[Surgical tactics and causes of death in ulcer gastroduodenal bleedings]

4212 patients with ulcer gastrointestinal bleedings were treated during 1990-2007 years. 364 patients had gastric ulcers, other patients had duodenal ulcers. 1819 patients (43.2%) were operated. 418 patients (23%) were operated due to ineffective endoscopic hemostasis and recurrent bleedings. 409 patients (22.5%) underwent urgent operations because of risk for recurrent bleeding. Elective operations were carried out to 1358 patients (74.7%). Postoperative lethality amounted 5.8% including 19.1% lethality after emergency operations, 4.2% lethality - after urgent operations and 0.8% lethality - after delayed operations. The general hospital lethality amounted 3.3%. Lethality can be decreased by extension of indications for urgent operations, preventing recurrent bleedings.

WITHDRAWN: Argon plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

Endoscopic treatment is recommended for initial hemostasis in non-variceal upper gastrointestinal bleeding. Many endoscopic hemostatic devices are used. Argon Plasma Coagulation (APC) is an alternative.

OBJECTIVES

This study reviews all available literature to access the efficacy of APC compared to other endoscopic therapies in the control of acute non-variceal upper GI hemorrhage.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4 2003), MEDLINE 1966 to December 2003, EMBASE 1980 to December 2003, Web of Science for SCISEARCH (1980 to December 2003), BIOSIS (1985 to December 2003), and the National Research Register Issue 4 2003. We also handsearched abstracts from conference proceedings of the United European Gastroenterology Week and Digestive Disease Week.

SELECTION CRITERIA

Randomized, controlled trials of APC compared with other endoscopic hemostasis interventions in the treatment of non-variceal upper gastrointestinal bleeding.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and independently extracted data.

MAIN RESULTS

Two trials involving 121 people were included. There was no common intervention to pool. One trial compared APC to heat probe, another trial compared APC to injection sclerotherapy. There was no significant difference between groups in either of these trials.

AUTHORS' CONCLUSIONS

On the basis of the two randomised controlled trials identified in this review, there is no evidence to suggest that APC is superior to other endoscopic therapies. Further randomised controlled trials are needed.

[Standards of clinico-diagnostic and treatment algorhythms in patients with peptic and chronic medicinal ulcers, complicated by acute gastrointestinal hemorrhage]

The results of the patients surgical treatment for peptic ulcer and chronic medicinal gastroduodenal ulcer, complicated by an acute gastrointestinal hemorrhage, were analyzed. The standards and protocols of treatment, the tactic of treatment, permitting to lower the complications rate and to reduce mortality significantly, were elaborated.

[Associated complications of peptic ulcer and their surgical treatment]

Based on an experience with treatment of 269 patients with complicated peptic ulcer the authors came to a conclusion that the most sparing and radical operation was subdiaphragmatic truncal vagotomy with Finney pyloroplasty with lethality of 6.8%. Resection of the stomach and forced palliative interventions such as suturing of perforated and bleeding ulcers resulted in lethal outcomes in more than 50% of them.

[Treatment protocol of gastrointestinal bleedings]

900 patients with gastrointestinal bleedings were included in the study. Basing on the endoscopic findings, prognosis for recurrent bleeding and clinical evaluation of the patients, diagnostic algorithm and treatment protocol were worked out. Use of forecasting system concerning the bleeding risk and clinical evaluation of the patients applying SAPS II for medical tactics choice allowed decreasing lethality from acute hemorrhage from 6.1 to 0.9%, in case of conservative treatment--from 4.5 to 1.0%, postoperative lethality--from 14.5% to 0.

[Hemostasis in acute ulcerous bleedings from the stomach and duodenum in experiment]

For the first time in experiment on animals ways of surgical treatment of 'sharp ulcer bleedings' stomach and a duodenal gut with application microporous nikelid-titanic implants are developed, the morphological picture healing processes in ulcer defect with implanted microporous nicelid-titanic plate is studied. Introduction in 'ulcer defect' microporous Ti-Ni implants, the sated 7,5% a solution capropher, provides a stable hemostasis, reduces risk of relapse of bleedings (p < or = 0,05). Possibility of performance of operations by the developed technique is proved at sharp ulcer bleedings of a stomach and a duodenal gut.

