JPGN Reports · 7 authors, 5 centres
This summary was generated by AI from a single paper. It has not been reviewed by a clinician and is not clinical advice. Verify against the source before acting on it.
This case series describes a technique where a small metal coil is placed near a gastrointestinal vascular malformation using angiography before laparoscopic surgery. The coil acts as a marker under fluoroscopy, helping surgeons precisely locate and remove the lesion. This approach may improve surgical accuracy and reduce operative time for children and young adults with these rare bleeding lesions.
**Background:** Intestinal vascular malformations are rare in children and difficult to diagnose. Repeated investigations often fail to identify the source of gastrointestinal (GI) bleeding. While surgical resection is the best treatment when the lesion is accurately localized, published pediatric reports are sparse. This study describes a technique of intentional preoperative coil localization by interventional radiology to facilitate fluoroscopically assisted laparoscopic resection of symptomatic GI vascular malformations in children and young adults.
**Methods:** A retrospective review of the electronic medical record and radiology picture archive and communication system was performed for a series of 3 patients. All angiographic and laparoscopic procedures were performed under general anesthesia by the same interventional radiologist and surgeon. Angiography via femoral artery access was performed. Once a vascular malformation was identified by a hallmark 'blush', a low-flow microcatheter and microwire were advanced to the feeding arcuate artery level. A 0.018 inch × 2 cm Hilal pushable straight coil was deployed in an arcuate artery as close to the vascular malformation as possible. Post localization, images were reviewed with the operating surgeon. Laparoscopic surgery was performed within 24 hours of coil placement. The small intestine was interrogated from the ligament of Trietz to the ileocecal valve. If a lesion was identified visually, the segment was manually manipulated under fluoroscopy and confirmed by observing the localization coil at the same location. If not visually apparent, fluoroscopy and coil localization were used to identify the abnormal bowel segment. The intestine segment (plus a prudent margin of ~5 cm proximally and distally) was resected with endoscopic staplers, including a wedge of mesentery containing the coil. Specimens were imaged by fluoroscopy to confirm the presence of the coil and sent for pathologic evaluation.
**Key Results:** Three cases are described. Case 1: A 20-year-old male with a 7-week history of intermittent painless hematochezia and transfusion-dependent anemia. CTA demonstrated a 15 cm hyperenhancing loop of bowel in the left upper quadrant. A coil was placed just proximal to the blush. Laparoscopic surgery immediately postcoil localization confirmed the resected specimen contained an altered venous pattern and transmural hematoma (operative time, 2½ hours), proven to be a jejunal arteriovenous malformation (AVM). Follow-up for 5 years revealed no recurrent hemorrhage. Case 2: A 13-year-old male with a 1-year history of anemia (hemoglobin 6.6 g/dL). Angiography demonstrated venous blush with a dysplastic vein in the jejunal loop. A microcoil was placed. Laparoscopic resection was performed the next day, and 10 cm of grossly abnormal jejunum was resected (operative time, 1½ hours). Histology confirmed a venous malformation. The child remained asymptomatic on follow-up for 5 months. Case 3: A 5-year-old boy with a 9-month history of intermittent hematochezia (hemoglobin as low as 6 g/dL). CTA demonstrated abnormal vascularity in the right upper quadrant. A coil was placed in a distal arcuate artery adjacent to the lesion prior to laparoscopic surgery immediately postangiography. The surgeon resected a cecal ulcer (operative time, 3½ hours), but the resection length was shorter than the angiographic abnormality. Histology confirmed an underlying AVM of the cecum. Intermittent hematochezia continued for another 6 months. Repeat angiography with additional coil localization demonstrated residual AVM. The patient underwent a second laparoscopic resection (operative time, 3 hours) the next day after coil placement. After the second surgery, GI bleeding resolved completely. The mean additional interventional procedural time for coil placement was 22 minutes (range 11–38 minutes). Radiation dose ranged from 40.7 to 72 mGy for angiography and 0.65 to 1.78 mGy for intraoperative fluoroscopy.
**Clinical Implications:** Intentional endovascular coil localization has the potential to increase the precision of lesion localization and may reduce laparoscopic operative time, when guided by the coil position. This combined technique may offer more confident localization of lesions, avoids laparotomy incisions, and may decrease intraoperative time. It may be considered especially in situations where lesions may not be clearly serosal or easily localized on cross-sectional imaging. The need for a second operative intervention in Case 3 highlights the accuracy of angiographic findings compared with operative visual inspection. Placing a coil at the most superior and inferior angiographic extent may be helpful in future cases. Ideally, localization and resection should be performed on the same day to avoid a second administration of anesthesia.