title: Combined endoscopic and surgical management of Dieulafoy vascular malformation.
abstract: BACKGROUND
  Dieulafoy's disease (exulceratio simplex) is an uncommon cause of gastric hemorrhage as a result of an abnormally large, submucosal, eroded gastric artery, often located in the upper part of the stomach. It represents a clinical challenge because of the intermittent nature of massive bleeding accounting for a constantly fatal course in conservatively (nonsurgically or nonendoscopically) treated patients. Published therapeutic options include techniques of endoscopic hemostasis or operative procedures.
  
  
  METHODS
  Herein we report two patients in whom a combined endoscopic and operative approach was performed to obtain a definitive prevention of rebleeding and an undoubted anatomopathologic diagnosis.
  
  
  RESULTS
  Our innovative combined endoscopic and operative approach has offered three significant advantages: endoscopic preoperative diagnosis and control of the bleeding; valid aid in the intraoperative localization of hemorrhagic lesions, which is erratic 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 oversewing of the involved vessel, local excision, or wide wedge resections that used to be recommended until the recent past.
  
  
  CONCLUSIONS
  We confirm that seemingly obscure origins of massive recurring hemorrhage of the upper part of the gastrointestinal tract should increase the suspicion of Dieulafoy's disease, prompting careful examination of the gastric fundic area and greater curvature. Endoscopic hemostasis is the first choice; whenever operative treatment is indicated (because of the endoscopic or clinical situation), it should be as conservative as possible because of intraoperative endoscopic localization of the bleeding source.
authors.affiliation: First Department of Internal Medicine, Ospedale Civile di Modena, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Grisendi
authors.forename: A
authors.initials: A
authors.lastname: Lonardo
authors.forename: G
authors.initials: G
authors.lastname: Della Casa
authors.forename: M
authors.initials: M
authors.lastname: Frazzoni
authors.forename: M
authors.initials: M
authors.lastname: Pulvirenti
authors.forename: A M
authors.initials: AM
authors.lastname: Ferrari
authors.forename: M
authors.initials: M
authors.lastname: Varoli
authors.forename: G
authors.initials: G
authors.lastname: Mezzanotte
authors.forename: L
authors.initials: L
authors.lastname: Melini
mesh_terms: D000368:Aged; D001158:Arteries / Q000473:pathology; D004384:Duodenoscopy; D004945:Esophagoscopy; D005500:Follow-Up Studies; D005753:Gastric Mucosa / Q000098:blood supply; D006471:Gastrointestinal Hemorrhage / Q000601:surgery*; D005773:Gastroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D012422:Rupture, Spontaneous; D013270:Stomach / Q000098:blood supply*