Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching

BACKGROUND AND AIMS

Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far.

METHODS

This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups.

RESULTS

The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001).

CONCLUSIONS

For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.

Reduced mortality for over-the-scope clips (OTSC) versus surgery for refractory peptic ulcer bleeding: a retrospective study

BACKGROUND

Surgery or transcatheter arterial embolization or are both considered as standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-The-Scope clips (OTSC) have shown superiority to standard endoscopic treatment but a comparison with surgery has not been performed, yet.

PATIENTS AND METHODS

In this retrospective, multicenter study, 103 patients treated with OTSC (n = 66) or surgery (n = 37) for refractory PUB in four tertiary care centers between 2009 and 2019 were analyzed. Primary endpoint was clinical success (successful hemostasis and no rebleeding within seven days). Secondary endpoints were adverse events, length of ICU-stay and in-hospital mortality. Univariable and multivariable regression models were performed to define predictive factors for allocation to surgical therapy and for mortality.

RESULTS

Age, comorbidities, anticoagulation therapy, number of pretreatments, ulcer location, and Rockall-Score were similar in both groups. In the surgical group, there were significantly more patients in shock at rebleeding (78.1% vs. 43.9%; p = 0.002), larger ulcers (18.6 ± 7.4 mm vs. 23.0 ± 9.4 mm; p = 0.017) and more FIa bleedings (64.9% vs. 19.7%; p < 0.001) were detected. Clinical success was comparable (74.2% vs. 83.8%; p = 0.329). In the surgical group, length of ICU-stay (16.2 ± 18.0 days vs. 4.7 ± 6.6 days; p < 0.001), severe adverse events (70.3% vs. 4.5%; p < 0.001) and in-hospital mortality (35.1% vs. 9.1%; p = 0.003) were significantly higher. Multivariable analysis defined shock at rebleeding as the main predictor for allocation to surgical therapy (OR 4.063, 95%CI {1.496-11.033}, p = 0.006). Postsurgical adverse events were the main reason for the in-hospital mortality (OR 5.167, 95% CI {1.311-20.363}, p = 0.019).

CONCLUSION

In this retrospective study, OTSC compared to surgical treatment showed comparable clinical success but was associated with shorter ICU-stay, less severe adverse events and lower in-hospital mortality.

Scheduled second look endoscopy after endoscopic hemostasis to patients with high risk bleeding peptic ulcers: a Randomized Controlled Trial

BACKGROUND

The recommendation of second look endoscopy (SLOGD) in selected patients at high risk for rebleeding has been inconclusive. This study aimed to evaluate the benefit of SLOGD in selected patients predicted at high risk of recurrent bleeding.

METHODS

From a cohort of 939 patients with bleeding peptic ulcers who underwent endoscopic hemostasis, we derived a 9-point risk score (age > 60, Male, ulcer ≥ 2 cm in size, posterior bulbar or lesser curve gastric ulcer, Forrest I bleeding, haemoglobin < 8 g/dl) to predict recurrent bleeding. We then validated the score in another cohort of 1334 patients (AUROC 0.77). To test the hypothesis that SLOGD in high-risk patients would improve outcomes, we did a randomized controlled trial to compare scheduled SLOGD with observation alone in those predicted at high risk of rebleeding (a score of ≥ 5). The primary outcome was clinical bleeding within 30 days of the index bleed.

RESULTS

Of 314 required, we enrolled 157 (50%) patients (SLOGD n = 78, observation n = 79). Nine (11.8%) in SLOGD group and 14 (18.2%) in observation group reached primary outcome (absolute difference 6.4%, 95% CI - 5.0% to 17.8%). Twenty-one of 69 (30.4%) patients who underwent SLOGD needed further endoscopic treatment. No surgery for bleeding control was needed. There were 6 vs. 3 of 30-day deaths in either group (p = 0.285, log rank). No difference was observed regarding blood transfusion and hospitalization.

CONCLUSIONS

In this aborted trial that enrolled patients with bleeding peptic ulcers at high-risk of recurrent bleeding, scheduled SLOGD did not significantly improve outcomes.

CLINICALTRIALS

gov:NCT02352155.

Recurrent Bleeding From a Duodenal Ulcer Halted by Laparoscopic Oversewing Under Endoscopic Guidance

Peptic ulcers are the most common causes of upper gastrointestinal bleeding. Although most peptic ulcer bleeding can be controlled by medical and endoscopic treatment, a small number of patients with recurrent bleeding eventually require surgical treatment. In recent years, laparoscopy, a minimally invasive surgical method, has gained popularity and acceptance. We, herein, report a case of recurrent duodenal ulcer bleeding. Laparoscopic oversewing of the bleeding ulcer under endoscopic guidance resulted in satisfactory recovery. We suggest that for recurrent bleeding from peptic ulcers, laparoscopic oversewing under endoscopic guidance should be recommended as a possible early option to halt the bleeding. Key Words: Upper gastrointestinal bleeding, Peptic ulcer, Laparoscopy, Treatment.

