经导管动脉栓塞术治疗动脉性上消化道出血

目的评价经导管动脉栓塞术治疗动脉性上消化道出血的临床疗效。方法回顾性分析58例上消化道出血患者的临床资料。对58例动脉性上消化道出血患者行动脉造影,发现出血征象时超选择插管造影,并根据不同出血原因和出血部位采用不同栓塞材料进行栓塞。随访1~3个月,并观察疗效。结果 58例患者中,50例动脉造影表现为对比剂外溢、假性动脉瘤、血管畸形等,栓塞治疗止血有效率为94.00%（47/50）,栓塞后再出血率为4.26%（2/47）,未见严重并发症。结论经导管动脉栓塞术治疗动脉性上消化道出血安全、有效,具有较高临床应用价值。     

Transcatheter arterial embolization for cancer-related non-variceal upper gastrointestinal bleeding: A multicenter retrospective study of 107 patients

PurposeThe purpose of this study was to retrospectively evaluate the outcome of transcatheter arterial embolization (TAE) in the treatment of cancer-related non-variceal upper gastrointestinal bleeding (UGIB).Materials and methodsOne-hundred and seven patients who underwent TAE for the treatment of cancer-related non-variceal UGIB at five institutions between June 2016 and May 2019 were retrospectively included. There were 78 men and 29 women, with a mean age of 60.6 ± 13.2 (SD) (age range: 31–87 years). Clinical success was defined as no rebleeding within 30 days after TAE. Rebleeding was defined as non-variceal UGIB resulting in a decrease in hemoglobin > 2 g/dL within 24 h. The Kaplan-Meier method was used to estimate actuarial probabilities of rebleeding and survival within 30 days after TAE. Univariable and multivariable analyses were performed to identify variables associated with clinical success and 30-day mortality.ResultsTechnical success was achieved in 106 out of 107 patients (99.1%). Positive angiographic findings (contrast extravasation and pseudoaneurysm) were observed in 30/107 patients (28.0%). Empiric embolization was performed in 77/107 patients (72.0%). Clinical success was achieved in 60/107 patients (56.1%). The 3-day, 7-day, and 30-day actuarial probabilities of rebleeding were 21.5%, 31.0%, and 44.6%, respectively. No variables were identified as predictors of clinical success. Nineteen patients (19/107; 17.8%) died within 30 days after TAE; of them, 14 (14/107; 13.1%) died due to bleeding-related causes. The 3-day, 7-day, and 30-day actuarial probabilities of survival were 91.6%, 88.8%, and 77.4%, respectively. A baseline hemoglobin level of ≤ 60 g/L (Odds ratio [OR]: 3.376; 95% confidence interval [CI]: 1.223–9.318; P = 0.019) and clinical failure (OR: 6.149; 95% CI: 2.113–17.893; P = 0.001) were identified as predictors of 30-day mortality. Major complications (gastrointestinal perforation) occurred in one patient (1/107; 0.9%). Minor complications (abdominal pain, fever, and vomiting) occurred in 19 patients (19/107; 17.8%).ConclusionTAE is a safe treatment option for patients with cancer-related non-variceal UGIB, and seems to be effective in more than half of these patients.     

Role of endoscopy in the treatment of non-variceal upper gastrointestinal hemorrhage

Over the past three decades important progress has been made in the diagnosis and treatment of non-variceal upper gastrointestinal bleeding. We discuss the endoscopic techniques available today in combination therapies. The data in the literature regarding endoscopic techniques are discordant and no single technique has proved statistically superior in the management of bleeding. We believe that the initial injection approach is still the procedure of choice, particularly when performed by less expert endoscopists.     

经导管动脉栓塞治疗急性消化道大出血78例

目的探讨急诊血管造影及动脉栓塞对消化道出血的诊治价值。方法对 1988年 5月至 2 0 0 1年 7月临床收治的 78例消化道大出血患者应用Seldinger法经皮股动脉穿刺插管 ,将导管超选至出血动脉 ,经导管注入明胶海绵颗粒 ,共栓塞 86根动脉 ,其中胃左动脉 4根、胃十二指肠动脉2 1根、肠系膜上下动脉分支 5 9根、隔动脉 1根及肝动脉 1根。全部患者随访 1～ 10年。结果技术成功率 10 0 % (86 /86 ) ,立即止血 10 0 % (78/78) ,2 0 5 % (16 /78)复发出血。 78例患者中 71例出现腹痛、4 9例腹胀等轻微合并症。无胃肠道坏死穿孔等严重并发症发生。结论　经导管动脉栓塞治疗急性消化道大出血 ,定位准确、安全有效 ,同时为外科手术争取了时间。     

Selective embolization for control of gastrointestinal hemorrhage.

