COMBINED ENDOSCOPIC AND SURGICAL-MANAGEMENT OF DIEULAFOY VASCULAR MALFORMATION

BACKGROUND: Dieulafoy's disease (exulceratio simplex) is an uncommon c ause of gastric hemorrhage as a result of an abnormally large, submuco sal, eroded gastric artery, often located in the upper part of the sto mach. It represents a clinical challenge because of the intermittent n ature of massive bleeding accounting for a constantly fatal course in conservatively (nonsurgically or nonendoscopically) treated patients. Published therapeutic options include techniques of endoscopic hemosta sis or operative procedures. STUDY DESIGN: Herein we report two patien ts in whom a combined endoscopic and operative approach was performed to obtain a definitive prevention of rebleeding and an undoubted anato mopathologic diagnosis. RESULTS: Our innovative combined endoscopic an d operative approach has offered three significant advantages: endosco pic preoperative diagnosis and control of the bleeding; valid aid in t he intraoperative localization of hemorrhagic lesions, which is errati c intraoperatively, requires gastrotomy, and prolongs the duration of operation; and endoscopy-guided limited wedge resection as opposed to standard techniques involving gastrotomy for simple ligation or overse wing of the involved vessel, local excision, or wide wedge resections that used, to be recommended until the recent past. CONCLUSIONS: We co nfirm that seemingly obscure origins of massive recurring hemorrhage o f the upper part of the gastrointestinal tract should increase the sus picion of Dieulafoy's disease, prompting careful examination of the ga stric fundic area and greater curvature. Endoscopic hemostasis is the first choice; whenever operative treatment is indicated (because of th e endoscopic or clinical situation), it should be as conservative as p ossible because of intraoperative endoscopic localization of the bleed ing source.