Oral Proton Pump Inhibitors May Be as Effective as Intravenous in Peptic Ulcer Bleeding: A Systematic Review and Meta-analysis

INTRODUCTION

Current guidelines recommend intravenous (IV) proton pump inhibitor (PPI) therapy in peptic ulcer bleeding (PUB). We aimed to compare the efficacy of oral and IV administration of PPIs in PUB.

METHODS

We performed a systematic search in 4 databases for randomized controlled trials, which compared the outcomes of oral PPI therapy with IV PPI therapy for PUB. The primary outcomes were 30-day recurrent bleeding and 30-day mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes, while weighted mean differences (WMDs) with CI were calculated for continuous outcomes in meta-analysis. The protocol was registered a priori onto PROSPERO (CRD42020155852).

RESULTS

A total of 14 randomized controlled trials reported 1,951 peptic ulcer patients, 977 and 974 of which were in the control and intervention groups, respectively. There were no statistically significant differences between oral and IV administration regarding 30-day rebleeding rate (OR = 0.96, CI: 0.65-1.44); 30-day mortality (OR = 0.70, CI: 0.35-1.40); length of hospital stay (WMD = -0.25, CI: -0.93 to -0.42); transfusion requirements (WMD = -0.09, CI: -0.07 to 0.24); need for surgery (OR = 0.91, CI: 0.40-2.07); further endoscopic therapy (OR = 1.04, CI: 0.56-1.93); and need for re-endoscopy (OR = 0.81, CI: 0.52-1.28). Heterogeneity was negligible in all analysis, except for the analysis on the length of hospitalization (I2 = 82.3%, P = 0.001).

DISCUSSION

Recent evidence suggests that the oral administration of PPI is not inferior to the IV PPI treatment in PUB after endoscopic management, but further studies are warranted.

Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India

BACKGROUND/PURPOSE OF THE STUDY

Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality.

METHODS

Clinical and endoscopic findings were recorded in patients aged > 12 years who presented within 72 h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6 weeks after discharge.

RESULTS

A total of 305 patients were included in this study, mean age being 44 ± 17 years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6 weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6 weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis.

CONCLUSION

Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.

Surgical emergencies in pregnancy in the era of modern diagnostics and treatment

Pregnancy can be complicated with different surgical emergencies which may potentially endanger the mother as well as foetus. In the modern era of advanced diagnostics and treatments, neither of them in response to a surgical emergency in a pregnant woman should be delayed. Appropriate early intervention is essential to decrease the morbidity and mortality. Following article encompasses common surgical emergencies that can arise in a pregnant woman and tries to suggest the approach that may be taken to reduce the burden of morbidity and mortality.

Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study

OBJECTIVES

This study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also planned to explore factors associated with fatal outcome after surgery for perforated ulcers. These analyses were designed to provide a thorough understanding of current practice and identify potentially modifiable factors associated with outcome as targets for future quality improvement.

DESIGN

National cohort study using National Emergency Laparotomy Audit (NELA) data.

SETTING

English and Welsh hospitals within the National Health Service.

PARTICIPANTS

Adult patients admitted as an emergency with perforated or bleeding PUD between December 2013 and November 2015.

INTERVENTIONS

Laparotomy for bleeding or perforated peptic ulcer.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 60-day in-hospital mortality. Secondary outcomes included length of postoperative stay, readmission and reoperation rate.

RESULTS

2444 and 382 procedures were performed for perforated and bleeding ulcers, respectively. In-hospital 60-day mortality rates were 287/2444 (11.7%, 95% CI 10.5% to 13.1%) for perforations, and 68/382 (17.8%, 95% CI 14.1% to 22.0%) for bleeding. Median (IQR) 2-year institutional volume was 12 (7-17) and 2 (1-3) for perforation and bleeding, respectively. In the exploratory analysis, age, American Society of Anesthesiology score and preoperative systolic blood pressure were associated with mortality, with no association with time from admission to operation, surgeon grade or operative approach.

CONCLUSIONS

Patients undergoing surgery for complicated PUD face a high 60-day mortality risk. Exploratory analyses suggested fatal outcome was primarily associated with patient rather than provider care factors. Therefore, it may be challenging to reduce mortality rates further. NELA data provide important benchmarking for patient consent and has highlighted low institutional volume and high mortality rates after surgery for bleeding peptic ulcers as a target for future research and improvement.

Single-Incision Laparoscopic Transgastric Underrunning and Closure of Cameron Ulcers in Acute Gastrointestinal Bleeding

INTRODUCTION

Endoscopic therapy remains the cornerstone of hemostasis for gastrointestinal bleeding. In situations where hemostasis cannot be achieved via endoscopic or radiological methods, surgery is necessary. Traditional open surgery for bleeding gastric ulcers can be very morbid and unsuitable especially in hemodynamically unstable patients in extremis. We describe a minimally invasive, transgastric approach for underrunning and closure of Cameron ulcers.