[Surgical tactics in gastrointestinal hemorrhages in elderly]

At the present stage the number of operations is reduced at a ulcer gastroenteric bleeding. Occurrence modern antysecretor drags and wide introduction endoscopic and endovascular methods of hemostasis has led to decrease of urgent operative interventions in group of patients with high risk of rebleeding in 4 times. The number of such minimal operations was reduced in 10 times. They do not give expected hemostasis effect and are accompanied high mortality. Change of surgical tactics at elderly patients has led to decrease postoperative mortality from 15.8 up to 5.8% and the general mortality from 15.8 up to 9.6%.

[Characteristics of outpatient rehabilitation of patients with duodenal ulcer complicated by bleeding]

Now current of a stomach ulcer differs special aggression. Treatment of patients with complicated current gastroduodenal ulcer remains the big problem. The method argon plasma coagulations (APC) now finds primary application for a stop extensive [Russian characters: see text] bleedings. At the same time, the important factor of favorable current of the complicated stomach ulcer is the continuity in treatment of patients and carrying out of adequate therapy from the moment of receipt in a surgical hospital and its continuation at an outpatient stage.

[Timing of the surgery in patients with stopped bleeding from duodenal ulcers with the threat of recurrent bleeding]

This article is devoted choosing the optimal time of operation at patients with stopped ulcerative duodenal bleeding. It has been shown that surgical treatment during the first two days at patients with a high probability of recurrence of bleeding leads to statistically significant mortality reduction in compared with patients who were operated upon within the time frame 3-12 days after stopping bleeding. It is concluded that active surgical tactics at patients with a high probability of recurrence of bleeding at the current stage of modern medicine is more justified than waiting tactic.

Creation of an effective and reproducible nonsurvival porcine model that simulates actively bleeding peptic ulcers

BACKGROUND

Efforts to develop improved endoscopic therapeutic methods for upper GI bleeding require an effective animal model.

OBJECTIVE

To develop a nonsurvival porcine model that simulates acute peptic ulcer bleeding.

DESIGN

Prospective animal (porcine) study.

SETTING

Animal laboratory.

INTERVENTIONS

A surgical seromyotomy was created along the external surface of the greater curvature of the stomach in anesthesized pigs. A submucosal plane was developed and the gastroepiploic bundle, in continuity, was placed adjacent to the mucosa, and the seromuscular tissues were re-approximated over the vascular bundle. By using EGD, a needle-knife with electrocautery was then used to incise the mucosal tissue overlying the vascular bundle. Standard endoscopic methods for bleeding control were then tested in this animal model.

MAIN OUTCOME MEASUREMENTS

To evaluate whether successful bleeding that simulates submucosal arterial bleeding from peptic ulcer disease could be achieved in a porcine animal model.

RESULTS

Successful simulation of active peptic ulcer bleeding was achieved with this nonsurvival porcine model in a total of 5 sequential pigs. Other porcine models for bleeding were tested and found to be unsatisfactory. Hemoclips and combination injection-thermal therapy were used to stop bleeding over Doppler-positive areas, with subsequent endoscopic nonimaging Doppler US probe examination of the ulcer bed revealing a negative Doppler signal.

LIMITATIONS

This was an animal laboratory study. Further human studies would be ideal once any future endoscopic interventions are proven to be safe in animals.

CONCLUSIONS

This active bleeding ulcer model can be used to develop future endoscopic therapies and for training purposes.

Surgical conservative treatment of recurrent bleeding duodenal ulcer

BACKGROUND/AIMS

Endoscopic hemostasis and proton pump inhibitors (PPI) have decreased the incidence of rebleeding and reduced the need for surgery for bleeding duodenal ulcer (BDU). The gold standard surgical treatment of BDU remains vagotomy-antrectomy. Currently, no recommendation is made on the best procedure when emergency surgery is necessary. The aim of this study was to assess the results of a systematic conservative treatment (CT): under-running bleeding gastroduodenal artery (GDA) and ulcer suture through a duodenotomy with (CT+L group) or without (CT group) GDA double ligation along with continuous intravenous PPI.

METHODOLOGY

From 1995 to 2006, 22 consecutive patients (11 per group) underwent emergency surgery for BDU. Mean age was 63 +/- 18 years, ASA score 2.64 +/- 0.7. Ten patients (45%) presented collapse. Mean transfusion number was 11 +/- 9, number of therapeutic endoscopies 1.7 +/- 1, and Rockall score 6 +/- 2.

RESULTS

Overall, 2 patients (9%) had rebleeding and 5 patients (22%) died. No death was reported secondary to rebleeding. In the CT+L group, 9 patients (82%) had intravenous PPI, no patient had rebleeding and 2 patients died (22%).

