Endoscopic Band Ligation of Bleeding Dieulafoy Lesions: The Best Therapeutic Strategy

Abstract

Dieulafoys lesion is a vascular lesion that is widely recognized as a persistently en− gorged, tortuous artery in the muscularis mucosa which is not associated with in− flammation or atherosclerosis. The inci− dence of this lesion in patients with upper gastrointestinal bleeding has been estima− ted to be between 0.3 % and 6.7 %. Clinical− ly, these lesions manifest as massive gas− trointestinal hemorrhage, with no preced− ing symptoms. If the lesion is not treated, patients continue to bleed intermittently over the following days [1]. The advent of therapeutic endoscopic management has resulted in significantly improved out− comes. Success rates between 75 % and 96 % have been reported for endoscopic in− tervention [1 ± 3]. As a result, endoscopic management has replaced surgery as the gold standard for the diagnosis and treat− ment of Dieulafoy lesions.We read with great interest the article by Romozinho et al. [4] which described the clinical pattern and reported the long− term outcome in 70 patients admitted for acute upper gastrointestinal bleeding due to Dieulafoys lesion. Endoscopic hemo− stasis was initially successful in 63 pa− tients (91 %); 11 patients (16 %) required surgery because of eventual failure of en− doscopic therapy. A total of 52 patients were followed up for between 32 months and 137 months after discharge from hos− pital and no further bleeding was noted. These results suggest that the long−term prognosis for Dieulafoys lesion is excel− lent, even when patients are treated using endoscopic therapies alone.The last four patients we admitted with acute upper gastrointestinal bleeding due to Dieulafoys lesion have been treat− ed with injection therapy and band liga− tion (two or three bands) ( Figure [1], [2]) and no complications were noted after treatment. One experienced recurrent bleeding on day 5 after injection therapy alone. These patients have been followed up for between 12 months and 16 months and no further bleeding has been noted. Based on a recent study [3] and on our own experience, we would like to briefly review the current position and our con− clusions on the endoscopic treatment of bleeding Dieulafoy lesions.The first mode of therapy advocated for bleeding Dieulafoy lesions was surgery, which was associated with high mortality and morbidity (related to the emergency subtotal gastrectomy). The advent of en− doscopy significantly improved the diag− nosis of Dieulafoys lesion and offered safe and effective therapeutics options [1 ± 4]. Based on the results described above and elsewhere, we concur that en− doscopic therapies are now the first and the best option in the management of Dieulafoys lesion.There are now some data on the relative efficacies of different endoscopic treat− ment modalities in patients with bleeding Dieulafoys lesion. Chung et al. [2] found that mechanical treatment (hemoclip and band ligation) successfully achieved primary hemostasis in 91.7 % of patients, compared with a primary hemostasis rate of 75 % in patients treated with injec− tion therapy alo...

Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation

“…5,6 With the advances in endoscopic techniques for locating and managing a bleeding site, endoscopic treatment has replaced surgery as the standard diagnostic and therapeutic approach for bleeding DLs. 5,7 The rate of hemostasis with endoscopic treatment is known to reach 75% to 100%, 1,5,6,[8][9][10][11][12][13][14][15][16][17][18][19] and a good long-term prognosis after endoscopic treatment has been proved to date. 1,6,9,14,15 Studies have shown that mechanical endoscopic methods, such as endoscopic hemoclip placement (EHP) and endoscopic band ligation (EBL), are more effective treatments than other endoscopic methods, such as injection and thermal therapy.…”

Evaluation of treatment results of patients with acute gastrointestinal bleeding due to dieulafoy's lesion admitted to emergency department

“…[20][21][22][23] EBL varisiyel üst GİS kanamalarında rutin uygulanan bir prosedürdür. İlk kez Brown ve arkadaş-ları [15] DL'de EBL ile kanama kontrolünü sağladıkları-nı 1994 yılında rapor etmişlerdir.…”

“…İlk kez Brown ve arkadaş-ları [15] DL'de EBL ile kanama kontrolünü sağladıkları-nı 1994 yılında rapor etmişlerdir. Yine Valera ve arkadaşları [20] DL kanaması nedeniyle EBL uyguladıkları 4 hastalarında band ligasyonu ile başarılı hemostaz sağladıklarını rapor etmişler, hastalarının hiçbirinde tekrar kanama görülmediğini belirtmişlerdir. EBL uygulaması sonrasında 14-21 günde iyileşen sığ, temiz tabanlı, ülserler görülebilmektedir.…”

Double Dieulafoy's lesions of the stomach in a patient with chronic renal failure on long-term hemodialysis

“…Mechanical endoscopic treatment, especially band ligation, has been suggested to achieve better primary hemostasis than injection therapy alone. Furthermore, the risk of rebleeding has been shown to be much lower with mechanical treatment compared to injection treatment (16,17). In addition, endoscopic band ligation is technically easier than hemoclip applications and injection methods, especially when the esophagogastric junction or the posterior wall of the proximal body of the stomach is involved.…”