatic forceps, and endoscopic hemoclips, but we could not control the bleeding. Technical refinements and advances both in diagnostic angiography and TAE have strengthened these options for the evaluation and management of acute gastrointestinal hemorrhage. The current technique of TAE in the treatment of acute gastrointestinal hemorrhage successfully controls bleeding in about 80–90 % of patients, and TAE is safe, with major adverse events occurring in \2 % of patients [4]. Minor, asymptomatic and self-limited ischemic changes such as small ulcers were reported in a fraction of patients embolized superselectively [4]. Preoperative TAE of large tumors has been reported to be an effective procedure to reduce intraoperative bleeding during surgery [10, 11]. However, the effectiveness of preoperative TAE before ESD has not been reported, and the ischemic changes after superselective TAE may delay wound healing after ESD. Therefore, we do not recommend scheduled TAE before ESD to prevent immediate bleeding during ESD. Wong et al. [7] reported that TAE reduced the need for surgery without increasing the overall mortality in patients with ulcer bleeding after failed endoscopic hemostasis. Katano et al. [12] reported that TAE is a safe and effective first-choice treatment for patients with peptic ulcer in whom endoscopic hemostasis has failed. Nowadays, TAE is well-recognized as an effective and safe alternative to emergency surgery in controlling acute gastrointestinal bleeding. However, we could not find any reports of TAE for uncontrolled immediate bleeding during ESD in the PubMed Database using the key words ESD and TAE. In our case, TAE was performed for immediate bleeding
123
222
during ESD, and ESD was subsequently completed. In conclusion, TAE is suggested to be a useful hemostatic method for uncontrolled bleeding during ESD. Disclosures Conflict of Interest: Osamu Komatsu, Tomohito Matsushita, Kyo Kishimoto and Wataru Adachi declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from a patient for being included in the study.
References 1. Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol. 2006;41:929–42. 2. Oda I, Suzuki H, Nonaka S, Yoshinaga S. Complications of gastric endoscopic submucosal dissection. Dig Endosc. 2013; 25(Suppl. 1):71–8. 3. Muraki Y, Enomoto S, Iguchi M, Fujishiro M, Yahagi N, Ichinose M. Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection. World J Gastroenterol. 2012;4:1–8. 4. Walker TG, Salazar GM, Waltman AC. Angiographic evaluation and management of acute gastrointestinal hemorrhage. World J Gastroenterol. 2012;18:1191–201.
123
Clin J Gastroenterol (2014) 7:219–222 5. Wong TC, Wong KT, Chiu PW, et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc. 2011;73:900–8. 6. Onozato Y, Ishihara H, Iizuka H, Sohara N, Kakizaki S, Okamura S, Mori M. Endoscopic submucosal dissection for early gastric cancers and large flat adenomas. Endoscopy. 2006;38:980–6. 7. Jeon SW, Jung MK, Cho CM, Tak WY, Kweon YO, Kim SK, Choi YH. Predictors of immediate bleeding during endoscopic submucosal dissection in gastric lesions. Surg Endosc. 2009;23:1974–9. 8. Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, Yoshihara M, Chayama K. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc. 2006;64:877–83. 9. Park CH, Lee SK. Preventing and controlling bleeding in gastric endoscopic submucosal dissection. Clin Endosc. 2013;46:456–62. 10. Puma F, Cardini CL, Passalacqua G, Ragusa M. Preoperative embolization in surgical management of giant thoracic sarcomas. Eur J Cardiothorac Surg. 2008;33:127–9. 11. Shen WH, Pan JH, Yan JN, Chen ZW, Zhou ZS, Lu GS, Li WB. Resection of a giant renal angiomyolipoma in a solitary kidney with preoperative arterial embolization. Chin Med J. 2011;124: 1435–7. 12. Katano T, Mizoshita T, Senoo K, Sobue S, Takada H, Sakamoto T, Mochiduki H, Ozeki T, Kato A, Matsunami K, Ito K, Joh T. The efficacy of transcatheter arterial embolization as the firstchoice treatment after failure of endoscopic hemostasis and endoscopic treatment resistance factors. Dig Endosc. 2012;24: 364–9.
