Treatment experience of delayed massive gastrointestinal bleeding caused by intra-abdominal arteriointestinal fistula in gastric cancer patients after radical gastrectomy

BACKGROUND: Gastric cancer (GC) remains one of the leading causes of cancer-related death. Arteriointestinal fistula is a very rare but lethal postoperative complication in GC patients after gastrectomy. However, very few reports associated with arteriointestinal fistula have been published, and there is no matured diagnosis and treatment consensus for arteriointestinal fistula. Herein, we will investigate the etiology, clinical feature, diagnostic method, treatment, and prognosis by summarizing two patients we treated and consulting related cases reported in recent years. CASE PRESENTATION: A 61-year-old male and 75-year-old female with advanced gastric cancer of gastric antrum underwent radical distal gastrectomy and D2 regional lymphadenectomy. Residual gastrojejunostomies by the Roux-en-Y method were performed. The two patients recovered well after gastrectomy, and they received postoperative adjuvant chemotherapy. However, both of them suffered sudden hematemesis and melena about 2 months after surgery, resulting in unstable vital signs. Emergency exploratory laparotomy and interventional embolotherapy by digital subtraction angiography were immediately respectively performed. During this process, arteriointestinal fistulas were found in both of them. Pseudoaneurysms of gastroduodenal artery and common hepatic artery were respectively ruptured and bleeding into the duodenum. Finally, the male patient recovered, while the female patient died because of rebleeding and hemorrhagic shock. CONCLUSIONS: Arteriointestinal fistula, with low morbidity but high mortality, is an acute and fatal postoperative complication for GC patients after radical gastrectomy. DSA is the preferred method to diagnose arteriointestinal fistula. Embolotherapy by DSA should be performed immediately once arteriointestinal fistula is confirmed. Emergency laparotomy is another selection if the embolotherapy failed. We should pay more attention to perioperative preventive measures for formation of pseudoaneurysm, which is the leading cause of arteriointestinal fistula.