British Journal of Radiology (2006) 79, e96-e98
© 2006 British Institute of Radiology
doi: 10.1259/bjr/61547332
A case of successful embolotherapy for gastric ulcer bleeding from the intercostal artery after oesophagectomy and gastric reconstruction
J-W Kim, MD
J H Shin, MD
G-Y Ko, MD
H G Yoon, MD
H Y Song, MD
and
K B Sung, MD
Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap-2dong, Songpa-gu, Seoul 138-736, Korea
Correspondence: Ji Hoon Shin
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Abstract
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We report a successful treatment with coil embolisation of an intercostal artery for ulcer bleeding in a gastric tube in a 70-year-old man who underwent a total oesophagectomy and gastric tube reconstruction for oesophageal cancer. This case teaches us to search aberrant feeding vessels when active bleeding is suspected in reconstructed gastric tube in the patient with oesophagectomy and oesophagogastrostomy.
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Introduction
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A reconstructed gastric tube has commonly been used as a replacement for the oesophagus after oesophagectomy for oesophageal cancer [1]. Although bilateral truncal vagotomy is performed during the oesophagectomy, peptic ulcer disease of the reconstructed gastric tube is not uncommon [2] and life-threatening complications such as haemorrhage, perforation or fistula formation, can occur if this condition goes unrecognized or untreated [3–6]. In several reports of ulcer bleeding of the gastric tube, surgical treatments of resection and bypass were performed [3, 4]. To the best of our knowledge, however, there have been no reports of coil embolisation for peptic ulcer bleeding of a reconstructed gastric tube from the intercostal artery.
We present a case of successful coil embolisation of the intercostal artery for gastric ulcer bleeding in a patient with total oesophagectomy and gastric reconstruction for oesophageal cancer.
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Case report
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A 70-year-old man underwent total oesophagectomy and gastric tube reconstruction in the posterior mediastinum with cervical oesophagogastrostomy (McKewon operation) for squamous cell carcinoma of the oesophagus. The treatment was completed with adjuvant radiotherapy and chemotherapy. There was no gastric ulcer in the initial gastroscopy. 1 year post-operatively, the patient experienced dysphagia and episodes of substernal pain. Gastroscopy revealed a peptic ulcer on the anterior wall of the interposed stomach, and conservative treatment was initiated. Biopsy of the ulcer was negative for malignancy. 5 years post-operatively, this patient was admitted to the emergency unit of our hospital due to an episode of massive haematemesis and melena. On admission, the patient was haemodynamically unstable (a systolic blood pressure of 70 mmHg, a pulse rate of 116 beats min–1 and an initial haematocrit of 23%). Gastroscopy failed because the endoscope could not advance due to anastomotic stenosis. Because we suspected upper gastrointestinal bleeding, angiography was performed. Although a bleeding focus was not seen on the coeliac and superior mesenteric arteriogram (Figure 1a
), we occluded the right gastric and gastroepiploic arteries with four microcoils (MWCE-18-2.0-2-Hilal; Cook, Bloomington, IN) through a microcatheter. However, active bleeding continued through the nasogastric tube. We then performed angiography, selecting the right intercostobronchial artery in order to search for the feeding artery (Figure 1b). As contrast leakage from the fifth intercostal branch of the right intercostobronchial trunk was noted, we embolised it with absorbable gelatin sponge material (Spongostan; Johnson & Johnson, Gargrave/Skipton, UK) and three microcoils (MWCE-18-2.0-2-Hilal; Cook) through a microcatheter (Figure 1c). Active bleeding stopped and the patient recovered after fluid replacement and transfusion. Gastroscopy performed 2 months after embolisation showed circumferential healing ulceration at the anterior wall of the gastric body. He had not had any recurrent ulcer bleeding for 5 months at the time of the preparation of this manuscript.
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Figure 1. 70-year-old man with oesophageal cancer who underwent total oesophagectomy and gastric tube reconstruction. (a) Coeliac trunk angiography shows trifurcation of the right hepatic artery, common hepatic artery, and splenic artery. The right gastric (arrowheads) and gastroepiploic arteries (arrows) pass through the mediastinum, but no bleeding site is seen. (b) Right intercostobronchial trunk (arrowheads) origins from the right wall of the aorta at the level of the left main bronchus. Active contrast leakage (arrow) from the intercostal artery is noted. (c) After embolisation with a gelatin sponge and microcoils (arrowheads), no further contrast leakage is noted.
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Discussion
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Peptic ulcer disease of a reconstructed gastric tube has been known to be a rare late complication because the concurrent bilateral truncal vagotomy and reduction of the fundic gland area result in decreased acid and fasting serum gastrin elevation [1, 7]. However, according to the recent study of Motoyama et al [2], of 114 patients who underwent oesophagectomy and gastric reconstruction for oesophageal cancer, 7 (6.1%) had gastric ulcer and 40 patients (35.1%) had erosive or haemorrhagic gastritis, and they reported that there was a four-fold increase in gastric ulceration in patients who underwent oesophagectomy than in patients residing in the same region who did not undergo oesophagectomy. The causes of the increase of gastric ulceration or haemorrhagic gastritis have been suggested as the following. First, although truncal vagotomy is performed routinely by oesophagectomy and gastric reconstruction, it does not lead to decreased qualitative gastric secretion [8]. Second, as the reconstructed gastric tube is only fed by the right gastroepiploic artery and partially by the right gastric artery, ischaemia of the reconstructed gastric tube is not uncommon [2, 4]. Besides, the blood supply of the cranial 20% of the greater curvature tube is through a microscopic network of capillaries and arterioles from an aberrant artery such as the intercostal artery or the bronchial artery as well as the right gastroepiploic artery [9], so haemorrhage secondary to gastric ulcer or gastritis may be more serious in this ischaemic area.
In our patient, 1 year after oesophagectomy and gastric reconstruction, peptic ulcer was detected on gastroscopy and 5 years later, massive bleeding developed from this peptic ulcer. On angiography, contrast leakage from the right fifth intercostal artery was noted in the diminished area of blood flow between the right gastroepiploic and the right gastric artery.
Although most patients with reconstructed gastric tube ulcers are healed by medical treatment using a proton-pump inhibitor or a histamine receptor blocker [2, 4], if the ulcer goes unrecognized or untreated, serious complications with high mortality can develop as a result of haemorrhage or even perforation into surrounding structures. Reviewing the literature, we found some cases of fistula formation by penetrating peptic ulcer of the gastric tube, including three cases of aortogastric fistulae [5], a case of tracheogastric fistula [3], and a case of simultaneous gastropericardial and gastrobrachiocephalic vein fistulae [6]. All patients with fistula formation with the aorta died during surgery or on the way to surgery. Only one patient who presented with massive bleeding due to an abscess enclosing the intrathoracic artery underwent an extended resection of the abscess and gastric tube ulcer [4]. To the best of our knowledge, treatment with coil embolisation for ulcer bleeding of a reconstructed gastric tube has not been reported.
With a patient who has undergone oesophagectomy and gastric reconstruction and presents with massive haematemesis and melena, we must keep in mind the possibility of ulcer bleeding from an aberrant vessel such as the intercostals or bronchial, as well as a normal feeding artery of the right gastric or gastroepiploic artery, and we can embolise the feeding artery with coil and gelfoam.
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Acknowledgments
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We would like to thank Bonnie Hami, MA, Department of Radiology, University Hospitals Health System, Cleveland, OH, USA, for her editorial assistance in the preparation of this manuscript.
Received for publication July 14, 2005.
Revision received September 5, 2005.
Accepted for publication October 11, 2005.
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References
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Abstract
Introduction
