Advantages and disadvantages of different methods of endoscopic hemostasis syndrome Delfoi

  • Authors: Orevkov E.B.1, Alieva E.S.1, Spiridonova E.V.1, Strinkevich A.V.2, Pavlova V.N.3
  • Affiliations:
    1. Пермский Государственный Медицинский Университет им. Е.А. Вагнера
    2. Пермский Государственный Медицинский Университет м. Е. А. Вагнера
    3. Пермский Государственный Медицинский Университет им. Е. А. Вагнера
  • Issue: Vol 10, No 1 (2021): Материалы XIV Международного хирургического форума «ИННОВАЦИОННЫЕ ТЕХНОЛОГИИ В ХИРУРГИИ»
  • Pages: 23-25
  • Section: ХИРУРГИЯ
  • URL: https://new.vestnik-surgery.com/index.php/2415-7805/article/view/6381
  • Cite item

Abstract


Abstract: the paper presents the experience of treating patients with lesions Delfoi.
Diagnosis and treatment of the syndrome Delfoi remains one of the most important problems of emergency surgery. Today is the actual task of creating a unified and effective tactics of treatment of lesions Delfoi.
Goal. Improve the results of diagnosis and treatment of Dielafua lesion by identifying the nuances of its clinical course and analyzing the use of different types of endoscopic hemostasis in patients with this syndrome.
Methods and materials. The analysis of 21 case histories of patients with Dielafua lesion who were treated in the Department of Surgery of the Tverye State Clinical Hospital in Perm was performed. The features of the clinical course and laboratory data, the results of fibroesophagogastroduodenoscopy( FEGDS), endoscopic and surgical methods of treatment and their final results were studied.
Results. 66.6% of patients with Dielafua lesion were men, 61.9% of patients were in the age category of 40-59 years. Upon admission, all patients underwent fibroesophagogastroduodenoscopy in combination with subsequent endoscopic hemostasis using alcohol irrigation, clipping, and argonoplasmic coagulation. Relapse of bleeding occurred in 4 patients who were treated with alcohol irrigation and clipping. When combined irrigation alcohol with argon plasma coagulation recurrence was not observed. All patients with recurrent bleeding were operated on.
Conclusion. Among patients with lesions Delfoi dominated by men 40-59 years with severe blood loss. The most effective method of endoscopic hemostasis with the defeat of Dieulafoy showed a combination of irrigation alcohol with argon plasma coagulation.


