Superselective microcoil embolization for endoscopically uncontrollable bleeding after endoscopic submucosal dissection

Inhaltsübersicht

A 57-year-old man underwent endoscopic submucosal dissection (ESD) for the treatment of early gastric cancer of the antrum ([Fig. 1]). There was no immediate bleeding after the procedure, and a proton pump inhibitor was given intravenously for the prevention of delayed bleeding after ESD. Twelve hours after ESD, the patient suddenly developed hematemesis and melena. His systolic blood pressure was 80 mm Hg and heart rate was 110 beats per minute. His hemoglobin level decreased from 14.5 g/dL to 9.2 g/dL. Emergency gastroscopy revealed profuse oozing of blood from the artificial ulcer with an overlying clot. Endoscopic hemostasis using hemoclips was attempted, however, cessation of bleeding was not achieved as the active oozing masked its source ([Fig. 2]).

Fig. 1 Gastroscopic view showing a large artificial ulcer after endoscopic submucosal dissection.

Fig. 2 Emergent gastroscopic views at 12 hours after endoscopic submucosal dissection: a ineffective hemostasis after two serial hemoclippings; and b close-up view of the bleeding focus – note the active, profuse oozing between the hemoclips.

Owing to hemodynamic instability, the patient underwent emergency angiography. Extravasation of contrast medium was seen from a small side branch of the left gastric artery in the antrum ([Fig. 3 a]). The bleeding branch was successfully embolized by the placement of microcoils, both proximal and distal to the bleeding site, to prevent re-bleeding related to retrograde perfusion through the collateral vessels. No further extravasation of contrast medium was noted ([Fig. 3 b]). The patient was discharged after 5 days of close observation and conservative treatment. Endoscopy after 1 month revealed an ESD ulcer scar, without any evidence of ischemic complications ([Fig. 4]).

Fig. 3 a Superselective angiogram demonstrating extravasation, originating from a small side branch of the left gastric artery (arrow). b Final angiogram showing successful hemostasis after superselective placement of microcoils within the source artery (arrowheads).

Fig. 4 Follow-up gastroscopic view at 30 days after endoscopic submucosal dissection (ESD) shows an ESD ulcer scar without evidence of ischemic complications.

Delayed bleeding, which is defined as hematemesis or melena at 0 – 30 days after the procedure, may be the most serious complication of ESD [1]. Delayed recognition or failure to attempt endoscopic hemostasis for such an event may cause subsequent cardiovascular compromise. This report suggests that superselective microcoil embolization can be a lifesaving therapeutic option for endoscopically uncontrollable bleeding after ESD, and it can help avoiding emergency laparotomy [2].

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References

• 1 Takizawa K, Oda I, Gotoda T. et al . Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection – an analysis of risk factors.  Endoscopy. 2008;  40 179-183
• 2 Mezawa S, Homma H, Murase K. et al . Superselective transcatheter embolization for acute lower gastrointestinal hemorrhage after endoscopic mucosal resection: a report of 3 cases.  Hepatogastroenterology. 2003;  50 735-737