Recent advances in the management of variceal bleeding

A prospective randomized trial of selective distal splenorenal shunt (DSRS)versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a socalled pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished. This report is the gist of a paper read by W. D. W. at the 85th Annual Meeting of the Japanese Surgical Society, Sendai, Japan, 1985     

Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades,transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis.Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options,have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications,such as peptic ulcerbleeding,malignant disease,hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding.Transcatheter interventions include the following:selective embolization of the feeding artery,sandwich coil occlusion of the gastroduodenal artery,blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery.Transcatheter embolization is a fast,safe and effective,minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract.This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.     

Injection sclerotherapy for the long-term management of variceal bleeding

Injection sclerotherapy for the long-term management of variceal bleeding is discussed with particular reference to our experience at King's College Hospital. The important questions of which techniques to use, which sclerosing agent to inject, the timing of the first and subsequent treatments, and the periods between follow-up endoscopic examinations are reviewed. The efficacy of sclerotherapy both with respect to rebleeding and survival are assessed on the basis of 2 completed controlled trials and a third study from which preliminary data are available. A possible role for the prophylatic use of sclerotherapy in selected high-risk patients is discussed. The complications associated with sclerotherpy are detailed and attention is drawn to the very low mortality rate of the procedure.

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Resumen Se discute la escleroterapia de inyección para el manejo a largo plazo del sangrado varicoso esofágico en referencia particular a neustra experiencia en el King's College Hospital de Londres. Se revisan interrogantes importantes tales como qué técnica debe ser utilizada, cuál agente esclerosante debe ser inyectado, el momento del primer tratamiento y de los subsiguientes, así como los intervalos entre los exámenes endoscópicos de seguimiento. La eficacia de la escleroterapia es evaluada con respecto a la hemorragia recurrente y a la supervivencia, con base en dos ensayos clínicos controlados ya terminados y un tercer estudio sobre el cual ya se dispone de datos preliminares. Se discute el posible uso profiláctico de la escleroterapia en pacientes seleccionados de alto riesgo. Se detallan las complicaciones asociadas con la escleroterapia y se llama la atención sobre la muy baja mortlidad del procedimiento.Nuestra política es realizar el primer procedimiento de escleroterapia dentro de las doce horas siguientes al control de la hemorragia y, en aquellos casos en los cuales el taponamiento con balón se hace necesario, la escleroterapia es ejecutada inmediatamente después de retirado el balón. Tal escleroterapia emprendida precozmente durante el intervalo libre de hemorragia activa actúa entonces como la primera de una serie de inyecciones orientadas a la obliteratión de las várices esofágicas y a establecer un método de control a largo plazo del sangrado varicoso.La muy reducida mortalidad que conlleva el procedimiento, combinada con la eficacia en la preventión de nuevas hemorragias, significan un enfoque terapéutico óptimo y ampliamente aplicable, en comparación con otras modalidades tales como la cirugía derivativa portai. Los resultados de estudios comparativos recientes y actualmente en progreso puede hacer posible el desarrollo de un enfoque más uniforme de este método de tratamiento.

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Résumé Le traitement à long terme des hémorragies par rupture des varices oesophagiennes à l'aide des injections sclérosantes est discuté en fonction de l'expérience du King College Hospital. Sont passées en revue les questions suivantes: la méthode à employer, l'agent sclérosant à injecter, le moment de l'intervention initiale et des interventions ultérieures, les intervalles séparant les endoscopies de contrôle. L'efficacité de la sclérothérapie en ce qui concerne deux paramètres: la récidive de l'hémorragie et la survie sont évalués à partir de deux essais contrôlés et d'une troisième tentative thérapeutique ancienne disponible. Le rôle possible de l'emploi à titre préventif de la sclérothérapie chez les malades à haut risque est également envisagé. Les complications de la sclérothérapie sont détaillées et la faible mortalité de la méthode est soulignée.

     

Sugiura procedure for management of variceal bleeding in Japan

During the last three decades the Sugiura procedure and other nonshunting operations have been widely performed as the operations of choice for bleeding esophageal varices in Japan. The Sugiura procedure (University of Tokyo method), a transthoracoabdominal esophageal transection, consists in paraesophageal devascularization, esophageal transection and reanastomosis, splenectomy, and pyloroplasty. The results have been satisfactory with low operative mortality and low rebleeding rate. The prognosis of the patients after this operation depended on the liver function at the time of operation but not on whether operation was done as an emergency, elective, or prophylactic measure. Although the Sugiura procedure has recently been performed in more selected cases with an advance in endoscopic injection sclerotherapy, this procedure remains the ultimate direct operation for portal hypertension in Japan.