Transcatheter embolization using Gelfoam plugs or autologous clot is an alternative or adjunct to the conventional management of gastrointestinal hemorrhage. During a 12 month period we successfully treated 10 patients who had massive gastrointestinal hemorrhage with selective embolization; 6 patients had upper gastrointestinal hemorrhage and 4 had bleeding from the colon. Most of these patients were critically ill and were poor surgical candidates. Hemorrhage was controlled by selective catheterization of the bleeding vessel, followed by injection of Gelfoam pledgets. Since the procedure was accomplished with ease and prolonged hemostasis obtained, we recommend it for gastrointestinal hemorrhage, especially in patients who are poor surgical risks or are unresponsive to vasopressin infusion, or both. Operative intervention for the primary disease could subsequently be performed electively, if necessary, days or weeks after transcatheter embolization.     

经导管动脉栓塞治疗胰十二指肠切除术后晚期出血

目的 观察经导管动脉栓塞(TAE)治疗胰十二指肠切除术(PD)后晚期(术后7天以上)出血的效果。方法 回顾性收集12例因PD术后晚期出血而接受TAE并存在C级胰瘘患者,观察血管造影表现,记录栓塞方法及其效果、TAE后并发症及其后2周胰瘘变化等。结果 12例中,6例存在假性动脉瘤,其中3例见于肝固有动脉或肝总动脉、3例见于胃十二指肠动脉;6例消化道出血,3例来源于胰十二指肠下动脉、3例源自胃十二指肠动脉假性动脉瘤。对6例以弹簧圈、6例以弹簧圈+明胶海绵颗粒进行栓塞;12例均有效止血,治疗后均未再发出血。TAE后4例发热(最高体温39.1℃)、2例腹痛;5例肝功能损伤主要表现为转氨酶升高;均经对症治疗后好转。TAE后2周,5例胰瘘分级降为B级、3例降为A级(即生化瘘),4例仍见C级胰瘘。结论 以单一弹簧圈或联合明胶海绵颗粒行TAE治疗PD术后晚期出血安全、有效,且能促进胰瘘愈合。     

Emergency endoscopy in acute gastrointestinal hemorrhage

The authors consider that wide use of urgent endoscopy in gastro-intestinal bleedings can optimize the surgical tactics in such cases and give better results of treatment. General lethality was 3%. Postoperative lethality in a bleeding ulcer of the stomach and duodenum was 9.7 and 4.7% correspondingly.     

Endoscopic management of non-variceal upper gastrointestinal haemorrhage

Endoscopy plays a central role in the diagnosis and treatment of non-variceal upper gastrointestinal haemorrhage. Advances in endoscopic techniques, supported by an increasing body of high quality data, have rendered endoscopy the first-line diagnostic and therapeutic intervention for the patient presenting with an upper gastrointestinal haemorrhage. However, endoscopic intervention must be considered in the context of the overall management of the bleeding patient, often with significant comorbidities. Although parameters such as hospitalization duration, transfusion requirements and surgery rates have improved with advances in endoscopic therapy, mortality rates remain relatively static. This review addresses the current status of endoscopic intervention for non-variceal upper gastrointestinal haemorrhage. Additionally, an overview of important periprocedural management issues is presented.     

MSCTA指导下急诊动脉栓塞治疗消化道大出血

目的探讨MSCTA指导下行急诊动脉栓塞治疗消化道大出血的临床价值。方法对14例消化道大出血病例,术前在抗休克治疗同时急诊行MSCTA检查,明确出血部位或出血动脉后行急诊动脉栓塞术,超选择插管至出血动脉支,并以明胶海绵颗粒进行栓塞。结果动脉栓塞后,12例患者有效控制了出血,休克得到纠正。1例明确出血部位及性质后行急诊手术治疗,1例疑静脉出血,后行急诊内镜治疗。结论MSCTA指导下行急诊动脉栓塞术治疗消化道大出血简便迅速、准确性高、安全性好、并发症少。     

Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage

Endoscopic haemostasis can be effective in non-variceal upper gastrointestinal haemorrhage, and should be regarded as potential front-line treatment. Diverse methods are available, and although no single technique has become firmly established, current evidence favours thermal coagulation and injection therapy.     

Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding

Acute nonvariceal upper gastrointestinal bleeding(UGIB) is a major medical emergency problem associated with significant morbidity and mortality.Endoscopy is considered the first method of choice to detect and treat UGIB.Endoscopic therapy usually achieves primary hemostasis,but 10%-30% of these patients have repeat bleeding.In patients in whom hemostasis is not achieved with endoscopic techniques,treatment with transcatheter angiographic embolization(TAE) or surgery is needed.Surgical intervention is usually an expeditious and gratifying endeavor,but it can be associated with high operative mortality rates.A large number of studies support the use of TAE as salvage therapy as an alternative to surgery.However,few studies have compared the results of TAE with that of emergency surgery in terms of efficiency,the frequency of repeat bleeding,and complications.Recently,Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment.There were no significant differences in 30 d mortality,complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery.In this commentary,we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB.We also attempt to define the exact role of TAE for acute nonvariceal UGIB.     

Surgical tactics in acute gastrointestinal hemorrhage]

The results of treatment of 595 patients with acute gastro-intestinal bleeding are presented. Ulcer disease is the most frequent cause of bleeding. In its diagnosis, the use of gastroduodeno-fibroscopy is effective. In ineffective conservative therapy, the operative intervention is indicated.     

经导管子宫动脉栓塞术治疗剖宫产后难治性晚期出血

目的探讨经导管子宫动脉栓塞术（TUAE）治疗剖宫产后难治性晚期出血的价值。方法对23例剖宫产后难治性晚期出血患者,以明胶海绵颗粒进行TUAE,观察治疗效果,并对数字减影血管造影（DSA）表现进行分析。结果 22例患者经导管TUAE术后均止血成功,1例术后仍有阴道流血,行全宫切除术,发现为剖宫产术中将大网膜与子宫缝合在一起所致;DSA示动脉早期见对比剂外溢（20例）,血管畸形（3例）。本组病例未发生严重并发症。结论 TUAE治疗剖宫产后难治性晚期出血快速、准确、创伤小,值得推广。     

经动脉介入栓塞治疗颅面部创伤性大出血

目的探讨经动脉介入栓塞治疗颅面部创伤致急性、难治性大出血的临床疗效及价值。方法 32例颅面部创伤患者中,颅底骨折致口、鼻、耳道大出血28例,面颅骨骨折致口、鼻大出血4例,所有患者经动脉造影确定出血靶血管及范围后接受经动脉介入栓塞治疗,并评价其疗效。结果 32例均成功止血,未出现严重并发症。结论经动脉介入栓塞治疗颅面部创伤致急性大出血,创伤小、止血迅速、安全有效,可成为临床首选治疗方法。     

Immediate operation for acute non-variceal gastrointestinal haemorrhage in patients aged 50 years and over

A prospective trial of immediate operation was carried out on all 123 patients aged 50 years and over who presented with acute non-variceal bleeding as shown endoscopically. The mortality rate was 11.4%. Four hundred and sixty-seven similar patients treated by a conventional and more conservative approach, viz., surgery only for massive, continuous or recurrent bleeding, over an earlier period of three years, had a mortality rate of 6.4% during the acute bleeding episode. In the latter series, the mortality for the 161 patients with emergency surgery was 11.8%. The aggressive approach carries no advantage over the conservative approach and is not to be recommended. In both series surgery for haemorrhage with associated medical illness carried a similarly high mortality (27.3% and 26.3% respectively), indicating that the timing of surgery in such patients, whether it is done as early or as late as possible, does not influence the outcome. This mortality rate of immediate Billroth gastrectomy for gastric ulcer was low (4.8%), so that operation in such patients should not be delayed.     

Transcatheter embolization of extensive left gastric artery collaterals presenting with massive upper gastrointestinal bleed

We report a case of extensive left gastric artery collaterals that were formed in the region of gastric fundus due to splenic artery occlusion and resulted in massive hematemesis. These collaterals were thought to be portosystemic collaterals related to portal hypertension during upper endoscopy study and single-phase venous computed tomography studies. The collaterals were treated by transcatheter endovascular coil embolization. Our case highlights the importance of recognizing and differentiating left gastric artery collaterals from gastric venous varices as a cause of hematemesis since the treatment approach for each condition is totally different. It also introduces the feasibility of percutaneous left gastric artery embolization as a treatment for this condition, without the need for surgical splenectomy and partial gastrectomy which have a higher mortality and morbidity.