METHODS

Our patient is a 75-year-old Chinese lady, who presented to the emergency department with fresh melena. She was hemodynamically unstable with severe metabolic acidosis. CT angiography revealed blood clots within the stomach, with no active blush. On urgent gastroscopy, large blood clots obscured the site of hemorrhage. A Mallory-Weiss tear was noted. Our patient subsequently underwent a successful single-incision laparoscopic transgastric (SLT) underrunning and closure of two Cameron ulcers.

RESULTS

Our patient had an uneventful recovery and subsequently underwent a successful laparoscopic para-esophageal hernia repair on postoperative day 9.

CONCLUSION

A SLT approach is a suitable minimally invasive option for the surgical management of hemostasis and closure of bleeding gastric ulcers not amenable to endoscopic or radiological interventions.

Clinical characteristics of peptic ulcer perforation in Korea

AIM

To elucidate the epidemiological characteristics and associated risk factors of perforated peptic ulcer (PPU).

METHODS

We retrospectively reviewed medical records of patients who were diagnosed with benign PPU from 2010 through 2015 at 6 Hallym university-affiliated hospitals.

RESULTS

A total of 396 patients were identified with postoperative complication rate of 9.1% and mortality rate of 0.8%. Among 174 (43.9%) patients who were examined for Helicobacter pylori (H. pylori) infection, 78 (44.8%) patients were positive for H. pylori infection, 21 (12.1%) were on non-steroidal anti-inflammatory drugs (NSAIDs) therapy, and 80 (46%) patients were neither infected of H. pylori nor treated by any kinds of NSAIDs. Multivariate analysis indicated that older age (OR = 1.09, 95%CI: 1.04-1.16) and comorbidity (OR = 4.11, 95%CI: 1.03-16.48) were risk factors for NSAID-associated PPU compared with non-H. pylori, non-NSAID associated PPU and older age (OR = 1.04, 95%CI: 1.02-1.07) and alcohol consumption (OR = 2.08, 95%CI: 1.05-4.13) were risk factors for non-H. pylori, non-NSAID associated PPU compared with solely H. pylori positive PPU.

CONCLUSION

Elderly patients with comorbidities are associated with NSAIDs-associated PPU. Non-H. pylori, non-NSAID peptic ulcer is important etiology of PPU and alcohol consumption is associated risk factor.

[Organization and results of surgical care for ulcerative gastroduodenal bleeding in the hospitals of Central Federal District]

AIM

To present treatment of 52 149 patients with ulcerative gastroduodenal bleeding (UGDB) who were treated in different regions of Central Federal District (CFD) for the period 2011-2014. It is noted that UGDB incidence per 100 thousands is increased proportionally from 32.9 to 77.8 according to population less than 20 and over 100 thousands, respectively. In hospitals of small and medium settlements the number of UGDB patients without surgery reaches 81.6 and 81.1%, the number of operated patients - 18.4 and 18.9% respectively. In hospitals of large settlements this ratio is 90.1 and 90.6%, the number of operated patients - 9.9 and 9.4%, respectively. In areas of Central Federal District the mortality rate in patients without surgery is 3.9-8.2%, in operated patients - 17.4-36.9%.

RESULTS

Structured analysis of the organization of surgical care in Central Federal District revealed the relationship between outcomes and efficient use of endoscopic diagnostics and haemostasis. In municipal hospitals of Central District endoscopic technologies are insufficiently used for final elimination of ulcerative bleeding.

Association of vagus nerve severance and decreased risk of subsequent type 2 diabetes in peptic ulcer patients: An Asian population cohort study

Vagus nerve may play a role in serum glucose modulation. The complicated peptic ulcer patients (with perforation or/and bleeding) who received surgical procedures with or without vagotomy provided 2 patient populations for studying the impact of vagus nerve integrity. We assessed the risk of developing type 2 diabetes in peptic ulcer patients without and with complications by surgical treatment received in a retrospective population study using the National Health Insurance database in Taiwan.A cohort of 163,385 patients with peptic ulcer and without Helicobacter pylori infection in 2000 to 2003 was established. A randomly selected cohort of 163,385 persons without peptic ulcer matched by age, sex, hypertension, hyperlipidemia, Charlson comorbidity index score, and index year was utilized for comparison. The risks of developing diabetes in both cohorts and in the complicated peptic ulcer patients who received truncal vagotomy or simple suture/hemostasis (SSH) were assessed at the end of 2011.The overall diabetes incidence was higher in patients with peptic ulcer than those without peptic ulcer (15.87 vs 12.60 per 1000 person-years) by an adjusted hazard ratio (aHR) of 1.43 (95% confidence interval [CI] = 1.40-1.47) based on the multivariable Cox proportional hazards regression analysis (competing risk). Comparing ulcer patients with truncal vagotomy and SSH or those without surgical treatment, the aHR was the lowest in the vagotomy group (0.48, 95% CI = 0.41-0.56).Peptic ulcer patients have an elevated risk of developing type 2 diabetes. Moreover, there were associations of vagus nerve severance and decreased risk of subsequent type 2 diabetes in complicated peptic ulcer patients.

Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding

BACKGROUND AND AIMS

For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB).

METHODS

Prospective cohort study of 163 consecutive patients with severe PUB and different SRH.

RESULTS

All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05).

