[Determination of the degree of surgical risk in treating peptic gastrointestinal hemorrhages]

Based on a complex analysis of case histories of 817 patients operated upon for ulcerous gastro-intestinal bleedings the authors have developed a system of the assessment of a degree of operative risk. High risk degree of the forthcoming surgery necessitates its shorter duration and less traumatic character as well as careful management of the patients in the nearest postoperative period.

Efficacy of monopolar electrocoagulation in the treatment of bleeding gastric ulcer: a controlled trial

With the aim of evaluating, in a controlled prospective fashion, the efficacy of monopolar electrocoagulation in the emergency treatment of bleeding gastric and stomal ulcers, 37 patients were studied: 16 were electrocoagulated (EC group) while the remaining 21 were treated by conventional methods (control group). The hemorrhage recurred in only one of the 16 patients belonging to the EC group, but in 11 of the 21 control patients (p less than 0.0005). Transfusion requirements were also reduced in the EC group (p less than 0.05), with no significant difference in relation to mortality. Stratifying the results according to hemorrhagic activity, electrocoagulation should be clearly effective in those patients with spurting hemorrhage, taking into account several limitations: deep ulcers bearing gross vessels, and lack of cooperation by the patient. Prophylactic treatment of the bleeding ulcer with a visible non-spurting vessel may be indicated whenever we make a proper selection of the patients with a greater possibility of hemorrhagic recurrence.

[Combined complications of pyloroduodenal ulcer and their treatment]

Associated complications took place in 68 cases (23.8%) among 286 patients operated upon for pyloroduodenal ulcer. A combination of stenosis and penetration was observed in 35.3%, hemorrhage with the penetration or stenosis was observed in 42.6%, perforation with stenosis or penetration in 22.1% of the patients. Choice of the operative intervention in the associated complications of pyloroduodenal ulcer was shown to mainly depend on the severity of the patient's state, character and degree of local pathological changes. Postoperative lethality was 5.9%.

[Surgical tactics in the esophago-gastric hemorrhages of liver cirrhosis patients]

The character of the source and rate of bleeding were taken into consideration in determining the surgical tactics in 342 patients with cirrhosis of the liver complicated by gastro-esophageal bleedings and with high risk of their appearance. The operation of choice is thought to be arrest of the gastro-esophageal collateral blood flow. At high portal pressure or its considerable growing after the separating operation the latter should be associated with vascular anastomosis. When cirrhosis of the liver is associated with ulcer disease of the duodenum the separating operation should be added by selective proximal vagotomy, for ulcer disease of the stomach--by a parsimonious resection.

[Effect of endoscopic hemostasis using an electrohydrothermic probe on the course of hemorrhaging stomach and duodenal ulcers]

This is a report on the application of the EHT-probe in 94 patients with bleeding ulcers (stomach and duodenum) during a period of three years (1981-1983). The effect upon the course of disease and mortality is discussed. A permanent termination of bleeding could be achieved in 71% of cases (59 patients of a total of 94 patients). The data are compared with a former period (1978-1980) without the possibility for endocopic treatment of bleeding ulcers. By using the EHT-probe less emergency operations were performed (19.1% compared to 36.4 during the earlier period). The over-all mortality decreased from 27.3% (1978-1980) to 17.7% (1981-1983). These favourable results are promoting the active intervention by endoscopic treatment with a electro-hydrothermic probe.

[Use of oil preparations for hemostasis in gastroduodenal hemorrhage]

The authors report on using oil preparations in endoscopic surgery for arrest of bleedings from vessels of the stomach and duodenum. Persistent hemostasis was obtained in 60 out of 64 patients.

[Hemorrhaging gastroduodenal ulcer--clinical aspects, therapy, prognosis]

Between 1974 and 1985 208 patients with acutely bleeding gastroduodenal ulcers have been treated operatively. Postoperative mortality rate was 14.4% and mainly influenced by age, intensity of bleeding, pre- and intraoperative blood pressure, amount of blood transfusions, and duration of ulcer disease. Results after resections were distinctly better than those achieved by ligation of the bleeding vessel with or without vagotomy. In 2.9% recurrent hemorrhage necessitated an early relaparotomy. During a close follow-up from 1 to 12 years reoperation had to be performed because of recurrent ulcers in 4.5%. In 88% of all cases a good long-term result was obtained.

