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HELIOS Klinikum Erfurt HELIOS Klinikum Erfurt LINC 2016 Prophylactic transcatheter embolization in peptic ulcer bleeding (PUB) A new Gold Standard? S. Basche & M. Mille

HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

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Page 1: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt

HELIOS Klinikum Erfurt

LINC 2016

Prophylactic transcatheter

embolization in peptic ulcer

bleeding (PUB) –

A new Gold Standard?

S. Basche & M. Mille

Page 2: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

GIB

Upper GIB

Ulcus

Varicosis

Mallory-Weiss-S

Cancer

Oesophagus

Gaster

Duodenum

Page 3: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

GIB

Prognosis

- 80% of GI- bleedings suspend spontaneously

- 20% recidivate within 3 days after therapy

- Emergency operation up to 50 % (Mortality)

Page 4: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

GIB

Category Activity of bleeding

Recurrent bleed

I Ia Ib II IIa IIb IIc III

Acute hemorrhage Spurting hemorrhage Oozing hemmorrhage Recent hemorrhage Visible vessel Adherent clot Hematin on ulcer base Lesions without signs of recent

hemorrhage

90% 30%

50 – 100% 20 – 50%

< 5%

< 5%

Forrest classification

Page 5: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Recurrence bleeding (high risk)

• Depending on:

– Forrest Ia/Ib 55%

– Forrest II 14 - 36%

– ulceration size > 1cm

– Localisation (posterior wall)

– Age 70,1%

– Comorbidities and drugs (anticoagulation) 70%

– Unsafety endoscopic therapy

Page 6: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Results

n = 147 (recruitment 01-2008 – 12-2013)

Endoscopy and endoscopic treatment

Successful

n = 129 ( 88 % )

Continuous bleeding

n = 18 ( 12 % )

Risk management

Low risk

n = 58 ( 40 % )

High risk

n = 71 ( 48 % )

Prophylactic TAE

Emergency TAE

Page 7: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Results

Prophylactic TAE (n=71) uncontrolled bleeding TAE (n=18)

Contrast

extravasation 7 (10%) 9 (50%)*

TAE technique

Coils 59 (83%) 11 (61%)

Glue 2 (3%) 4 (22%)

Coils + Glue 10 (14%) 3 (17%)

Technical success 69 (97%) 18 (100%)

Clinical success 61 (89%) 17 (94%)

Minor complication 10 (14%) 1 (6%)

Major complication 2 (3%) 1 (6%)

Page 8: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Comments

• 2014 Meta-Analysis Kyaw Moe et al.: Embolization versus surgery for peptic ulcer bleeding after failed endoscopic

hemostasis: a meta-analysis. Endoscopy International Open 2014

TAE Surgery

Rebleeding 15-42% 8-23%

Mortality 3-26% 14-34%

Material Coils, Gelfoam,

Glue (10 %)

Page 9: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Comments

Hwan JJ et al: Transcatheter Arterial Embolization of Nonvariceal Upper

Gastrointestinal Bleeding with N-Butyl Cyanoacrylate.

Korean J Radiol 2007;8:48-56

– n=32

– Success rate 100%

– Clinical success 91 %

– Material NBCA

– Highly effective in coagulopathy and complicated

microcatheter advencement

–No ischaemic complications!

Page 10: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Case 1

Page 11: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Case 2

Page 12: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Comments

Onset to Treat Time

• Early endoscopy (within 24 hours)

• Blood susbtitution

1. Marik P E, Corwin H L. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Critical Care

Medicine 2008; 36(9): 2667-2674.

2. Jairath V et al. Outcomes following acute nonvariceal upper gastrointestinal bleeding in relation to time to endoscopy: results from a

nationwide study. Endoscopy. 2012 Aug;44(8):723-30.

3. Biecker E. Diagnosis and therapy of non-variceal upper gastrointestinal bleeding. World J Gastrointest Pharmacol Ther 2015 November

6; 6(4): 172-182

Page 13: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Comments

Erfurt Results

Time to Endoscopy 3 h 15 min

Emergency TAE < 60 min

Prophylactic TAE 4 h 33 min

Diagnosis and Therapy within 8 hours

Page 14: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt LINC 2016

Summary

– Minimal invasive and safe

– Significant reduction of rebleeding

• act as soon as possible 24 / 7 !

• Choose the best material !

• Check the back flow !

Prophylactic Transcatheter Embolization is

currently the GOLD STANDARD

Page 15: HELIOS Klinikum Erfurt - linc2016.cncptdlx.com · HELIOS Klinikum Erfurt LINC 2016 GIB Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer Oesophagus Gaster Duodenum

HELIOS Klinikum Erfurt

HELIOS Klinikum Erfurt

LINC 2016

Prophylactic transcatheter

embolization in peptic ulcer

bleeding (PUB) –

A new Gold Standard?

S. Basche & M. Mille