CASE REPORT
Transcatheter arterial embolization for uncontrolled bleeding during endoscopic submucosal dissection of the stomach Osamu Komatsu • Tomohito Matsushita Kyo Kishimoto • Wataru Adachi
•
Received: 28 November 2013 / Accepted: 4 March 2014 / Published online: 18 March 2014 Ó Springer Japan 2014
Abstract Bleeding during endoscopic submucosal dissection (ESD) is an important complication. Here, we report a case of early gastric cancer in which endoscopic hemostasis during ESD failed, hemostasis by transcatheter arterial embolization (TAE) was performed, and ESD was subsequently completed. ESD was scheduled for an 89-year-old male with a type IIa ? IIc lesion located on the anterior wall of the gastric antrum. During ESD, bleeding started and then increased. Hemoclips were used but the bleeding could not be controlled. ESD could not be continued because of a poor field of vision. We decided on TAE for hemostasis of the bleeding. Celiac angiography clearly showed extravasation in a branch of the right gastric artery. TAE with a microcoil and gelfoam was performed through the right gastric artery. ESD was started again directly after TAE. We were able to completely resect the lesion with a good field of vision. No complications occurred after therapy. He was alive without recurrence at 18 months after ESD. Thus, TAE is suggested to be a useful hemostatic method during ESD.
Keywords Endoscopic submucosal dissection Immediate bleeding Transcatheter arterial embolization Early gastric cancer
Introduction Bleeding during endoscopic submucosal dissection (ESD) is an important complication [1]. Although several endoscopic methods for the management of bleeding have been reported [2, 3], hemostasis may occasionally be difficult due to continuous bleeding. If the bleeding cannot be endoscopically controlled, surgery is usually conducted. On the other hand, the effectiveness of transcatheter arterial embolization (TAE) for bleeding of the gastrointestinal tract has been reported [4, 5]. Here, we report a case of early gastric cancer in which endoscopic hemostasis during ESD failed, hemostasis by TAE was performed, and ESD was subsequently completed.
Case report O. Komatsu Department of Internal Medicine, Fujimi-kogen Medical Center, Fujimi-kogen Hospital, 11100 Ochiai, Fujimi, Suwa-gun, Nagano 399-0214, Japan T. Matsushita Department of Radiology, Fujimi-kogen Medical Center, Fujimikogen Hospital, 11100 Ochiai, Fujimi, Suwa-gun, Nagano 399-0214, Japan K. Kishimoto W. Adachi (&) Department of Surgery, Fujimi-kogen Medical Center, Fujimikogen Hospital, 11100 Ochiai, Fujimi, Suwa-gun, Nagano 399-0214, Japan e-mail: [email protected]
An 89-year-old male was admitted to the hospital to undergo ESD for early gastric cancer. The tumor was a type IIa ? IIc lesion measuring approximately 2.5 cm located on the anterior wall of the gastric antrum (Fig. 1), and was microscopically confirmed as a well-differentiated tubular adenocarcinoma. At that time, the patient was under treatment for hypertension and spastic paraplegia. He had received no anticoagulant drugs. Physical examination and routine laboratory data showed no special findings. Under conscious sedation, hyaluronic acid solution was injected into the submucosal layer, and circumferential cutting was performed. After completion of the
123
220
Clin J Gastroenterol (2014) 7:219–222
Fig. 1 Endoscopy before ESD. A type IIa ? IIc lesion measuring approximately 2.5 cm is shown on the anterior wall of the gastric antrum
Fig. 3 a Endoscopy after TAE. b Endoscopy after ESD. The lesion with circumferential cutting and submucosal dissection is observed with a good field of vision (a), and the lesion has been completely removed (b)
Fig. 2 a Celiac angiography. b Selective right gastric angiography. Clear extravasation in a branch of the right gastric artery near the hemoclips is observed. Arrows indicate extravasation
circumferential cutting, submucosal dissection of the connective tissue was started using a transparent hood attached to the endoscope. During submucosal dissection, bleeding