Controlled trial of Nd-YAG laser photocoagulation in bleeding peptic ulcers

The efficacy of Nd-YAG laser photocoagulation in the endoscopic control of haemorrhage from peptic ulcers was shown in a controlled trial. 527 patients admitted consecutively with acute upper gastrointestinal haemorrhage underwent urgent endoscopy. Peptic ulcers were seen in 260. All 138 ulcer patients with stigmata of recent haemorrhage (SRH) accessible to laser therapy were included in the trial (26 inaccessible, 96 no SRH). Patients were stratified into three groups--those with a visible vessel, those with other SRH, and those with clot that could not be washed off before therapy. Laser and control groups were well matched for other factors known to influence prognosis. Overall, 7/70 laser-treated and 27/68 control ulcers rebled (p less than 0.001). Rebleeding occurred from 6/39 treated and 23/43 control ulcers with a visible vessel (p less than 0.001); 0/17 treated and 1/13 ulcers with other SRH (NS); and 1/13 treated and 2/11 control ulcers with overlying clots (NS). 7/70 treated but 24/68 controls required emergency surgery (p less than 0.005). 1 treated patient but 8 control patients died after an episode of rebleeding (p less than 0.05).

Current status of argon laser hemostasis of bleeding ulcers

Endoscopic argon laser photocoagulation has been extensively studied in animals. Clinical pilot studies and randomized controlled trials have demonstrated that argon laser endoscopic hemostasis is both safe and efficient. Specific guidelines for successful endoscopic hemostasis have been determined. The limitations of the argon laser for emergency hemostasis are a strong absorption by blood, its expense and lack of portability, the inability to tamponade or to treat tangentially, and the vaporization potential. The Nd:YAG laser shares all these limitations except that it is less absorbed by blood. Because of these limitations, GI lasers are at present being used less for emergency hemostasis than for elective tumor ablation. Some new, non-laser, thermal devices which do not have these limitations have been developed. They are currently being evaluated in randomized trials. Perhaps because of these factors, the good results obtained with lasers for emergency hemostasis of bleeding ulcers have not been translated into clinical practice at most hospitals.

The benefits of endoscopy in upper gastrointestinal bleeding

Management of the patient with upper gastrointestinal bleeding is a continuing challenge to the gastroenterologist and the surgeon. Endoscopy early in the course of bleeding benefits the patient only when diagnostic accuracy is combined with definitive hemostatic therapy. Effective methods are now available for endoscopic hemostasis of bleeding ulcers and bleeding varices. However, an improvement in the outcome of gastrointestinal bleeding is not easily achieved, since age and the incidence of severe underlying disease in patients with upper G.I. hemorrhage have been steadily increasing over the years.

Endoscopic neodymium:YAG laser coagulation in gastrointestinal hemorrhage

The aim of a resolute, endoscopic treatment in acute gastrointestinal hemorrhage by a neodymium:YAG laser is to prevent massive loss of blood and to avoid transformation of the hemorrhagic shock event into an irreversible state. Parallel to endoscopic procedure treatment of coagulopathies is necessary. 1,029 (94%) out of 1,092 acute bleeding episodes of 852 unselected patients were treated successfully. In bleeding esophageal varices, reduction of mortality from 70% to 36.2% has been achieved by sclerotherapy following laser coagulation of the acute bleeding. Compared with the results of surgery the mortality rate of bleeding acute ulcers has been reduced from 58% to 23.4%, and of bleeding chronic ulcers from 25% for resection and 15% for vagotomy to 0%. For optimal treatment of the patients close cooperation with surgeons is also desirable.

Animal testing of endoscopic hemostasis with lasers and other devices

A variety of animal models for testing endoscopic control of gastrointestinal hemorrhage are reviewed. Advantages and disadvantages of each are discussed. New types of mechanical devices for controllable injury are presented, and the efficacy of laser photocoagulators and other recently developed electronic devices on these new lesions is compared.