The emergency management of bleeding oesophageal varices with sclerosing injections

Functionalized silk biomaterials for wound healing

Silk protein-biomaterial wound dressings with epidermal growth factor (EGF) and silver sulfadiazine were studied with a cutaneous excisional mouse wound model. Three different material designs and two different drug incorporation techniques were studied to compare wound healing responses. Material formats included silk films, lamellar porous silk films and electrospun silk nanofibers, each studied with the silk matrix alone and with drug loading or drug coatings on the silk matrices. Changes in wound size and histological assessments of wound tissues showed that the functionalized silk biomaterial wound dressings increased wound healing rate, including reepithelialization, dermis proliferation, collagen synthesis and reduced scar formation, when compared to air-permeable Tegaderm tape (3M) (- control) and a commercial wound dressing, Tegaderm Hydrocolloid dressing (3M) (+ control). All silk biomaterials were effective for wound healing, while the lamellar porous films and electrospun nanofibers and the incorporation of EGF/silver sulfadiazine, via drug loading or coating, provided the most rapid wound healing responses. This systematic approach to evaluating functionalized silk biomaterial wound dressings demonstrates a useful strategy to select formulations for further study towards new treatment options for chronic wounds.

The relationship of bacteremia to the length of injection needle in endoscopic variceal sclerotherapy

The authors evaluated whether depth of needle insertion as determined by needle length is an important factor in sclerotherapy-associated bacteremia. In 18 consecutive sclerotherapy sessions in which sodium morrhuate was used, blood cultures were positive in 11% when using an injector with only 3 to 4 mm of needle protruding beyond the sheath, compared with the 39% incidence of bacteremia previously observed when an injector was used which permitted 6 to 8 mm of needle to protrude (0.01 less than p less than 0.05). Twenty-five additional sclerotherapy sessions in which the shorter needle was used were performed with a different sclerosant, 1% sodium tetradecyl sulfate; only 8% of blood cultures were positive. No correlation was found between fever and bacteremia. The authors conclude that the exposed needle length of the injector must be specified in any report of endoscopic variceal sclerotherapy with the flexible endoscope since this length is critical in the incidence of associated bacteremia and possibly other complications.

Endoscopic variceal sclerosis: a one-year experience

Our first year's experience with endoscopic variceal sclerosis (EVS) performed with a cuffed balloon fiberoptic endoscope is presented. Seventy-five patients have been treated with EVS without requiring the use of general anesthesia. All but one patient had endoscopically documented variceal hemorrhage and underwent EVS while bleeding or shortly thereafter. Ninety-two per cent of the patients were discharged from the hospital after initial treatment with the current overall survival rate being 89.3%. Complications resulting in a prolonged hospitalization were infrequent, but two deaths occurred in which EVS complications may have been a contributing factor. Based on these results, EVS is recommended for managing variceal hemorrhage and is a reasonable alternative for shunt surgery in the management of variceal bleeding.

Sclerotherapy of bleeding esophageal varices. Long-term results

Sixty-one patients presenting with hemorrhage from esophageal varices were treated with sclerotherapy by means of a fiberoptic endoscope. Twenty-nine had acute bleeding, which was stopped in 90%. Thirty-two were treated after recent bleeding. The hospital mortality was 31%. Re-bleeding occurred in 55% of those discharged but was easily controlled. Fatal complications occurred in 5%. The calculated 4-year survival was 35%. Two thirds of this mortality could be attributed to liver failure. The intellectual function of the patients appeared to be unaffected.

Management of bleeding oesophageal varices: an eight-year prospective study

Ninety-one patients (56 men) were admitted with bleeding oesophageal varices on 132 occasions from 1972 to 1980 to the haematemesis and melaena unit of Prince Henry's Hospital, Melbourne. For 73 patients, alcoholic liver disease was the cause of portal hypertension. The management protocol for varices included early endoscopy, medical-surgical liaison, balloon tamponade for continued bleeding and strict criteria for surgery. The endoscopic diagnosis rate was 92%. There were 24 deaths (26%) during the initial admission to hospital and a further 12 patients (13%) died within one year. The mean transfusion requirement was 9.7 units per admission. Balloon tamponade was necessary on 103 occasions and failed to control bleeding on six of them. The results suggest that mortality from bleeding oesophageal varices can be reduced by a protocol which includes early endoscopy, intensive care, balloon tamponade, close medical-surgical liaison and portacaval shunt for recurrent bleeding in "good' risk patients.

New pathways in portal hypertension surgery

An individualized treatment of portal hypertension is advocated. The treatment is suggested to be based upon the presence of complications to the disease: bleeding oesophageal varices, insufficient cardia function, regurgitation and oesophagitis, hyperacidity, stomach and duodenal ulcer, ascites and hypersplenism. The choice of method of treatment of the patient depends on the presence of the symptoms. There are several methods available. These can be divided in methods directed against one symptom - unisymptomatic treatment - and methods directed against several symptoms - polysymptomatic treatments. The author advocates a more frequent use of decongestion operations and pexi operations. For acute control of bleeding varices it seems that sclerotherapy is the preferred choice at present.

Percutaneous transhepatic obliteration of gastro-oesophageal varices

Percutaneous transhepatic portal-vein catheterisation was attempted to obliterate the major variceal venous supply in 13 decompensated cirrhotic patients, who continued to bleed after conservative therapy. Obliteration was achieved and bleeding stopped in 7 patients. In 5 patients obliteration was technically unsuccessful. The remaining patient had an unsuspected portal-vein block diagnosed by the transhepatic technique. 1 patient with successfully obliterated varices died after a haemothorax and haemorperitoneum developed. Follow-up splenic venography at three to six months in the 6 successfully thrombosed patients showed that 4 had persistent obliteration and had not re-bled. 2 patients re-bled from incompletely obliterated varices. It is concluded that selective obliteration of the major variceal supply is effective in stopping acute gastro-oesophageal variceal bleeding, but that greater experience is necessary before the long-term effectiveness of the procedure can be determined.

Abdominal approach for the ligation of bleeding oesophageal varices

The conventional surgical treatment of bleeding oesophageal varices in the emergency situation is based upon the Boerema-Crile operation of transthoracic oesophagotomy and ligation of the varices. This and the other methods of treatment of this condition in current practice are discussed. Two cases are reported in which a transabdominal oesophagogastrotomy was used to approach the site of bleeding. This operation is described and the theoretical and practical advantages it appears to offer over the standard approach are considered.

Emergency oesophageal transection in uncontrolled variceal haemorrhage

The results of emergency oesophageal transection are described. The overall operative mortality-rate was 45 per cent. There were no operative deaths in the patients with extrahepatic obstruction and normal liver function. The operative mortality-rate for the patients with cirrhosis was 53 per cent, or a salvage rate of 47 per cent if one considers that this is a highly selected group of patients (albeit negatively)–patients with impaired liver function who had not responded to intensive medical treatment and who were still bleeding at the time of surgery.