Embolization versus surgery for peptic ulcer bleeding after failed endoscopic hemostasis: a meta-analysis

Background and study aims: A meta-analysis was conducted to assess the efficacy of transcatheter arterial embolization (TAE) compared with surgery in the management of patients with recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB) after failure of endoscopic hemostasis.

Patients and methods: Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts from major international conferences were searched for studies comparing TAE with surgery for treatment of NVUGIB after endoscopic hemostasis failure. Outcome measures included rebleeding rate, all-cause mortality rate, and need for additional interventions to secure hemostasis.

Results: From 1234 citations, 6 retrospective comparative studies were included that involved 423 patients (TAE, 182, 56 % male; surgery, 241, 68 % male). TAE patients were older (mean age, TAE 75, surgery, 68). The risk of rebleeding was significantly higher in TAE patients compared with surgically treated patients (relative risk [RR] 1.82, 95 % confidence interval [95 %CI] 1.23 – 2.67), with no statistically significant heterogeneity among the included studies (P = 0.66, I ² = 0.0 %). After sensitivity analysis excluding studies with a large age difference between the two groups, a higher risk of bleeding remained in the TAE group (RR 2.64, 95 %CI] 1.48 – 4.71). No significant difference in mortality (RR 0.87, 95 %CI 0.59 – 1.29) or requirement for additional interventions (RR 1.67, 95 %CI 0.75 – 3.70) was shown between the two groups.

Conclusion: A higher rebleeding rate was observed after TAE, suggesting surgery more definitively secured hemostasis, with no significant difference in mortality rate or requirement of additional interventions. The TAE patients were older and in poorer health, thus future randomized studies are needed for accurate comparison of the two modalities.

• References

• 1 Cook DJ, Guyatt GH, Salena BJ et al. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 1992; 102: 139-148
• 2 Rockall TA, Logan RF, Devlin HB. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage et al. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. BMJ 1995; 311: 222-226
• 3 de Manzoni G, Catalano F, Festini M et al. Emorragia acuta da ulcera duodenale. Risultati del trattamento endoscopico del primo sanguinamento e delle recidive. (In Italian.) [Acute hemorrhage caused by duodenal ulcer. Results of endoscopic treatment of the first bleeding episode and of recurrences]. Ann Ital Chir 2002; 73: 387-394 , discussion 394-396
• 4 Cheynel N, Peschaud F, Hagry O et al. Ulcère gastroduodénal hémorragique: résultats du traitement chirurgical. (in French). [Bleeding gastroduodenal ulcer: results of surgical management]. Ann Chir 2001; 126: 232-235
• 5 Lau JY, Sung JJ, Lam YH et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999; 340: 751-756
• 6 Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152: 101-113
• 7 Rösch J, Dotter CT, Brown MJ. Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology 1972; 102: 303-306
• 8 Wells GA, Shea B, O’Connell D et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. 2011 Accessed September 2, 2013.
• 9 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
• 10 Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539-1558
• 11 Egger M, Davey Smith G, Schneider M et al. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629-634
• 12 The Nordic Cochrane Centre. The Cochrane Collaboration Review Manager (RevMan) computer program, Version 5.0. 2012
• 13 Ang D, Teo EK, Tan A et al. A comparison of surgery versus transcatheter angiographic embolization in the treatment of nonvariceal upper gastrointestinal bleeding uncontrolled by endoscopy. Eur J Gastroenterol Hepatol 2012; 24: 929-938
• 14 Wong TC, Wong KT, Chiu PW et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc 2011; 73: 900-908
• 15 Venclauskas L, Bratlie SO, Zachrisson K et al. Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?. Scand J Gastroenterol 2010; 45: 299-304
• 16 Ripoll C, Bañares R, Beceiro I et al. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004; 15: 447-450
• 17 Larssen L, Moger T, Bjørnbeth BA et al. Transcatheter arterial embolization in the management of bleeding duodenal ulcers: a 5.5-year retrospective study of treatment and outcome. Scand J Gastroenterol 2008; 43: 217-222
• 18 Eriksson LG, Ljungdahl M, Sundbom M et al. Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 2008; 19: 1413-1418
• 19 Okazaki M, Higashihara H, Ono H et al. Embolotherapy of massive duodenal hemorrhage. Gastrointest Radiol 1992; 17: 319-323
• 20 Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992; 182: 703-707
• 21 Toyoda H, Nakano S, Takeda I et al. Transcatheter arterial embolization for massive bleeding from duodenal ulcers not controlled by endoscopic hemostasis. Endoscopy 1995; 27: 304-307
• 22 Walsh RM, Anain P, Geisinger M et al. Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg 1999; 3: 61-65, discussion 66
• 23 De Wispelaere JF, De Ronde T, Trigaux JP et al. Duodenal ulcer hemorrhage treated by embolization: results in 28 patients. Acta Gastroenterol Belg 2002; 65: 6-11
• 24 Ljungdahl M, Eriksson LG, Nyman R et al. Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers. Eur J Surg 2002; 168: 384-390
• 25 Holme JB, Nielsen DT, Funch-Jensen P et al. Transcatheter arterial embolization in patients with bleeding duodenal ulcer: an alternative to surgery. Acta Radiol 2006; 47: 244-247
• 26 Branicki FJ, Coleman SY, Fok PJ et al. Bleeding peptic ulcer: a prospective evaluation of risk factors for rebleeding and mortality. World J Surg 1990; 14 (02) 262-269, discussion 269-270
• 27 Loffroy R, Guiu B, D’Athis P et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009; 7: 515-523
• 28 Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012; 13: 31-S39
• 29 Loffroy R, Rao P, Ota S et al. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol 2010; 33: 1088-1100
• 30 Mine T, Murata S, Nakazawa K et al. Glue embolization for gastroduodenal ulcer bleeding: contribution to hemodynamics and healing process. Acta Radiol 2013; 54: 934-938
• 31 Murata S, Onozawa S, Nakazawa K et al. Glue embolization for endoscopically unmanageable gastrointestinal haemorrhage. Hepatogastroenterology 2012; 59: 1126-1130
• 32 Loffroy R, Estivalet L, Cherblanc V et al. Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding. World J Gastrointest Surg 2012; 4: 223-227
• 33 Aina R, Oliva VL, Therasse E et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001; 12: 195-200
• 34 Poultsides GA, Kim CJ, Orlando RIII et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008; 143: 457-461
• 35 Padia SA, Geisinger MA, Newman JS et al. Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage. J Vasc Interv Radiol 2009; 20: 461-466
• 36 Berlin JA. Invited commentary: benefits of heterogeneity in meta-analysis of data from epidemiologic studies. Am J Epidemiol 1995; 142: 383-387
• 37 Stroup DF, Berlin JA, Morton SC et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008-2012
• 38 Egger M, Schneider M, Davey SmithG. Spurious precision? Meta-analysis of observational studies. BMJ 1998; 316: 140-144
• 39 Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535