CONCLUSIONS

Surgical CT of BDU with continuous PPI is effective, with a low rate of rebleeding. The standard use of vagotomy-antrectomy is questionable.

[Diagnosis and treatment of bleeding peptic ulcer: our experience]

BACKGROUND

Bleeding peptic ulcer (PU) is the commonest cause of an acute upper gastrointestinal bleed. Aim of this study was to present our data regard the management of acute bleeding from PU during urgent endoscopy (examination performed in 2-6 h by the call).

MATERIALS AND METHODS

This study is based on an observational retrospective protocol. Records of 259 consecutive patients with PU (92 F, 167 M; median age 71.5 years; range: 19-100 years), attending our GI Unit from February 1st 2004 to July 31st 2007, were analyzed.

RESULTS

Out of 259 patients with PU, 170 (65.6%) were treated with endoscopic hemostasis followed by medical therapy (PPI 80 mg bolus within 12 h of endoscopy followed by 8 mg/for 72 h and then an oral PPI , 40 mg once daily for 30 days), while 89 (34.4%) patients received only medical therapy (PPI, 40 mg once daily for 30 days). All ulcerative lesions with endoscopic stigmata of acute bleeding, visible vessels or adherent clot (Forrest Ia-IIb) were treated during the gastroscopy. The endoscopic procedures used were: injection of 1:10000 adrenaline (about 10 mL) around the bleeding lesion in 93 cases (55%); injection therapy and thermal method (argon plasma coagulation) in 53 cases (31%); injection therapy and mechanical method (metallic clips) in 20 cases (12%); only mechanical method (metallic clips) in 4 cases (2%). Endoscopic hemostasis was achieved in 251 pts (97%), while 17 pts (6.5%) required second endoscopy for rebleeding. Three patients (1.16%) required immediate surgery for failure of primary endoscopic hemostasis. The mortality within 30 days from the bleeding episode was 3.9% (10 pts).

CONCLUSIONS

The treatment of this condition has made important progress since the introduction of emergency endoscopy and endoscopic techniques for hemostasis. The application of specific protocols, significantly decreases rebleeding and the need for surgery, whereas mortality is still high. Our data are in keeping with previous studies of the literature.

[Routine second look endoscopy after bleeding ulcers]

Treatment of peptic duodenal and gastric ulcers has improved in efficiency and become less invasive. There is still a considerable risk of re-bleeding (15-20%) and the mortality remains high (5-14%). A Danish study from 2000 showed that scheduled second look endoscopy (SLE) the day after the primary intervention decreased the re-bleeding rate. Studies have questioned this and suggest that SLE decreases the risk of re-bleeding, but do not reduce mortality. Since SLE is debated and a recent national survey found a variable practice, the evidence has been reviewed critically.

Bleeding duodenal ulcer after roux-en-Y gastric bypass surgery

Postoperative upper gastrointestinal bleeding, though rare, is a potentially fatal complication of gastric bypass surgery that usually occurs a few months postoperation. The current report describes a 57-year-old man with a bleeding duodenal ulcer who underwent Roux-en-Y gastric bypass surgery 12 years earlier. With an increasing number of gastric bypass surgeries performed each year, physicians must be aware of their patients' altered gastrointestinal anatomy and physiology-as well as the potential for pathophysiology.

[Minimal invasive methods of treatment of patients with gastroduodenal ulcerous bleedings]

An analysis of results of treatment of 913 patients has shown that the endoscopic methods of hemostasis allowed reducing the operative activity from 63 to 14%. Impossible implementing endoscopic hemostasis and high risk of bleeding in patients with giant ulcers were considered as indications to operative treatment.

[Treatment tactics of the patients with gastroduodenal ulcer bleeding]

Results of treatment of 263 patients aged 15 to 93 years with gastroduodenal ulcer bleeding are analyzed. There were 200 (76,1%) male and 63 (23,9%) female patients. Gastric ulcers were diagnosed at 85, duodenal ulcers--at 178 patients. Differential approach to conservative and surgical treatment of these complications is described.

[Treatment of gastroduodenal bleedings: from surgery to therapy?]

