Endoscopic hemostasis followed by preventive transarterial embolization in high-risk patients with bleeding peptic ulcer: 5-year experience

Abstract

Background Upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease is one of the leading causes of death in patients with non-variceal bleeding, resulting in up to 10% mortality rate, and the patient group at high risk of rebleeding (Forrest IA, IB, and IIA) often requires additional therapy after endoscopic hemostasis. Preventive transarterial embolization (P-TAE) after endoscopic hemostasis was introduced in our institution in 2014. The aim of the study is an assessment of the intermediate results of P-TAE following primary endoscopic hemostasis in patients with serious comorbid conditions and high risk of rebleeding. Methods During the period from 2014 to 2018, a total of 399 patients referred to our institution with a bleeding peptic ulcer, classified as type Forrest IA, IB, or IIA with the Rockall score ≥ 5, after endoscopic hemostasis was prospectively included in two groups—P-TAE group and control group, where endoscopy alone (EA) was performed. The P-TAE patients underwent flow-reducing left gastric artery or gastroduodenal artery embolization according to the ulcer type. The rebleeding rate, complications, frequency of surgical interventions, transfused packed red blood cells (PRBC), amount of fresh frozen plasma (FFP), and mortality rate were analyzed. Results From 738 patients with a bleeding peptic ulcer, 399 were at high risk for rebleeding after endoscopic hemostasis. From this cohort, 58 patients underwent P-TAE, and 341 were allocated to the EA. A significantly lower rebleeding rate was observed in the P-TAE group, 3.4% vs. 16.2% in the EA group; p = 0.005. The need for surgical intervention reached 10.3% vs. 20.6% in the P-TAE and EA groups accordingly; p = 0.065. Patients that underwent P-TAE required less FFP, 1.3 unit vs. 2.6 units in EA; p = 0.0001. The mortality rate was similar in groups with a tendency to decrease in the P-TAE group, 5.7% vs. 8.5% in EA; p = 0.417. Conclusion P-TAE is a feasible and safe procedure, and it may reduce the rebleeding rate and the need for surgical intervention in patients with a bleeding peptic ulcer when the rebleeding risk remains high after primary endoscopic hemostasis.

Prophylactic transcatheter arterial embolization for high-risk ulcers following endoscopic hemostasis: A meta-analysis

“…large ulcers, Forrest class I-IIb) and/or clinical presentation (i.e. hypotension, decreased hemoglobin during endoscopy) 8,[11][12][13]18 .…”

“…A total of 882 patients were included 8,[11][12][13]18 : 265 and 617 patients received PTAE and endoscopy only, respectively ( Table 1). Two studies were randomized controlled trials (RCT).…”

“…At 30-day follow-up, neither mortality nor rebleeding rate was statistically signi cant in terms of PTAE's e cacy over conservative management after endoscopy. Due to signi cant baseline differences between PTAE and endoscopy-only groups, subgroup analysis of the following variables was not possible: Forrest Classi cation 13 , Rockall score 13 , ASA Physical Classi cation 12 , and anticoagulation use (warfarin, heparin) 13 .…”

“…remain at high-risk for rebleeding [7][8][9] , leading to increased mortality compared to initial events 10 . Prior retrospective studies have explored the use of prophylactic transcatheter arterial embolization (PTAE) in this patient population to decrease the rebleeding risks, demonstrating promising results [11][12][13] .…”

Bleeding Duodenal Ulcer: Strategies in High-Risk Ulcers

“…In this study we could show for the first time that establishing prophylactic TAE in high-risk DU is safe and effective, resulting in a low surgery rate ( n = 1; 0.9%) and a low bleeding-associated mortality of 4.3% [72]. Additionally, Kaminskis et al [81] could also show in a following study including 399 patients with bleeding high-risk ulcers that prophylactic TAE resulted in a lower rebleeding rate (3.4 vs. 16.2%; p = 0.005) and a low rate of surgical intervention compared to the standard treatment. The main criteria for prophylactic TAE in this study were ulcer an classification of Forrest Ia to IIb, a Rockall score ≥5, and an individual high-risk profile (age and comorbidities).…”