A novel less-invasive therapy for a bleeding eroded artery in a giant duodenal ulcer: principles and technical description.

Background and aims: Giant duodenal ulcer (GDU) is a challenging condition to manage. Medical and endoscopic therapy often fails, and angiographic embolization can deteriorate GDUs because it may promote ischemia. Surgical treatment is challenging and may increase morbidity. In this article, we describe a promising technique based on the pathophysiology of this condition. Methods: We report a case of a novel mechanism-based treatment for healing GDU by using modified endoscopic vacuum therapy (EVT). Such therapy promotes macro- and micro-deformation, increases angiogenesis, decreases exudation, and reduces aggressive mucosal factors such as gastric and biliopancreatic secretions. Results: We describe the case of a 52-year-old man with a history of pancreatic cancer and metastatic disease to the liver who had undergone distal pancreatectomy and left hepatectomy 2 years prior. He was receiving selective internal radiation therapy for right-sided liver metastasis when he was admitted with hypotensive shock after massive GI bleeding. EGD demonstrated a GDU with a large eroded artery, which angiography revealed to be the hepatic artery. Inasmuch as surgery, embolization, and endoscopic vessel-directed therapy were not indicated, modified EVT was performed by use of a triple-lumen tube to allow EVT and nutrition with a single tube. After 3 weeks of therapy, EGD demonstrated healed mucosa, and imaging confirmed no liver ischemia. Conclusion: Modified EVT is feasible and appears safe and effective for managing complicated GDUs, especially when conventional therapies fail or are not indicated. This strategy may improve the outcomes in patients with GDU, avoiding surgery and reducing morbidity and mortality. Further studies are necessary to confirm our findings.