123
started and then increased. The bleeding was pulsating and oozing from multiple points. Hemoclips were used, but the bleeding could not be controlled. ESD could not be continued because of a poor field of vision. At this point, the general condition of the patient was stable. We decided on TAE for hemostasis of the bleeding. Celiac angiography clearly showed extravasation in a branch of the right gastric artery near the hemoclips (Fig. 2). TAE with a microcoil and gelfoam was performed through the right gastric artery, superselectively catheterized using a coaxial system. After TAE, hemostasis was angiographically confirmed. ESD was started again with a good field of vision directly after TAE (Fig. 3a). ESD was continued using a water-jet system, transparent hood attachment, and
Clin J Gastroenterol (2014) 7:219–222
221
Table 1 Laboratory data before and after ESD Before ESD
1 day after ESD
RBC (9104/ll)
425
380
HGB (g/dl)
13.0
11.6
HCT (%)
39.7
34.9
PLT (9104/ll)
16.4
18.8
WBC (/ll)
5,500
12,600
TP (g/dl)
6.7
6.1
Alb (g/dl)
3.4
3.2
AST (IU/l)
26
21
ALT (IU/l)
19
15
T.Bil (mg/dl)
0.2
0.2
BUN (mg/dl) Creat (mg/dl)
36 1.02
35 1.06
CRP (mg/dl)
0.77
3.6
electrocautery with hemostatic forceps. Submucosal dissection was not possible because the tumor had an ulcer scar in the submucosal layer. Hyaluronic acid solution injection did not clearly separate the submucosal layer. We performed snearing of the tumor before submucosal dissection was performed. The tumor could not be resected en bloc, but was resected completely without blood transfusion (Fig. 3b). Laboratory data before and after ESD are shown in Table 1. TAE did not create any difficulties for performing ESD. No complications occurred after therapy. Pathological examination of the resected specimens revealed a well-differentiated tubular adenocarcinoma in the mucosal layer and an ulcer scar in the submucosal layer. The vertical margin of the tumor was negative. He was alive without recurrence at 18 months after ESD.
Discussion Therapeutic endoscopy plays an important role in the management of gastric neoplasia. Although endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique, the EMR technique is not suitable for large lesions. Due to developments in therapeutic endoscopy, direct dissection of the submucosa has become possible, and the ESD technique has been established. ESD can be used to resect large lesions; however, it is still associated with a higher incidence of complications than standard EMR procedures, and it requires a high level of endoscopic skill [1]. Gastric ESD is associated with various complications, most importantly involving bleeding and perforation. Bleeding is divided into immediate (intraoperative) bleeding occurring during the procedure and delayed bleeding after the procedure [2]. Immediate bleeding is
common with ESD, and rates of immediate bleeding during ESD were reported to be 2.9 % [6], 12.0 % [7], and 22.6 % [8]. Park and Lee [9] reported that immediate bleeding is difficult to avoid and occurs in almost all ESDs. Reported immediate bleeding rates varied. This discrepancy is due to the definition of bleeding which ranges from minor bleeding that stops spontaneously to massive bleeding that requires transfusion. Massive bleeding interferes with the subsequent endoscopic procedure because of a poor field of vision. Therefore, the management of immediate bleeding plays a critical role in the successful completion of ESD. Several endoscopic hemostatic methods have been reported. When bleeding occurs during ESD, bleeding points can be rapidly identified by washing out the blood with a water-jet system using a transparent hood attachment [3]. Electrocautery using a cutting device can control minor oozing, and electrocautery using hemostatic forceps is suitable for arterial bleeding [2]. When hemostasis by electrocautery cannot be achieved, hemostasis using endoscopic hemoclips is necessary [3]. In this case, we used a water-jet system, transparent hood attachment, electrocautery with hemostatic