A systematic review of transarterial embolization versus emergency surgery in treatment of major nonvariceal upper gastrointestinal bleeding

Andrew D Beggs, Mark P Dilworth, Susan L Powell, Helen Atherton, Ewen A Griffiths, Andrew D Beggs, Mark P Dilworth, Susan L Powell, Helen Atherton, Ewen A Griffiths

Abstract

Background: Emergency surgery or transarterial embolization (TAE) are options for the treatment of recurrent or refractory nonvariceal upper gastrointestinal bleeding. Surgery has the disadvantage of high rates of postoperative morbidity and mortality. Embolization has become more available and has the advantage of avoiding laparotomy in this often unfit and elderly population.

Objective: To carry out a systematic review and meta-analysis of all studies that have directly compared TAE with emergency surgery in the treatment of major upper gastrointestinal bleeding that has failed therapeutic upper gastrointestinal endoscopy.

Methods: A literature search of Ovid MEDLINE, Embase, and Google Scholar was performed. The primary outcomes were all-cause mortality and rates of rebleeding. The secondary outcomes were length of stay and postoperative complications.

Results: A total of nine studies with 711 patients (347 who had embolization and 364 who had surgery) were analyzed. Patients in the TAE group were more likely to have ischemic heart disease (odds ratio [OR] =1.99; 95% confidence interval [CI]: 1.33, 2.98; P=0.0008; I (2)=67% [random effects model]) and be coagulopathic (pooled OR =2.23; 95% CI: 1.29, 3.87; P=0.004; I (2)=33% [fixed effects model]). Compared with TAE, surgery was associated with a lower risk of rebleeding (OR =0.41; 95% CI: 0.22, 0.77; P<0.0001; I (2)=55% [random effects]). There was no difference in mortality (OR =0.70; 95% CI: 0.48, 1.02; P=0.06; I (2)=44% [fixed effects]) between TAE and surgery.

Conclusion: When compared with surgery, TAE had a significant increased risk of rebleeding rates after TAE; however, there were no differences in mortality rates. These findings are subject to multiple sources of bias due to poor quality studies. These findings support the need for a well-designed clinical trial to ascertain which technique is superior.

Keywords: GI hemmorhage; interventional radiology; meta-analysis; radiology; surgery.

Figures

Figure 1
Figure 1
Flowchart showing study selection.
Figure 2
Figure 2
Forest plot of mean age, between the embolization and TAE groups. Abbreviations: CI, confidence interval; df, degrees of freedom; IV, initialization vector; SD, standard deviation; TAE, transarterial embolization.
Figure 3
Figure 3
Pooled mean differences in hemoglobin levels preprocedure, comparing TAE and surgery. Abbreviations: CI, confidence interval; df, degrees of freedom; IV, initialization vector; SD, standard deviation; TAE, transarterial embolization.
Figure 4
Figure 4
Forest plot of rates of mortality, comparing TAE versus surgery. Abbreviations: CI, confidence interval; df, degrees of freedom; M-H, Mantel-Haenszel; TAE, transarterial embolization.
Figure 5
Figure 5
Forest plot of rates of rebleeding after therapy, comparing TAE versus surgery. Abbreviations: CI, confidence interval; df, degrees of freedom; M-H, Mantel-Haenszel; TAE, transarterial embolization.

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