Full Text

Relevance: Gastrointestinal bleeding is one of the main problems and causes of mortality in emergency surgery [1, 2]. In the etiology of gastrointestinal bleeding, a number of well-known pathologies are distinguished, such as gastric ulcer and duodenal ulcer, Mallory-Weiss syndrome, neoplasms and varicose veins of the esophagus and stomach.
There are also a number of other rare, but no less dangerous diseases characterized by the development of acute gastroduodenal bleeding [3]. These include the Dielafua lesion, a rare genetic pathology characterized by abnormal development of the submucosal vessels without signs of an inflammatory process, with the rupture of which there is heavy bleeding [1, 3, 4].
Lesion treatment Delfoi remains a complex and unresolved until the end of the task. Conservative therapy of Dielafua syndrome is ineffective, due to the fact that the vessels of the submucosal layer are motionless in relation to the stomach muscles and do not spasm [3].
Currently, endoscopic techniques are fundamental in the treatment of a wide variety of surgical diseases [5]. In the treatment of Dielafua lesion, clipping, injection hemostasis, and thermal hemostasis, represented by monopolar, bipolar, and argonoplasmic coagulation, are commonly used among them [1, 2, 6].
Improving diagnosis and treatment is one of the main goals that are pursued when analyzing the experience of working with a particular pathology [7, 8].
To date, a significant number of authors describe less than twenty observations of Dielafua lesion [1, 3, 6]. Due to the rare occurrence of Dielafua syndrome (up to 1% of all gastro-duodenal bleeding), and as a result of lack of experience, there is no unanimous opinion in the choice of treatment tactics [1, 3].
Objective: To improve the results of diagnosis and treatment of Dielafua lesion by identifying the nuances of its clinical course and analyzing the use of different types of endoscopic hemostasis in patients with this syndrome.
Materials and methods: the analysis of 21 case histories of patients with Dielafua lesion who were treated in the Department of Surgery of the Tver State Clinical Hospital of Perm was performed. The features of the clinical course and laboratory data, the results of fibroesophagogastroduodenoscopy (FEGDS), endoscopic and surgical methods of treatment and their final results were studied.
Results: Among the patients with Dielafua lesion, the majority were men – there were 14 of them (66.6%). At the same time, there were only 7 women (33.4%). The majority of patients were of working age. The majority of patients were aged 40-59 years – 13 (61.9%) people. In the age group of 60-79 years, there were 5 patients (23.8%). Two (9.5%) patients were in the 20-39-year-old group and 1 (4.8%) patient was in the 80-year-old group. On average, the age of men with Dielafua lesion was 52.8±11.9 years, and women 53.2±11.7 years.
According to various sources, the source of bleeding in Dielafua lesion is localized on the posterior wall along the small curvature of the stomach, 6 cm from the gastroesophageal junction [1, 2, 4, 6, 9]. This is due to the intensive blood supply to this area, which is provided by the right and left gastric arteries[3]. In our study, in all patients, lesions were also localized on the posterior wall of the cardiac part of the stomach.
The severity of bleeding in patients was determined by the method of A. I. Gorbashko (1982). The subjects had only moderate and severe blood loss, 5 (23.8%) and 16 (76.2%) patients, respectively. All patients required blood transfusion.
All patients were performed faggs. Three endoscopic variants of Dielafua lesion were found in patients with FEGDS according to N. M. Dy and co-authors (1995) [4].
16 (76.2%) patients had a type 1 endoscopic picture, represented by pulsating arterial bleeding from a small mucosal defect with a diameter of less than 3 mm, while the mucosa around the defect was unchanged and raised around the bleeding vessel in the form of a polyp.
In 2 (9.5%) patients, a type 2 endoscopic picture was revealed. A thrombosed vessel without active bleeding was found protruding from a superficial defect of the mucous membrane. The mucous membrane around the vessel was not changed.
3 (14.3%) patients were found to have a type 3 endoscopic pattern. They were found to have a fixed clot in a small surface defect of the unchanged mucosa with a diameter of up to 3 mm.
When performing FEGDS, all patients underwent hemostasis. Used injection hemostasis, argon plasma coagulation, clipping of vessels and spraying alcohol. In all cases, the bleeding was stopped.
Irrigation alcohol was applied at 1 (4,8%)patient with a third type of endoscopic picture of defeat Delfoi. However, this patient later had a relapse of bleeding.
Injectable hemostasis was used in 2 (9.5%) patients, while in 1 (4.8%) case there was a recurrence of bleeding.
Vessel clipping was performed in 3 (14.3%) patients. Two (9.5%) of them had a relapse of bleeding on the 2nd day.
The main group, which included 15 (71.4%) patients, underwent hemostasis according to the following scheme: first, the bleeding site or clot was irrigated with alcohol, which led to a decrease in the rate or even cessation of bleeding. After that, the defect of the mucous membrane, and not changed the lining around the defect was treated with argon plasma coagulation. Among the 15 patients who were treated with combined irrigation and argonoplasmic coagulation, there were patients with all variants of the endoscopic picture. No relapses of bleeding were observed in this group.
As a result, relapses of bleeding occurred only in 4 patients.
All patients with recurrent bleeding were operated on. Of the 2 patients with relapse after clipping, one patient underwent a wedge - shaped resection of the stomach, and the other-a gastrotomy with stitching of the bleeding vessel. In a patient who underwent hemostasis with alcohol irrigation, a gastrotomy was performed with the vessel suturing. And in the case of a relapse after injectable hemostasis, a tubular resection of the stomach was performed.
Given some features of the syndrome, such as the presence of vascular malformation, surgeons sought to limit the minimum amount of intervention. For example, after suturing the vessel, neither ligation of the left gastric artery nor vagotomy was performed. When performing resection, they were limited only to excision of a small section of the gastric wall.
After the operations, a histological examination of the stomach was performed. In both cases the diagnosis was confirmed Delfoi. Here is a fragment of the histological conclusion of one of the two cases of gastric resection: "in the gastric wall in the clipping area, there is ... a defect that covers the entire thickness of the mucous membrane, with granulation tissue and necrotic detritus in the bottom. In the submucosal layer, there are numerous abnormally large thick-walled dilated vessels located close to the mucous membrane...". This characteristic histological pattern corresponding to the clinical diagnosis of the lesion Delfoi.
All patients were discharged with recovery. There were no fatal outcomes in the study group. The average number of bed days in patients after successful endoscopic treatment was 6 days, after relapse and surgery - 12.6 days.
Subsequently, in the period from 1 to 8 years after discharge, none of these patients were re-admitted to the gastrointestinal bleeding clinic. All these patients are residents of the Industrial, Sverdlovsk and Dzerzhinsk districts of the city of Perm. All patients with gastrointestinal bleeding from these areas of the city are admitted to the emergency surgery department of the Tver State Clinical Hospital. These facts indicate that there were no relapses of bleeding after discharge in these patients.
Discussion: the paper presents the experience in the treatment of 21 patients with lesions of Dieulafoy. A relatively small number of patients is explained by the fact that this syndrome is quite rare. Similar data are given by other researchers [1, 2, 6]. Therefore, our study of the experience of using endoscopic methods for the treatment of Dielafua lesions seems to us quite important and relevant.
The results obtained allow us to say with confidence that the endoscopic method of hemostasis, represented by a combination of alcohol irrigation and argonoplasmic coagulation, is highly effective in the case of Dielafua lesion.
It is noteworthy that when using vascular clipping, we observed 66.7% of relapses. In our opinion, this fact is explained by the fact that when clipping, it is not possible to capture the entire pathological vessel represented by an aneurysm. Moreover, the boundaries of this pathologically expanded vessel under the mucosa are not visible. From the above, it follows that argonoplasma coagulation is the most effective endoscopic method of treating Dielafua lesions, in which the effect occurs on the mucosa around the vessel and the aneurysm.
Conclusions:
1. Among patients with Dielafua lesion, men of working age predominate.
2. Blood loss with the defeat of Dieulafoy often severe, at least moderate severity.
3. The most effective method of endoscopic treatment of Dielafua lesion is a combination of alcohol irrigation and argonoplasmic coagulation.
4. The combination of argonoplasmic coagulation and alcohol irrigation should also be used in cases where there is no ongoing bleeding.