forceps, and endoscopic hemoclips, but we could not control the bleeding. Technical refinements and advances both in diagnostic angiography and TAE have strengthened these options for the evaluation and management of acute gastrointestinal hemorrhage. The current technique of TAE in the treatment of acute gastrointestinal hemorrhage successfully controls bleeding in about 80–90 % of patients, and TAE is safe, with major adverse events occurring in \2 % of patients [4]. Minor, asymptomatic and self-limited ischemic changes such as small ulcers were reported in a fraction of patients embolized superselectively [4]. Preoperative TAE of large tumors has been reported to be an effective procedure to reduce intraoperative bleeding during surgery [10, 11]. However, the effectiveness of preoperative TAE before ESD has not been reported, and the ischemic changes after superselective TAE may delay wound healing after ESD. Therefore, we do not recommend scheduled TAE before ESD to prevent immediate bleeding during ESD. Wong et al. [7] reported that TAE reduced the need for surgery without increasing the overall mortality in patients with ulcer bleeding after failed endoscopic hemostasis. Katano et al. [12] reported that TAE is a safe and effective first-choice treatment for patients with peptic ulcer in whom endoscopic hemostasis has failed. Nowadays, TAE is well-recognized as an effective and safe alternative to emergency surgery in controlling acute gastrointestinal bleeding. However, we could not find any reports of TAE for uncontrolled immediate bleeding during ESD in the PubMed Database using the key words ESD and TAE. In our case, TAE was performed for immediate bleeding
123
222
during ESD, and ESD was subsequently completed. In conclusion, TAE is suggested to be a useful hemostatic method for uncontrolled bleeding during ESD. Disclosures Conflict of Interest: Osamu Komatsu, Tomohito Matsushita, Kyo Kishimoto and Wataru Adachi declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from a patient for being included in the study.
References 1. Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol. 2006;41:929–42. 2. Oda I, Suzuki H, Nonaka S, Yoshinaga S. Complications of gastric endoscopic submucosal dissection. Dig Endosc. 2013; 25(Suppl. 1):71–8. 3. Muraki Y, Enomoto S, Iguchi M, Fujishiro M, Yahagi N, Ichinose M. Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection. World J Gastroenterol. 2012;4:1–8. 4. Walker TG, Salazar GM, Waltman AC. Angiographic evaluation and management of acute gastrointestinal hemorrhage. World J Gastroenterol. 2012;18:1191–201.
123
Clin J Gastroenterol (2014) 7:219–222 5. Wong TC, Wong KT, Chiu PW, et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc. 2011;73:900–8. 6. Onozato Y, Ishihara H, Iizuka H, Sohara N, Kakizaki S, Okamura S, Mori M. Endoscopic submucosal dissection for early gastric cancers and large flat adenomas. Endoscopy. 2006;38:980–6. 7. Jeon SW, Jung MK, Cho CM, Tak WY, Kweon YO, Kim SK, Choi YH. Predictors of immediate bleeding during endoscopic submucosal dissection in gastric lesions. Surg Endosc. 2009;23:1974–9. 8. Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, Yoshihara M, Chayama K. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc. 2006;64:877–83. 9. Park CH, Lee SK. Preventing and controlling bleeding in gastric endoscopic submucosal dissection. Clin Endosc. 2013;46:456–62. 10. Puma F, Cardini CL, Passalacqua G, Ragusa M. Preoperative embolization in surgical management of giant thoracic sarcomas. Eur J Cardiothorac Surg. 2008;33:127–9. 11. Shen WH, Pan JH, Yan JN, Chen ZW, Zhou ZS, Lu GS, Li WB. Resection of a giant renal angiomyolipoma in a solitary kidney with preoperative arterial embolization. Chin Med J. 2011;124: 1435–7. 12. Katano T, Mizoshita T, Senoo K, Sobue S, Takada H, Sakamoto T, Mochiduki H, Ozeki T, Kato A, Matsunami K, Ito K, Joh T. The efficacy of transcatheter arterial embolization as the firstchoice treatment after failure of endoscopic hemostasis and endoscopic treatment resistance factors. Dig Endosc. 2012;24: 364–9.
