Duodenal infarction after therapeutic gelfoam embolization of a bleeding duodenal ulcer

N, Shapiro; Brandt, Lawrence J.; Sprayregan, Seymour; Mitsudo, Sumi; Glotzer, Philip

doi:10.1016/0016-5085(81)90211-0

Cited by 46 publications

(12 citation statements)

References 10 publications

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“…Specifically the duodenal hemorrhage did not appear to be related to gemcitabine dose, as it occurred in Patient 1 at a dose 36mg/m2 and in Patient 4 at 115mg/m2. Duodenal ischemia, including ulcer formation and necrosis, are uncommon complications of synchronous GDA and IPDA embolization for non-variceal upper gastrointestinal hemorrhage, thus we believe that the observed complications are specific toxicities related to gemcitabine, and the length of gemcitabine perfusion [19]. The GI toxicity was also observed despite avoidance of complete isolation of the duodenal arterial supply, and was not reported in the Homma et al study which did not use gemcitabine.…”

Section: Discussionmentioning

confidence: 98%

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Duodenal ischemia and upper GI bleeding are dose-limiting toxicities of 24-h continuous intra-arterial pancreatic perfusion of gemcitabine following vascular isolation of the pancreatic head: early results from the Regional Chemotherapy in Locally Advanced Pancreatic Cancer (RECLAP) study

et al. 2014

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Background Regional chemotherapy is used successfully in the treatment of both primary and secondary malignancies, in particular of the peritoneal surface and the liver, and is currently explored as an attractive approach for patients with locally advanced pancreatic ductal adenocarcinoma. To establish the feasibility and toxicity of regional intra-arterial gemcitabine delivered as a 24-hour continuous infusion to the pancreas as a novel treatment option for patients with locally advanced PDAC a phase I clinical trial was conducted. Methods Between April 2011 and September 2013 six patients with biopsy confirmed, borderline or unresectable pancreatic adenocarcinoma, and having received at least one line of systemic chemotherapy, underwent vascular redistribution of the inflow to the head of the pancreas by arterial coil embolization followed by perfusion catheter placement within the splenic artery. Patients were treated with increasing doses of gemcitabine administered by continuous splenic arterial infusion over 24 hours with inter-patient and intra-patient dose escalation scheme. The primary endpoint was toxicity of the intra-arterial gemcitabine regimen and to establish the maximum tolerated dose. Results Catheter placement and gemcitabine infusion was successful in all patients enrolled to date (n=6). Four out of 6 patients experienced catheter tip migration requiring replacement or revision. Patients received a median of 4 doses of 24-hour gemcitabine infusion. Two patients developed grade 3 and 4 duodenal ischemia and upper gastrointestinal bleeding. Median overall survival was 15.3 months and median time to progression was 3 months. Three patients (50%, n=3/6) progressed systemically. Two patients had stable disease >4 months following treatment and underwent pancreaticoduodenectomy. Conclusions While technically feasible to treat locally advanced pancreatic ductal adenocarcinoma, prolonged regional pancreatic perfusion with gemcitabine following pancreatic arterial redistribution carries a high risk for gastrointestinal toxicity. Shorter infusion schedules with frequent on treatment evaluations should be considered for future clinical trials.

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Section: Discussionmentioning

confidence: 98%

“…Pancreatic ductal adenocarcinoma is the fourth leading cause of cancer-related death in the United States and carries a poor prognosis with an overall survival of 5% [1,2]. In addition to its inherent aggressive biology, PDAC is difficult to diagnose in its early stages due to its anatomical location.…”

Section: Introductionmentioning

confidence: 99%

Duodenal ischemia and upper GI bleeding are dose-limiting toxicities of 24-h continuous intra-arterial pancreatic perfusion of gemcitabine following vascular isolation of the pancreatic head: early results from the Regional Chemotherapy in Locally Advanced Pancreatic Cancer (RECLAP) study

et al. 2014

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“…Another study with 95 patients showed a success rate of 98% in achieving haemostasis and with bowel ischaemic complications in 4% of the patients 9. Few case reports have been published on duodenal infarction10 and hepatic infarction11 following TAE of the gastroduodenal artery.…”

Section: Discussionmentioning

confidence: 99%

Acute necrotising pancreatitis: a late and fatal complication of pancreaticoduodenal arterial embolisation

et al. 2014

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SUMMARYA 70-year-old man was diagnosed with a massive bleeding duodenal ulcer which was refractory to emergency endoscopic management. Angiogram of the coeliac and superior mesenteric arteries revealed bleeding from the superior and inferior pancreaticoduodenal arteries. Transcatheter arterial embolisation of superior and inferior pancreaticoduodenal arteries along with the gastroduodenal artery was performed. Two weeks later he developed severe necrotising pancreatitis of the pancreatic head probably due to ischaemia, which was managed conservatively. Three months later the patient experienced another episode of pancreatitis which progressed into multiorgan dysfunction and the patient passed away. BACKGROUND

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“…It was hard to determine if the initial ulcer had healed but recurred due to the migrating coil eroding down to the duodenal mucosa or the initial duodenal ulcer did not heal and eroded down to expose the coil, causing the subsequent gastrointestinal bleeding. There is no evidence that coil embolisation affects the healing of duodenal ulcer, as there is rich collateral supply to the stomach and duodenum 9 10. Patients might be at higher risk of ischaemia from therapeutic embolisation if potential collateral vessels are damaged from previous abdominal surgery, atherosclerosis or previous abdominal radiation therapy 10.…”

Section: Discussionmentioning

confidence: 99%

Migrating coil

Tey¹,

Aggarwal

Banerjee

2017

BMJ Case Reports

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We describe a rare case of a 60-year-old man with known history of peptic ulcer disease who presented with melena and epigastric pain secondary to coil migration into duodenal mucosa 4 years after the initial therapeutic embolisation of the gastroduodenal artery. Upper endoscopy revealed oozing duodenal ulcer at the same site of the previously located duodenal ulcer 4 years ago and metal coil impacted at the duodenal mucosa. It is unclear if the coil migration is the effect or the cause of the bleeding duodenal ulcer. Our patient was treated by surgical intervention due to failed endoscopic haemostasis and medical management.

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Duodenal infarction after therapeutic gelfoam embolization of a bleeding duodenal ulcer

Cited by 46 publications

References 10 publications

Duodenal ischemia and upper GI bleeding are dose-limiting toxicities of 24-h continuous intra-arterial pancreatic perfusion of gemcitabine following vascular isolation of the pancreatic head: early results from the Regional Chemotherapy in Locally Advanced Pancreatic Cancer (RECLAP) study

Duodenal ischemia and upper GI bleeding are dose-limiting toxicities of 24-h continuous intra-arterial pancreatic perfusion of gemcitabine following vascular isolation of the pancreatic head: early results from the Regional Chemotherapy in Locally Advanced Pancreatic Cancer (RECLAP) study

Acute necrotising pancreatitis: a late and fatal complication of pancreaticoduodenal arterial embolisation

Migrating coil

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