CONCLUSIONS

(1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.

[Repeated endoscopic hemostasis as an alternative to surgical treatment of patients with gastroduodenal ulcerative bleeding]

AIM

To define the role of endoscopic hemostasis in treatment of gastroduodenal ulcers complicated by bleeding.

MATERIAL AND METHODS

The results of endoscopic hemostasis in 770 patients with peptic ulcers were analyzed.

RESULTS

Injection hemostasis had the highest efficacy in case of recurrent bleeding. No other method showed significant advantage in its efficiency. The efficacy of injection method was 52%, argon-plasma coagulation - 83.3%, radiowave technique - 78%, combined endoscopic method  - 96%. In case of recurrent bleeding endoscopic hemostasis is effective alternative to surgery especially in high-risk patients. Repeated endoscopic hemostasis significantly decreases mortality from 45% to 23% in case of recurrent bleeding.

[IMPACT OF OPERATIVE INTERVENTION ON DYNAMICS OF THE IMMUNITY INDICES IN AN ACUTE GASTRODUODENAL HEMORRHAGE]

The results of surgical treatment of 39 patients, suffering an acute gastroduodenal ulcer hemorrhage, were analyzed. Gastric ulcer disease was diagnosed in 9 patients, duodenal ulcer disease--in 29, combined ulcer--in 1. A light degree blood loss was noted in 13 patients, while a middle degree--in 12, and severe--in 14. In accordance to J. Forrest classification in 6 patients an active bleeding was revealed (FIa, FIb), in 11--nonstable hemostasis (FIIa, FIIb, FIIc), and in 22--FIII. Preoperatively in patients on the third, seventh and fourteenth day the contents of CD3+, CD4+, CD8+, CD19, calculation of a CD4+/CD8+ ratio, the level of immunoglobulins (IgA, IgM, IgG) and circulating immune complexes were determined in peripheral blood. Phagocytic activity of neutrophils was estimated, using determination of phagocytic index and phagocytic number. In an acute gastroduodenal ulcer hemorrhage immunosuppression was noted, and severity of disorders in T- and B-chains of immunity have depended upon a blood loss severity. Conduction of a routine basic conservative therapy in postoperative period did not guarantee elimination of immunosuppression.

[TREATMENT MODALITIES OF THE FOREGUT HEMORRHAGES WHILE PERFORMING ENDOSCOPIC MONITORING]

Complex clinical examination was done in 107 patients, in whom gastrointestinal hemorrhage (GIH) of various etiology, have had occurred. Special attention was drawn toward early conduction of esophagogastroduodenofibroscopy, as a leading instrumental method, permitting to reveal a GIH source, its character and degree of hemostasis in accordance to J. Forrest scale. The patients state severity while hemorrhage from the foregut presence was estimated in accordance to routine principles, depending on the circulating blood volume deficiency. The structure algorithm for the patients' management, in accordance to which treatment tactic must be selected individually, permitting to improve the quality of the medical help delivery for the patients, was elaborated.

Successful treatment of life-threatening bleeding from a duodenal posterior bulb peptic ulcer by an over-the-scope-clip

Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome. In this article, we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall, using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock. Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.

[BIOLOGICAL RESERVOIRS AS A THE RESPONSE OF THE ORGANISM TO INJURY AND PROOF FOR METABOLIC CORRECTION IN GASTRODUODENAL HEMORRHAGE IN PATIENTS WITH HIGH OPERATING-ANESTHETIC RISK]

In the authors opinion in the process of self-regulation the human body creates some biological reservoirs in response to damage (disturbance of homeostasis) for constant internal environment In cases of decompensation and depletion of these pools metabolic correction is necessary. This opinion was based on the results of the endoscopic metabolic hemostasis in ulcer gastroduodenal bleeding in patients with high operational and anesthetic risk.

Upper-gastrointestinal bleeding secondary to peptic ulcer disease: Incidence and outcomes

AIM: To evaluate the incidence, surgery, mortality, and readmission of upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).

METHODS: Administrative databases identified all hospitalizations for UGIB secondary to PUD in Alberta, Canada from 2004 to 2010 (n = 7079) using the International Classification of Diseases Codes (ICD-10). A subset of the data was validated using endoscopy reports. Positive predictive value and sensitivity with 95% confidence intervals (CI) were calculated. Incidence of UGIB secondary to PUD was calculated. Logistic regression was used to evaluate surgery, in-hospital mortality, and 30-d readmission to hospital with recurrent UGIB secondary to PUD. Co-variants accounted for in our logistic regression model included: age, sex, area of residence (i.e., urban vs rural), number of Charlson comorbidities, presence of perforated PUD, undergoing upper endoscopy, year of admission, and interventional radiological attempt at controlling bleeding. A subgroup analysis (n = 6356) compared outcomes of patients with gastric ulcers to those with duodenal ulcers. Adjusted estimates are presented as odds ratios (OR) with 95%CI.

