Scandinavian Journal of Gastroenterology, 2010; 45: 1003–1004

LETTER TO THE EDITOR

Transcatheter arterial embolization should be the salvage treatment ofchoice in all patients with bleeding from duodenal ulcers resistant toendoscopic hemostasis

ROMARIC LOFFROY

The Russell H. Morgan Department of Radiology and Radiological Science, Division of Cardiovascular and InterventionalRadiology, The Johns Hopkins Hospital, Baltimore, USA

TO THE EDITOR: We read with great interest thearticle by Venclauskas et al. [1] published recently inthe Scandinavian Journal of Gastroenterology and com-paring results of transcatheter arterial embolization(TAE) and surgery in patients with massive bleedingfrom duodenal ulcers. We have several comments.Arterial embolization is now accepted as the sal-vage treatment of choice for acute bleeding fromduodenal ulcers despite endoscopic treatment.Many published studies confirm the feasibility ofthis approach and the high technical and clinicalsuccess rates, ranging from 91% to 100% and from63% to 100%, respectively [2–4]. In the presentstudy, the rebleeding rate in the TAE group wasnearly twice as high as that in the surgery group. Itmay be ascribable to several factors: first, coils wereused as the only embolic agent in 12 (50%) patients.Second, the authors did not perform blind emboliza-tion in the absence of angiographic extravasation in 3(12.5%) patients. Third, the time from hospitaladmission to the definitive procedure and the numberof comorbidities were significantly longer and greater,respectively, in the TAE group. At last, patientstreated by endovascular approach were older thanthose treated by surgery. Indeed, we recently reportedour results obtained during nearly 10 years of expe-rience with arterial embolization used to treat refrac-tory massive bleeding from gastroduodenal ulcers [5].We had 60 patients, the largest case-series in the

literature. Using coils alone to occlude the feedingartery significantly predicted early rebleeding (within30 days) by univariate (p = 0.003) and multivariate(p = 0.022) analysis. We therefore advocate the use ofgelatin particles in combination with coils in thegastroduodenal artery (GDA) territory, when thesandwich technique is used. Consequently, we donot recommend the use of coils as the only embolicagent for TAE in bleeding duodenal ulcers. On theother hand, our study, as previous reports [2,3], alsoshowed that empirical embolization based on endo-scopic findings, in the absence of contrast extravasa-tion, can be performed successfully, with no differenceaccording to whether angiography identified the blee-ding site. Thus, embolization of the GDA should beperformed in patients with bleeding duodenal ulcer atendoscopy and no signs of active bleeding at angiogra-phy. In addition, we found that early rebleeding wasassociated with a longer time from shock onset toangiography (p = 0.0005) and having two or morecomorbid conditions (p = 0.005) in the univariateanalysis [5]. Consequently, every effort should bemade to perform embolization early after bleedingonset. Finally, the rebleeding and mortality rates afterTAE could probably have been reduced in the presentstudy [1]. So we do not agree with the authors’ con-clusions concerning low-risk patients. Overall, surgerymay be associated with up to 40% mortality and 45%morbidity [6]. The low postoperative morbidity rate

Correspondence: Romaric Loffroy, MD, The Russell H. Morgan Department of Radiology and Radiological Science, Division of Cardiovascular andInterventional Radiology, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 545, Baltimore, Maryland 21287, USA. Tel: +1 410 955 6081.Fax: +1 410 955 0233. E-mail: romaric.loffroy@yahoo.fr

(Received 18 January 2010; accepted 16 March 2010)

ISSN 0036-5521 print/ISSN 1502-7708 online � 2010 Informa UK Ltd.DOI: 10.3109/00365521003793733

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is one of the main advantages of embolization oversurgery, as confirmed in the study by Venclauskaset al. [1]. In addition, embolization is less invasiveand less aggressive than surgery. In conclusion, wethink that TAE must be considered the treatment ofchoice after failed endoscopic treatment for bleedingduodenal ulcers, not only in high-operative-riskpatients, but also in low-risk patients.

References

[1] Venclauskas L, Bratlie SO, Zachrisson K, Maleckas A,Pundzius J, Jönson C. Is transcatheter arterial embolizationa safer alternative than surgery when endoscopic therapy failsin bleeding duodenal ulcer? Scand J Gastroenterol 2010;45:299–304.

[2] Defreyne L, Vanlangenhove P, De Vos M, Pattyn P,Van Maele G, Decruyenaere J, et al. Embolization as a

first approach with endoscopically unmanageable acute non-variceal gastrointestinal hemorrhage. Radiology 2001;218:739–48.

[3] Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M,Hillon P, et al. Refractory bleeding from gastroduodenalulcers: arterial embolization in high-operative-risk patients.J Clin Gastroenterol 2008;42:361–7.

[4] Larssen L, Moger T, Bjornbeth BA, Lygren I, Klow NE.Transcatheter arterial embolization in the management ofbleeding duodenal ulcers: a 5.5-year retrospective study oftreatment and outcome. Scand J Gastroenterol 2008;43:217–22.

[5] Loffroy R, Guiu B, D’Athis P, Mezzetta L, Gagnaire A,Jouve JL, et al. Arterial embolotherapy for endoscopicallyunmanageable acute gastroduodenal hemorrhage: predictorsof early rebleeding. Clin Gastroenterol Hepatol 2009;7:515–23.

[6] Cheynel N, Peschaud F, Hagry O, Rat P, Ognois-Ausset P,Favre JP. Bleeding gastroduodenal ulcer: results of surgicalmanagement. Ann Chir 2001;126:232–5.

1004 Letter to the Editor

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