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Resumen En los últimos tres decenios, el procedimiento de Sugiura y otras operaciones no derivativas han sido extensamente practicadas como el tipo de operación de preferencia para várices esofágicas sangrantes en el Japón. El procedimiento de Sugiura (o método de la Universidad de Tokyo) es una transección esofágica transtoracoabdominal, que consiste en desvascularización paraesofágica, transección esofágica y reanastomosis, esplenectomía y píloroplastia. Los resultados han sido satisfactorios con baja mortalidad operatoria y baja tasa de hemorragia recurrente.El pronóstico luego de esta operación depende del estado de la función hepática en el momento de la cirugía, pero nó de si la operación es realizada como medida de emergencia, electiva o profiláctica. Aunque el procedimiento de Sugiura ha sido recientemente practicado en casos más seleccionados, sigue siendo la operación directa definitiva para el tratamiento de la hipertensión portal en el Japón.

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Résumé Depuis les trois dernières décades, au Japon, on préfère pratiquer l'opération de Suguira et d'autres procédés non anastomotiques pour rupture de varices oesophagiennes. L'opération de Suguira (ou la méthode de l'Université de Tokyo) est une transsection oesophagienne transthoracoabdominale suivie d'anastomose associée une dévascularisation paraoesophagienne, une splénectomie et une pyloroplastie. Les résultats ont été satisfaisants avec une mortalité et un taux de récidive bas. Le pronostic des patients après cette opération dépend de la fonction hépatique au moment de l'intervention, mais pas du caractère urgent de l'intervention. Bien que cette intervention ait été pratiquée récemment dans quelques cas sélectionnés après sclérothérapie, l'opération de Suguira reste l'intervention directe ultime pour l'hypertension portale au Japon.

     

Narrow-diameter portacaval shunts for management of variceal bleeding

Over the past decade, we have developed and refined a method for partial portosystemic shunting for the control of bleeding esophageal varices in alcoholic cirrhotic patients. The narrow-diameter interposition portacaval H-graft using 8 mm polytetraffuoroethylene has been performed in 32 patients at our institution with low operativ mortality (16.3%) and nearly complete cessation of variceal bleeding (96.7%) over a mean follow-up period of 43 months. In comparison with total shunts, diminished rates of postshunt encephalopathy (13% versus 40%) have been observed. Prograde portal blood flow has been preserved in 90% of 30 patients studied by perioperative portography. Shunt patency with continued prograde flow has been demonstrated at up to 9 years of follow-up. Investigators at three other centers have studied partial shunting using substantially similar techniques, with similar findings. Based on these results, we conclude that narrow-diameter shunts provide effective, long-lasting treatment for variceal hemorrhage due to portal hypertension in the alcoholic.

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Resumen En el curso del último decenio hemos desarrollado y refinado un método de derivación portasistémica parcial para el control del sangrado por várices esofágicas en pacientes con cirrosis alcohólica. La interposición portacava en H por medio de un injerto de politetrafluoroetileno de diámetro delgado, 8mm, ha sido utilizada en 32 pacientes en nuestra institución, con baja mortalidad operatoria (6.3%) y el logro casi total del cese del sangrado varicoso (96.7%) en el curso de un seguimiento promedio de 43 meses. Al comparar con los shunts totales, se observan menores tasas de encefalopatía (13% versus 40%). Se ha logrado preservar el flujo portal prógrado en un 90% de 30 pacientes estudiados mediante portografía perioperatoria. La permeabilidad del shunt con flujo prógrado confirmado ha sido demostrada hasta en 9 años de seguimiento. Investigadores en otros tres centros han estudiado la derivación parcial utilizando una técnica similar, registrando resultados similares. Con base en estos resultados, llegamos a la conclusión de que los shunts de diámetro delgado representan una modalidad terapéutica efectiva y de larga duración en el manejo de la hemorragia por hipertensión portal causada por cirrosis.

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Résumé Pendant ces 10 dernières années, nous avons conçu et perfectionné une méthode d'anastomose porto-cave partielle pour contrôler l'hémorragie par rupture des varices oesophagiennes chez le cirrhotique d'origine alcoolique. Nous réalisons une anastomose par interposition portocave avec une prothèse de 8 mm en polytétrafluoroéthylène (PTFE). Ceci a été effectué chez 32 patients avec une mortalité faible (6.3%) en obtenant un arrêt de saignement chez 96.7% des patients avec un suivi de 43 mois. En comparaison avec d'autres types d'anastomose, la fréquence d'encéphalopathie est amoindrie (23% vs 48%). Le flux portal antérograde a été conservé chez 90% des 30 patients étudiés par portographie périopératoire. La perméabilité de l'anastomose avec une conservation de flux antérograde a été retrouvé jusqu'à 9 ans après l'intervention initiale. Les investigateurs de trois autres centres ont étudié cette anastomose partielle avec une technique similaire et des résultats tout à fait comparables. En nous appuyant sur ces résultats, nous concluons que l'anastomose par prothèse interposée de petit calibre peut donner un résultat efficace et durable dans le traitement de la rupture de varices oesophagiennes en rapport avec l'hypertension portale chez le cirrhotique d'origine alcoolique.