RESULTS: The positive predictive value and sensitivity of ICD-10 coding for UGIB secondary to PUD were 85.2% (95%CI: 80.2%-90.2%) and 77.1% (95%CI: 69.1%-85.2%), respectively. The annual incidence between 2004 and 2010 ranged from 35.4 to 41.2 per 100000. Overall risk of surgery, in-hospital mortality, and 30-d readmission to hospital for UGIB secondary to PUD were 4.3%, 8.5%, and 4.7%, respectively. Interventional radiology to control bleeding was performed in 0.6% of patients and 76% of these patients avoided surgical intervention. Thirty-day readmission significantly increased from 3.1% in 2004 to 5.2% in 2010 (OR = 1.07; 95%CI: 1.01-1.14). Rural residents (OR rural vs urban: 2.35; 95%CI: 1.83-3.01) and older individuals (OR ≥ 65 vs < 65: 1.57; 95%CI: 1.21-2.04) were at higher odds of being readmitted to hospital. Patients with duodenal ulcers had higher odds of dying (OR = 1.27; 95%CI: 1.05-1.53), requiring surgery (OR = 1.73; 95%CI: 1.34-2.23), and being readmitted to hospital (OR = 1.54; 95%CI: 1.19-1.99) when compared to gastric ulcers.

CONCLUSION: UGIB secondary to PUD, particularly duodenal ulcers, was associated with significant morbidity and mortality. Early readmissions increased over time and occurred more commonly in rural areas.

Monopolar soft-mode coagulation using hemostatic forceps for peptic ulcer bleeding

BACKGROUND/AIMS

Upper gastrointestinal hemorrhage from bleeding peptic ulcer is sometimes difficult to treat by conventional endoscopic methods. Recently, monopolar electrocoagulation using a soft-coagulation system and hemostatic forceps (soft coagulation) has been used to prevent bleeding during endoscopic submucosal dissection. The aim of this study was to assess the safety and efficacy of soft coagulation in the treatment of bleeding peptic ulcer.

METHODOLOGY

A total of 39 patients with peptic ulcers were treated using soft coagulation at our hospital between January 2005 and March 2010. Emergency treatment employed an ERBE soft-mode coagulation system using hemostatic forceps. Second-look endoscopy was performed to evaluate the efficacy of prior therapy. Initial hemostasis was defined as accomplished by soft coagulation, with or without other endoscopic therapy prior to soft coagulation. The rate of initial hemostasis, rebleeding, and ultimate hemostasis were retrospectively analyzed.

RESULTS

The study subjects were 31 men and 8 women with a mean age of 68.3±13.7 years, with 29 gastric ulcers and 10 duodenal ulcers. Initial hemostasis was achieved in 37 patients (95%). During follow-up, bleeding recurred in two patients, who were retreated with soft coagulation.

CONCLUSIONS

The monopolar soft coagulation is feasible and safe for treating bleeding peptic ulcers.

[Mucosal changes in the periulcer zone and endocrine system in patients with gastroduodenal ulcer, complicated by hemorrhage]

Examination of patients, suffering gastroduodenal ulcer, complicated by hemorrhage, was conducted, using clinical, microbiological, immunohistochemical methods and chromatomassspectrography. Enhanced activity of inducible NO-synthase, contamination of periulcer zone with microorganisms Klebsiella pneumoniae, Streptococcus beta-haemoliticus, enhancement of contents of catecholamines and serotonin in the blood serum were revealed. These changes are most expressed in severe blood loss, unstable local endoscopic hemostasis, high risk of a recurrent hemorrhage occurrence. The data obtained permit to prognosticate severity of a pathologic process course and to improve the treatment programe.

Methods of emergency surgery in high-risk stigmata peptic ulcer hemorrhage

AIM

The choice of emergency operative methods in management of peptic ulcer hemorrhage (PUH) is controversial. The aim of this study was to analyze the patient characteristics, surgical methods and treatment outcome of patients with PUH during 10 years.

METHODS

Of the 953 admitted PUH patients all 67 (7.0%) operated cases had high-risk stigmata PUH (Forrest classification). These patients were grouped and their data were compared under two 5-year periods: period I - 32 patients (2003-2007) and period II - 35 patients (2008-2012).

RESULTS

The majority of the patients had giant ulcer (diameter ≥ 2 cm) hemorrhage at 75.0% (24/32) and 94.3% (33/35) during study periods I and II, respectively (P=0.04). Giant duodenal and gastric ulcers for PUH were operated in 16 and 8 vs 27 and 6 during periods I and II, respectively. Ulcer exclusion or ulcerectomy combined with definitive acid reducing surgery was applied in 68.7% (22/32) and 71.4% (25/35) of the patients, respectively, without early recurrent hemorrhage. Postoperative in hospital mortality in the 10-year study period was 6.0% (4/67); 2.1% (1/48) of the patients died after definitive operations and 15.8% (3/19) (P=0.04) died after non-definitive operations.

CONCLUSION

The surgical treatment of high-risk stigmata PUH was mainly associated with giant, particularly giant duodenal ulcer. As a rule, ulcer exclusion or ulcerectomy as hemorrhage control, combined with definitive surgery, was applied in the majority of the cases with an in hospital mortality of 2.1%.