About the authors

Evgenii B. Orevkov

Пермский Государственный Медицинский Университет им. Е.А. Вагнера

Email: orevkov-fanat@yandex.ru
ORCID iD: 0000-0001-9622-724X

Russian Federation, 614045, Россия, Пермь ул. Петропавловская, 26

ординатор 1 года, кафедра факультетской хирургии №2

Elnura S. Alieva

Пермский Государственный Медицинский Университет им. Е.А. Вагнера

Author for correspondence.
Email: Elnuraalieva1@gmail.com
ORCID iD: 0000-0002-0033-1550

Russian Federation, 614045, Россия, Пермь ул. Петропавловская, 26

студентка 5 курса, педиатрического факультета. 

Ekaterina V. Spiridonova

Пермский Государственный Медицинский Университет им. Е.А. Вагнера

Email: spiridonovp95@bk.ru
ORCID iD: 0000-0002-7473-1450

Russian Federation, 614045, Россия, Пермь ул. Петропавловская, 26

студентка 5 курса, педиатрического факультета 

Alexander V. Strinkevich

Пермский Государственный Медицинский Университет м. Е. А. Вагнера

Email: strinkevi4@gmail.com
ORCID iD: 0000-0002-9935-4495

Russian Federation, 614045, Россия, Пермь ул. Петропавловская, 26

ординатор 1 года, кафедра факультетской хирургии №2

Varvara N. Pavlova

Пермский Государственный Медицинский Университет им. Е. А. Вагнера

Email: var.pawlowa2013@yandex.ru
ORCID iD: 0000-0003-2011-7663
SPIN-code: 5398-4349

Russian Federation, 614045, Россия, Пермь ул. Петропавловская, 26

студентка 4 курса, лечебного факультета

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