     

Total shunting and elective management of variceal bleeding

A 20-year experience with treatment of esophageal varices in patients with cirrhosis is reported. Considering that total shunts are well tolerated iminediately after operation (hospital mortality rate for all elective procedures being 6.4%), that they offer a good protection against rebleeding (rebleeding variceal rate of 7.6%), and that they offer the same long-term survival as given by other shunts (5-and 10-year survival rates of 57% and 31%, respectively), the authors affirm that these kinds of shunts are still useful in well selected cases. Late follow-up results of a prospective randomized trial of elective mesocaval shunts compared to portacaval shunt have shown no significant differences in operative mortality, reoleeding rates, encephalopathy rates, or survival. Based on this information, the authors currently use portacaval shunt as their operation of choice.

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Resumen Se informa nuestra experiencia de 20 años, con el tratamiento de la hipertensión portal, la cual es, fundamentalmente con shunts porta-sistémicos.Considerando que los shunts de derivación total son bien tolerados en el período post-operatorio inmediato (la mortalidad hospitalaria para los procedimientos electivos es 6,4%), que ofrecen buena protección contra resangrado (la tasa de hemorragia varicosa recurrente es de 7.6%) y la misma sobrevida a largo plazo que otros tipos de derivación (tasas de sobrevida a 5 y 10 años de 57% y 31% respectivamente), los autores afirman que esta clase de shunt todavía son de utilidad en casos seleccionados.Los resultados a largo plazo de un ensayo clínico prospectivo y randomizado de shunts electivos mesocava y portacava para comparar mortalidad operatoria y las tasas de hemorragia recurrente, encefalopatía y sobrevida, no muestran diferencias significativas. Con base en estos datos, los autores actualmente utilizan el shunt portacava como la operación de preferencia.

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Résumé L'expérience du traitement des varices oesophagiennes des 20 dernières annèes est rapportée. Etant donné que les dérivations portocaves sont bien tolérées en postopératoire immédiat (la mortalité postopératoire pour tous procédés électifs est de 6.4%), qu'elles préviennent la récidive hémorragique (7.6% après chirurgie), et que est la survie à distance est similaire à celle des autres shunts (57% et 31% à 5 et à 10 ans, respectivement), les auteurs affirment l'utilité de ces shunts chez des patients bien sélectionnés. Les résultats à distance d'un essai prospectif randomisé comparant l'anastomose portocave et l'anastomose mésentérico-cave ont montré aucune différence significative de la mortalité opératoire, des taux de récidive, d'encéphalopathie ou de la survie. Se basant sur ces données, l'anastomose portocave reste l'opération de choix dans cette indication.

     

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目的 探讨应用吻合器经腹行食管下段部分切除再吻合治疗门静脉高压食管胃底静脉曲张出血的疗效。方法 回顾分析了自1995年10月至2001年11月行贲门周围血管离断术加用吻合器作食管下段部分切除再吻合48例(切除组)的疗效，并与20例同期仅行周围血管离断术(单纯组)的疗效进行比较，分别观察食管曲张的消除率、再出血率、手术死亡率、吻合口狭窄以及吻合口瘘的发生率。结果平均随访20个月。单纯组再出血率为25％(5／20)，切除组无再发出血。食管静脉曲张的治愈率切除组为100％，而单纯组为50．0％(10／20)。吻合狭窄发生率切除组为4．1％(2／48)，单纯组为0。两组均未发生吻合口瘘。结论 应用吻合器行食管下段切除再吻合术是安全的，可使断离更为彻底，降低复发，从而进一步提高周围血管离断术的疗效。     

急诊内镜治疗食管胃底静脉曲张破裂出血的护理风险管理

目的探讨急诊内镜治疗食管胃底静脉曲张破裂出血护理风险管理方法及应用效果。方法将201例食管胃底静脉曲张破裂出血患者按照时间顺序分组,2015年1~12月的93例设为实施前组,实施常规护理。2016年1~12月108例设为实施后组,应用医疗失效模式与效应分析(HFMEA)方法,分析急诊内镜治疗食管胃底静脉曲张破裂出血失效模式和潜在风险原因,计算优先风险数(RPN),对需要优先解决的问题进行干预,并对实施HFMEA前后的效果进行评价。结果实施HFMEA管理后,患者护理安全不良事件发生率显著低于实施前(均P<0.05),RPN下降。结论应用HFMEA能改进急诊内镜治疗食管胃底静脉曲张破裂出血的流程,降低围手术期患者护理安全不良事件风险率,保证患者安全。     