[The ways of prophylaxis of the gastro-intestinal hemorrhage recurrence]

Through three-years period 57 patients, suffering gastro-intestinal hemorrhage (GIH) of the ulcer genesis, were treated in the clinic. Among them were 37 (64.9%) men and 20 (35.1%) women. The patients have had (56.3 +/- 4.7) yrs old at average. The treatment programm for the patients have included a local arrest of GIH, medicinal therapy, directed on restoration of the circulating blood volume, gastric secretion inhibition, rising of the blood coagulation property. In cases of a middle and severe blood loss the blood preparations were transfused--the erythrocytic mass and freshly frozen plasm. Three patients were operated in the high period of GIH. The GIH recurrence was absent. In 7 - 8 days, if a persistent hemostasis was achieved, the patients were transferred to therapeutic department for the conservative therapy prolongation.

[Complex application of laparoscopic vagotomy in case of hard scarring ulcers after gastroduodenal bleeding]

654 patients with ulcerative gastroduodenal bleeding from duodenum were under observation. It was done the meta-analysis of treatment results of 111 patients with hard scarring duodenal ulcers. It was discovered high efficiency of organ-preserving operations such aslaparoscopic vagotomy and proton pump inhibitors in these observations.

[The combined endoscopic hemostasis in case of gastroduodenal ulcerative bleeding]

It was done the retrospective analysis of the endoscopic hemostasis effectiveness in 207 patients with gastroduodenal bleeding in the period from November 2011 to April 2013. The differential approach to the choice of hemostasis methods and consistency of their application were developed. It was done the comparative analysis of two- and three-stages combined hemostasis results. The analysis included the infiltration of the submucosal layer by 0.01% solution of adrenaline, argon-plasma coagulation and hemostatic glue applique.

[Endoscopic and roentgenovascular interventions in treatment of patients with bleeding from a gastroduodenal ulcer]

The authors analyzed the results of treatment of 965 patients with bleeding from gastroduodenal ulcers. The endoscopic hemostasis was carried out in 20.2% patients, however a recurrence of bleeding was noted in 12.8% cases. The combined endoscopic hemostasis was performed in 76.9% patients, though the relapse of bleeding had only 4.2% and 49 patients were safe. A surgery was required for 3.2% patients.

Comparison the efficacy of intermediate dose argon plasma coagulation versus hemoclip for upper gastrointestinal non-variceal bleeding

BACKGROUND/AIMS

Endoscopic argon plasma coagulation (APC) and hemoclip were used for the treatment of bleeding peptic ulcers. There are wide ranges of hemostatic doses (power and flow) of APC used in previous studies. The aim of our study was to assess the efficacy and safety of "intermediate dose" APC compared to hemoclips for hemostasis from bleeding peptic ulcer.

METHODOLOGY

The present study was designed as a retrospective study using historical controls. One hundred and ninety-four consecutive upper GI bleeding patients with bleeding visible vessel lesions were treated with either APC or hemoclips. There are 110 patients received APC treatment and 84 patients received hemoclip hemostasis. The main outcome measurements were one week rebleeding rate, one month rebleeding rate, surgery, morality, amount of blood transfusion and durations of hospital stay.

RESULTS

There were no significant differences between the two groups in 1 week rebleeding rate (1.8% vs. 2.4%, p = 1.0), 1 month rebleeding rate (0% vs. 1.2%, p = 0.433), mortality, surgery and amount of blood transfusion (2.67 +/- 3.27 vs. 3.04 +/- 2.75 units, p = 0.322). However, the hospital stay was longer in hemoclip group (5.38 +/- 6.76 vs. 8.49 +/- 11.19 days p = 0.011).

CONCLUSIONS

APC and hemoclip are with different hemostatic mechanisms, but the hemostatic outcomes were not significantly different between the two groups. APC is an effective, safe, and easily applicable endoscopic hemostatic modality as hemoclip for patients with non-variceal bleeding.

An upper gastrointestinal ulcer still bleeding after endoscopy: what comes next?

INTRODUCTION

Recurrent bleeding from an upper gastrointestinal ulcer when endoscopy fails is a reason for radiological or surgical treatment, both of which have their advantages and disadvantages.

CASE

Based on a patient with recurrent gastrointestinal bleeding, we reviewed the available evidence regarding the efficacy and safety of surgical treatment and embolisation, respectively.

DISCUSSION

Transarterial embolisation (TAE) and surgical treatment are both options for recurrent gastrointestinal bleeding when endoscopy fails. Both therapies have serious complications and a risk of rebleeding. Choosing the therapy depends on the capability of the patient to tolerate haemodynamic instability, resuscitation and hypotension.

CONCLUSION

Choosing between TAE and surgery depends a great deal on the case presented, haemodynamic stability and the skills and tools available at that moment.