Results of treatment of 2352 patients with gastroduodenal ulcer bleedings were analyzed. Surgical treatment was performed at 495 (21%) of them. Emergency life-saving operation was performed at 78 (15%) patients, urgent operation after primary hemostasis - at 114 (23%), elective operations - at 303 (62%). Various resections were carried out at 78% cases, organ-saving surgeries - at 22%. The main problem in the treatment program of these patients is the prophylaxis of bleeding recurrence. Rational pathogenetic out-patient treatment of ulcer disease, prophylaxis of recurrences and complications are the key points which need close collaboration between surgeons and gastroenterologists.

Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis

BACKGROUND

Hemoclips, injection therapy and thermocoagulation (heater probe or electrocoagulation) are the most commonly used types of endoscopic hemostasis for the control of non-variceal gastrointestinal bleeding.

AIM

To compare the efficacy of hemoclips versus injection or thermocoagulation in endoscopic hemostasis by pooling data from the literature.

METHOD

Publications in the English literature (MEDLINE, EMBASE and Cochrane Library) as well as abstracts in major international conferences were searched using the keywords "hemoclips" and "bleeding", and 15 trials fulfilling the search criteria were found. Outcome measures included: initial hemostasis (after endoscopic intervention); recurrent bleeding; definitive hemostasis (no recurrent bleeding until the end of follow-up); the requirement for surgical intervention; and all-cause mortality. The heterogeneity of trials was examined and the effects were pooled by meta-analysis.

RESULTS

Of 1156 patients recruited in the 15 studies, 390 were randomly assigned to receive clips alone, 242 received clips combined with injection, 359 received injection alone, and 165 received thermocoagulation with or without injection. Definitive hemostasis was higher with hemoclips (86.5%) than injection (75.4%; RR 1.14, 95% CI 1.00-1.30), or endoscopic clips with injection (88.5%) compared with injections alone (78.1%; RR 1.13, 95% CI 1.03-1.23), leading to a reduced requirement for surgery but no difference in mortality. Compared with thermocoagulation, there was no improvement in definitive hemostasis with clips (81.5% versus 81.2%; RR 1.00, 95% CI 0.77-1.31). These estimates were robust in sensitivity analyses. There was also no difference between clips and thermocoagulation in rebleeding, the need for surgery and mortality. The reported locations of failed hemoclip applications included posterior wall of duodenal bulb, posterior wall of gastric body and lesser curve of the stomach.

CONCLUSION

Successful application of hemoclips is superior to injection alone but comparable to thermocoagulation in producing definitive hemostasis. There was no difference in all-cause mortality irrespective of the modalities of endoscopic treatment.

RANDOMIZED TRIAL COMPARING PANTOPRAZOLE INFUSION, BOLUS AND NO TREATMENT ON GASTRIC pH AND RECURRENT BLEEDING IN PEPTIC ULCERS

BACKGROUND

To study the effects of pantoprazole on gastric pH and recurrent bleeding after endoscopic treatment for bleeding peptic ulcers.

METHODS

After endoscopic haemostasis, patients were randomly assigned to infusion group (pantoprazole 80 mg i.v. bolus followed by continuous infusion of 8 mg/h for 3 days), bolus group (pantoprazole 80 mg i.v. bolus followed by 40 mg i.v. bolus every 12 h for 3 days) and no-treatment group (no acid suppression in the first 3 days). Gastric pH was monitored. Rebleeding rate within 30 days, the need for surgery, transfusion requirement, total hospital stay, mortality rate and gastric pH were compared.

RESULTS

One hundred and sixty-eight patients were included, with 15 patients excluded from the analysis. There were 54 patients in the infusion group, 49 in the bolus group and 50 in the no-treatment group. There was fewer rebleeding (3.7 vs 16.0%, P = 0.034), less operative intervention (0 vs 8.0%, P = 0.034) and shorter hospital stay (6.4 vs 8.2 days, P = 0.040) in the infusion group compared with that in no-treatment group. When the bolus group was compared with no-treatment group, there were fewer rebleed (4.1 vs 16.0%, P = 0.049) and less blood transfusion (1.5 vs 2.9 units, P = 0.007). There was no difference in mortality among the three groups. Patients who received either pantoprazole infusion or bolus had significantly higher mean pH and longer duration of pH above 6 compared with the no-treatment group. There was no difference in the rebleeding rate, transfusion requirement, need for operation and hospital stay between the infusion and bolus groups. The mean pH and the duration of pH above 6 were also similar.

CONCLUSION

Pantoprazole either as infusion or bolus decreased rebleeding after endoscopic treatment for bleeding peptic ulcer.