İnatçı Gastroözofageal Kavşak Dieulafoy Lezyonunun İntraoperatif Endoskopik Dövme ile Cerrahi Tedavisi

Öz

Giriş: Dieulafoy lezyonu (DL), üst gastrointestinal kanamanın nadir görülen ancak potansiyel olarak yaşamı tehdit eden bir nedenidir. Endoskopik tedavi ilk basamak tedavidir; ancak tekrarlayan kanama cerrahi müdahaleyi gerektirebilir. Olgu Sunumu: 55 yaşında erkek hasta hematemez ve hemodinamik instabilite ile acil servise başvurdu. İlk endoskopide mide fundusundaki aktif kanamalı Dieulafoy lezyonu görüldü. Hemostaz, epinefrin enjeksiyonu, termal koagülasyon ve hemoklip yerleştirilmesi ile sağlandı ve kan transfüzyonundan sonra geçici stabilizasyon sağlandı. Hastanedeki üçüncü günde, tekrarlayan kanama tekrar endoskopi ve ek bir hemoklip uygulaması gerektirdi, ancak hasta semptomlarını yaşamaya devam etti. Sekizinci günde, metilen mavisi ile intraoperatif endoskopik dövmeleme lezyonun doğru lokalizasyonunu kolaylaştırdı ve kama rezeksiyonu yapıldı. Ameliyat sonrası süreç sorunsuz geçti ve histopatolojik inceleme DL tanısını doğruladı. Sonuç: Bu olgu, refrakter Dieulafoy lezyonlarında intraoperatif endoskopik işaretlemenin değerli bir yardımcı olduğunu, hassas lokalizasyona olanak sağladığını, gereksiz radikal cerrahiden kaçınılmasını sağladığını ve başarılı sınırlı rezeksiyona izin verdiğini göstermektedir.

Anahtar Kelimeler

• Dieulafoy lezyonu
• Endoskopik hemostaz
• Tekrarlayan kanama
• inrtaoperatif endoskopi
• wegde rezeksiyon

Surgical Treatment of a Refractory Gastroesophageal Junction Dieulafoy Lesion Using Intraoperative Endoscopic Tattooing

Öz

Introduction: Dieulafoy’s lesion (DL) is a rare but potentially life-threatening cause of upper gastrointestinal bleeding. Endoscopic therapy is the first-line treatment; however, recurrent bleeding may necessitate surgical intervention. Case Report:A 55-year-old male presented to the emergency department with hematemesis and hemodynamic instability. Initial endoscopy revealed a Dieulafoy’s lesion in the gastric fundus with active bleeding. Hemostasis was achieved with epinephrine injection, thermal coagulation, and hemoclip placement, and temporary stabilization was obtained after blood transfusion. On the third hospital day, recurrent bleeding required repeat endoscopy and an additional hemoclip application, but the patient continued to experience symptoms. On day eight, intraoperative endoscopic tattooing with methylene blue facilitated accurate localization of the lesion, and wedge resection was performed. The postoperative course was uneventful, and histopathological examination confirmed the diagnosis of DL. Conclusion:This case demonstrates that intraoperative endoscopic marking is a valuable adjunct in refractory Dieulafoy’s lesions, enabling precise localization, avoiding unnecessary radical surgery, and allowing successful limited resection.

Anahtar Kelimeler

• Dieulafoy’s lesion
• Endoscopic hemostasis
• Recurrent bleeding
• Intraoperative endoscopy
• Wedge resection

Kaynakça

1. Nojkov B, Cappell MS. Gastrointestinal bleeding from Dieulafoy’s lesion: Clinical presentation, endoscopic findings, and endoscopic therapy. World J Gastrointest Endosc. 2015 Apr 16;7(4):295–307. doi: 10.4253/wjge.v7.i4.295
2. Gallard Lee, Y. T., Walmsley, R. S., Leong, R. W. L., & Sung, J. J. Y. (2003). Dieulafoy’s lesion. Gastrointestinal Endoscopy, 58(2), 236–243. doi:10.1067/mge.2003.328
3. Chen W, Chen P, Li X, Gao X, Li J. Clinical characteristics and treatments for bronchial Dieulafoy’s disease. Respir Med Case Rep. 2019 Jan 7;26:229-235. doi: 10.1016/j.rmcr.2019.01.004. PMID: 30740302; PMCID: PMC6357209
4. Veldhuyzen van Zanten, S. J., Bartelsman, J. F., Schipper, M. E., & Tytgat, G. N. (1986). Recurrent massive haematemesis from Dieulafoy vascular malformations--a review of 101 cases. Gut, 27(2), 213–222. doi:10.1136/gut.27.2.213
5. Jeon HK, Kim GH. Endoscopic Management of Dieulafoy’s Lesion. Clin Endosc. 2015 Mar;48(2):112-20. doi: 10.5946/ce.2015.48.2.112. Epub 2015 Mar 27. PMID: 25844338; PMCID: PMC4381137.
6. Baxter M, Aly EH. Dieulafoy’s lesion: current trends in diagnosis and management. Ann R Coll Surg Engl. 2010 Oct;92(7):548-54. doi: 10.1308/003588410X1269966390531 1. PMID: 20883603; PMCID: PMC3229341.
7. Norton, I. D., Petersen, B. T., Sorbi, D., Balm, R. K., Alexander, G. L., & Gostout, C. J. (1999). Management and long-term prognosis of Dieulafoy lesion. Gastrointestinal Endoscopy, 50(6), 762–767. doi:10.1016/s0016-5107(99)70155-0
8. Saleh R, Lucerna A, Espinosa J, Scali V. Dieulafoy lesion: the little known sleeping giant of gastrointestinal bleeds. Am J Emerg Med. 2016 Dec;34(12):2464.e3-2464.e5.

9. Shin HJ, Ju JS, Kim KD, Kim SW, Kang SH, Kang SH, Moon HS, Sung JK, Jeong HY. Risk Factors for Dieulafoy Lesions in the Upper Gastrointestinal Tract. Clin Endosc. 2015 May;48(3):228-33. doi: 10.5946/ce.2015.48.3.228. Epub 2015 May 29.
10. Ding YJ, Zhao L, Liu J, Luo HS. Clinical and endoscopic analysis of gastric Dieulafoy’s lesion. World J Gastroenterol. 2010 Feb 7;16(5):631-5. doi: 10.3748/wjg.v16.i5.631.
11. Baettig B, Haecki W, Lammer F, Jost R. Dieulafoy’s disease: endoscopic treatment and follow up. Gut. 1993 Oct;34(10):1418-21. doi: 10.1136/gut.34.10.1418. PMID: 8244112; PMCID: PMC1374553
12. Aabdi B, Kharrasse G, Zazour A, Koulali H, Elmqaddem O, Zahi I. Clinical, endoscopic and therapeutic features of bleeding Dieulafoy’s lesions: case series and literature review. BMJ Open Gastroenterol. 2024 May 24;11(1):e001299. doi: 10.1136/bmjgast-2023-001299. PMID: 38789268; PMCID: PMC11129027.
13. Levy AR, Broad S, Loomis Iii JR, Thomas JA. Diagnosis and Treatment of a Recurrent Bleeding Dieulafoy’s Lesion: A Case Report. Cureus. 2022 Nov 30;14(11):e32051. doi: 10.7759/cureus.32051. PMID: 36600857; PMCID: PMC9802011.
14. Zhiwei, Zhang, and Chen Junqiang. “Laparoscopy and methylene blue staining angiography for precise synchronous resection of small intestinal vascular malformations: A case report.” Frontiers in Medicine 12 (2025): 1621874.