[Modern approach to prognostication of the acute hemorrhage recurrence from duodenal ulcer]

There was 2223 of 2285 patients, treated in the Kyiv's municipal center of gastrointestinal hemorrhage in 1994-1996 yrs (the control group) and in 2004-2008 yrs (the main group) for an acute hemorrhage from duodenal ulcer. The integral prognostic index (IPI) was determined for the early recurrence risk (ERR) assessment. The point prognostication system, based on the step by step discriminant analysis, was transformed while its application. While in a control group of an acute hemorrhage early recurrence prognostication and its low risk (ERR was 5.6%) the IPI have had constituted 7-9 points, in the middle risk (ERR was 34%) the IPI have measured 10-16 points and in the conditions of a high risk (ERR have constituted 89.1%), the IPI was 17-22 points, vs in the main group in conditions of application of potent intravenous proton pump inhibitors and effective endoscopic hemostasis measures in a low risk group (the realized ERR was 1.2%) the IPI have measured 7-12 points, in middle ERR (realized ERR 7.15%) the IPI raised to 13-19 points and in a high ERR (realized ERR was 23.81%) 20-22 points.

[Remote results of conservative and operative treatment of patients with duodenal ulcer complicated by bleeding]

Analyzed long-term outcomes of 690 patients with duodenal ulcer, complicated by bleeding in Kyiv City Centre gastrointestinal bleeding for the periods 1994-1996 (control group) and 2004-2008 (main group). In the late period of patients who were found giperhlorgidry (moderate and severe), increased by 1.4 tImes, indicating a higher voltage continuous acid production In the main group. With the introduction of modern circuits Helicobacter therapy incidence of H. pylori reduced by half. Improving modern tactical approaches to conservative treatment helped to reduce the frequency of relapses in duodenal ulcer remote period by 2.2 times, acute bleeding--in 1.9 times, increase the frequency of excellent results--in 2.8 times.

[Prognosis of the hemorrhage recurrence in the patients suffering from acute gastroduodenal ulcer bleeding]

The prognostication method for the hemorrhage recurrence, permitting to estimate the risk of its occurrence and to prescribe an adequate antirecurrence treatment, was proposed. Among numerous predictors of recurrence the most significant clinical, endoscopic and laboratory factors were selected to raise the prognostication precision. Depending on therisk degree of a recurrent hemorrhage, different methods of treatment were prescribed to the patients. The proposed method was applied in 112 patients, suffering ulcer gastroduodenal hemorrhage. The hemorrhage recurrence have had occurred in 45 (43.3%) of them, in 5 (4.46%)--operative intervention was conducted, using organpreserving methods. General lethality have had constituted 0.89%, postoperative one in a control group--7.14%, and in the main all the patients were alive. The method proposed permits with a high precision to prognosticate and to determine effective tactics of treatment. Taking into account the additional factors of risk raises the prognosis precision and permits to prescribe antihelicobacter therapy and the proton pump inhibirors in a rational dosage soundly.

[The comparison of prognostic scales of the gastroduodenal bleeding recurrence]

229 patients with ulcerous gastroduodenal bleeding were included in the study. Prognostic scales of the bleeding recurrence by Rockall, Blatchford, Vinokurov and System of Prognosing of Bleeding Recurrence (SPBR) I and II were comparatively analyzed. The SPBR II proved to be statistically relevant and the most accurate in prognosing the bleeding recurrence, then other scales.

[Treatment strategy for ulcerative gastrointestinal bleeding from the upper gastrointestinal tract]

The deep statistical analysis of patients treatment with the ulcerous gastroduodenal bleeding set 2 years works of Center of the gastroduodenal bleeding of Dnepropetrovsk is conducted. It is exposed, that wide application of methods of endoscopic haemostasis and endoscopic monitoring allowed substantially to reduce the amount of operations at this category of patients and improve the results.

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy

BACKGROUND

Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality.

OBJECTIVE

To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB).

DESIGN

Secondary analysis of prospectively collected data from 3 national databases.

SETTINGS

Community and teaching hospitals.

PATIENTS

Consecutive patients admitted for acute nonvariceal UGIB.

INTERVENTIONS

Early endoscopy, medical and endoscopic treatment as appropriate.

MAIN OUTCOME MEASUREMENTS

Thirty-day mortality, recurrent bleeding, and need for surgery.

RESULTS

A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001).

LIMITATIONS

No data on the American Society of Anesthesiologists class score in the Prometeo study.

CONCLUSIONS

Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

Heater probe thermocoagulation for high-risk patients who show rebleeding from peptic ulcers

AIM

To investigate whether heater probe therapy is effective for patients showing rebleeding from peptic ulcers.

METHODS

We retrospectively reviewed the case profiles in our previous studies on endoscopic therapy for high-risk patients with peptic ulcer bleeding in the past two decades. We analysed the outcomes of 191 patients who showed rebleeding after initial endoscopic haemostasis and received endoscopic therapy with heater probe thermocoagulation. .

RESULTS

A total of 191 patients showing rebleeding received heater probe thermocoagulation. After re-therapy, 158 patients (82.7%) achieved ultimate haemostasis. Twenty-five of the 33 patients who failed to achieve haemostasis received surgical intervention. Ten patients (5.2%) died within 1 month after re-therapy.

CONCLUSION

Heater probe thermocoagulation can be used as the first choice for management of patients showing rebleeding after initial endoscopic therapy.

