Letters to the Editor
We read with great interest the article written by Ang et al. 1, comparing surgery with transcatheter angiographic embolization (TAE) in the treatment of nonvariceal upper gastrointestinal bleeding (NVUGIB) uncontrolled by endoscopy. We have several comments. The higher rebleeding rate after TAE could be one of the reasons why there was no difference in the mortality rate between the embolotherapy and the surgical treatment groups in this report, as well as in two other retrospective studies that compared TAE and surgery 2,3. The fact that the mortality rate was similar and the rebleeding rate was higher after TAE, raises the question of whether we should offer TAE as an alternative to surgery in low-risk surgical candidates. Only a future randomized-controlled trial can answer this question. However, there are several logistical problems involved in such a study. One main concern is the possibility of selection bias. It is unlikely that an endoscopist/surgeon who has diagnosed severe bleeding from the gastroduodenal artery in an unstable patient would transfer that patient to a radiology suite if randomization resulted in TAE. To be able to carry out a true randomized study, the involved centers must be equipped with an operating theater with both angiographic and surgical facilities.
Two retrospective comparisons showed at least similar efficacy in terms of the rate of rebleeding, morbidity, and mortality 3,4. The findings in this study appear to confirm previously published retrospective case series that support the role of TAE and show that it reduces the need for surgery, has a low complication rate, and does not increase mortality. The findings of this study also support recently published international consensus recommendations on the role of surgery and TAE in the management of NVUGIB 5. TAE should be considered, if not before, at least as an alternative to surgery in patients with NVUGIB in whom primary endoscopic hemostasis fails or in those who have a second rebleeding event 6.
Therefore, will surgery be a thing of the past in NVUGIB? No, not exactly, because there will always be selected patients in whom endoscopic hemostasis therapy fails, who may not be candidates for embolization therapy or in whom it fails, or who may not have access to interventional radiology hemostasis techniques. However, the role of the surgeon in this clinical sphere is certainly diminishing and will continue to diminish in ensuing years. This is to the credit of endoscopists, who are providing improved endoscopic care to patients with bleeding, to a more standardized approach to endoscopic hemostasis, and to the interventional radiologists who can provide less invasive yet as effective treatment options as salvage surgical therapy.
In conclusion, in patients with unsuccessful endoscopic control of NVUGIB, surgery remains a very effective treatment. However, in patients with a high surgical risk because of unknown bleeding sources and/or severe pre-existing diseases/comorbidities, endovascular therapy offers an excellent treatment option. These patients should then be operated on as early as possible to minimize the risk of recurrent bleeding episodes, which are associated with high morbidity and mortality. Future prospective randomized trials have to clarify whether this treatment regimen can reduce mortality rates in patients with a high risk for surgery.
Conflicts of interest
There are no conflicts of interest.
1. Ang D, Teo EK, Tan A, Ibrahim S, Tan PS, Ang TL, 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
2. Eriksson LG, Ljungdahl M, Sundbom M, Nyman R. Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol. 2008;19:1413–1418
3. Ripoll C, Banares R, Beceiro I, Menchen P, Catalina MV, Echenagusia A, 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
4. Wong TC, Wong KT, Chiu PW, Teoh AY, Yu SC, KW AU, et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc. 2011;73:900–908
5. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101–113
6. Loffroy R, Guiu B. Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers. World J Gastroenterol. 2009;15:5889–5897