[Surgical treatment of gastroduodenal ulcers according to principles of a modern antirecurrence therapy with postoperative complications prophylaxis]

Modern approaches to surgical treatment of gastroduodenal ulcers in accordance with principles of antirecurrence therapy, directed on prophylaxis of postoperative complications occurrence, are enlighted.

[The prevention and treatment of the gastroduodenal ulcer bleedings]

The results of the complex prophylaxis and treatment of 33 458 patients with gastric or duodenal ulcer were analyzed. Of the analyzed group, 1002 (2,99%) patients experienced ulcer bleeding. The complex out-patient and stationary treatment of the ulcer disease allowed of bleeding frequency from 8,6 to 2,1%; the decrease of recurrent bleedings from 13,0% to 0; allowed to avoid major surgery (the previous frequency was as high as 14,5%) and decreased lethality rate from 9 to 1%.

Successful treatment of a compromised patient with intractable pneumothorax using a semiflexible thoracofiberscope under local anesthesia: A case report

We herein present the case of a 69-year-old male with intractable pneumothorax, which occurred after gastrectomy, who could not tolerate general anesthesia because of a poor cardiopulmonary reserve and renal and hepatic insufficiency. We performed a ligation of perforated bulla using a semiflexible thoracofiberscope under an intercostal nerve block and subcutaneous anesthesia. The postoperative course was uneventful. The chest tube was removed the next day, and he was transferred to the department of medicine on the 2nd postoperative day.

Impact of nonresective operations for complicated peptic ulcer disease in a high-risk population

Over the past two decades, surgery for complicated peptic ulcer disease has evolved to a "less-is-more" approach due predominately to improved medical therapy. This study sought to determine whether a nonresective operative strategy has been an effective and prudent approach. A 20-year retrospective evaluation was conducted to compare outcomes of patients from the first decade (1990-1999) with those from the more recent decade (2000-2009). In all, 50 patients underwent surgery for complications of peptic ulcer disease, 36 in the early period and 14 in the later period, with 94 per cent being urgent or emergent. Acid-reducing procedures (vagotomy) decreased significantly from 29 to 7 over the two periods (P = 0.04), as did gastric resections from 23 to 3 (P = 0.01). The prevalence of H. pylori and use of NSAIDs both increased from 28 per cent to 36 per cent and 31 per cent to 43 per cent, respectively. Postoperative mortality remained unchanged, 22 per cent vs. 7 per cent (P = 0.41) over the two periods. Resections and definitive acid-reducing procedures continue to decline with no increase in adverse outcomes. This more moderate operative approach to complicated peptic ulcer surgery is appropriate given the trend towards lower mortality and improved medical treatment. In our high-risk veteran population, overall perioperative mortality, length of stay, and reoperations have been reduced.

Present state of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding

The subjects of this study were 208 patients who underwent endoscopic hemostasis at the Department of Gastroenterology and Hepatology, Iwate University between January 2004 and December 2008. There were 153 men and 55 women with a mean age of 65.3 years. Among them, 181 patients underwent endoscopic hemostasis in the stomach or duodenum and were divided into the peptic ulcer and artificial ulcer groups. The following were retrospectively analyzed: success rates of endoscopic hemostasis, rates of rebleeding, and devices used during treatment. The overall success rate of endoscopic hemostasis was 97.2%. Hemostasis was achieved in 98.2% of the cases with peptic ulcer bleeding and in 88.9% of the cases with artificial ulcer bleeding. Monotherapy (one hemostatic device) was used in 141 cases (77.9%), combination therapy (multiple hemostatic devices) was used in 39 cases (21.5%), and primary hemostasis was used in one case (0.6%) because of blood flow reduction during the observation period. A heat probe was used in 145 cases (80.1%), making it the most frequently used device. Endoscopic hemostasis is very effective for nonvariceal upper gastrointestinal bleeding.

[The choice of surgical tactics in patients with unstable hemostasis and gastroduodenal ulcer bleeding]

Treatment results of 476 patients with acute gastroduodenal ulcer bleeding were analyzed. Men comprised 75% (n=357), women - 25% (n=119). All patients were divided in two groups. Treatment principles of patients of the first group (36.8%; n=175) were based on active conservative treatment. Surgery was performed in 70.3%, postoperative lethality comprised 12.2%, overall mortality was 9.7%. Second group consisted of 301 patients (63.2%). Individual based active surgical treatment was performed, including clinical and endoscopic evaluation of local hemostasis, prognostic criteria of bleeding recurrence, differential approach in time, extent and method of the applied surgery. Operative treatment was used in 81.1% of patients of the second group, postoperative lethality comprised 9.8%, overall mortality was 8.0%. Emergency operations were performed in 43.6% (n=160) of all patients, early elective surgery in 56.4% (n=207). Postoperative lethality comprised 10.6%, overall mortality rate was 8.6%. Therefore, individual based active surgical treatment proved to be preferable. Gastric resection showed to be more advisable then organ-preserving operations, considering emergency ulcer surgery.

[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.