Surgical management of extrahepatic portal hypertension and variceal bleeding

Variceal bleeding remains an important complication in extrahepatic portal vein thrombosis (EPVT). As for portal hypertension due to other etiologies, an elective treatment to decrease the risk of subsequent rebleeding is warranted. The results of the Sugiura-Futagawa procedure (SP) in 38 patients with variceal bleeding secondary to EPVT are reported: 20 women and 18 men, with a mean age of 28±2 years (SEM). Thirty-seven patients were classified as Child-Pugh class A, and one patient as class B. In terms of diagnosis, 45% of patients had idiopathic EPVT, and 18% had associated hypercoagulability disorders; 52% of patients had associated splenic vein thrombosis. The SP was completed in two surgical stages in 18 patients and in one surgical stage in 14; 6 patients had only the abdominal stage. One patient had mild postoperative encephalopathy, and three patients rebled at long-term follow-up study. There were two operative deaths. Actuarial survival was 70% at 64 months. It is concluded that the SP is an excellent alternative for patients with variceal bleeding secondary to EPVT.

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Resumen La trombosis portal extrahepática sin patologia hepática asociada (TPEH) constituye alrededor del 7% de los casos de hipertensión portal en adultos, y es la causa más frecuente en el paciente pediátrico. Como en otros tipos de hipertensión portal, una de las más importantes complicaciones en pacientes con TPEH es la hemorragia varicosa, la cual requiere algún tipo de tratamiento electivo. Se informan los resultados de nuestra experiencia con el procedimiento de Sugiura-Futagawa (PSP) en 38 pacientes con hemorragia varicosa secundaria a TPEH. El grupo consiste en 20 mujeres y 18 hombres con edad promedio de 28±2 años; 37 pacientes fueron clasificados como Child-Pugh A y uno como B. Se diagnosticó TPEH en 40% de los casos y 18% presentaban alteraciones asociadas de hipercoagulabilidad; 40% presentó trombosis esplénica concomitante. El PSP fue realizado en dos etapas en 18 pacientes y en una en 14; en 6 pacientes se realizó la etapa abdominal solamente. Se registraron dos muertes operatorias. Una paciente presentó encefalopatía postoperatoria leve y tres pacientes desarrollaron sangrado en el seguimiento a largo plazo. La tasa actuarial de sobrevida fue de 70% a los 64 meses.Nuestra conclusión es que el PSP es una excelente alternativa para pacientes con hemorragia varicosa debida a TPEH.

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Résumé L'hémorragie par varices oesophagiennes est une complication importante de la thrombose porte extrahépatique (TPEH). Comme dans d'autres étiologies d'hypertension portale, un traitement électif, dans le but de prévenir la récidive hémorragique est souhaitable. Les résultats de l'intervention de Sugiura-Futagawa (SF) sont rapportés chez 38 patients ayant saigné en raison d'une TPEH. Il y avait 20 femmes, et 18 hommes dont l'âge moyen était de 28±2 ans (Erreur de la moyenne). Parmi eux, 37 était de grade Child-Pugh A, et 1, de grade Child-Pugh B. Quarante-cinq p. cent des patients avaient une TPEH idiopathique, associée dans 18% des cas à une hypercoagulabilité. Une thrombose de la veine splénque a été retroyvée chez 52% des patients. L'intervention de SF a été réalisée chez 18 patients en deux temps et chez 14 patients en un temps. Le temps abdominal n'a été réalisé que chez six patients. Il y a eu deux décès peropératoires, un cas d'encéphalopathie modérée et trois patients ont eu une récidive hémorragique. La survie actuarielle était de 70% à 64 mois. On conclue que l'intervention de SF est une excellente alternative chez le patient ayant présenté une hémorragie par rupture de varices oesophagiennes secondaire à une TPEH.

     

Has sclerotherapy altered the management of patients with variceal bleeding?

Sclerotherapy is currently the primary treatment of choice for the majority of patients who present with esophageal variceal bleeding. Although it has altered the management of these patients, unanswered questions and controversies remain. Patients with acute variceal bleeding should preferably be treated in a specialized center. The primary treatment should be immediate sclerotherapy, when possible. Portosystemic shunts and esophageal transection should be reserved for the 5% to 10% of patients in whom sclerotherapy fails to control acute bleeding. There are several treatment options for long-term management after a variceal bleeding episode. Sclerotherapy is one option and has become the primary treatment in most major centers. All patients with end-stage liver disease must be considered for liver transplantation, and sclerotherapy should be the primary method of treatment in those who are selected. Pharmacologic therapy remains controversial. I propose that portosystemic shunts and devascularization and transection operations be reserved for those few patients in whom sclerotherapy fails to eradicate the varices and to prevent recurrent variceal bleeding. Patients in whom sclerotherapy is unsuccessful should be identified and treated early.     

Recent advances in the management of erectile dysfunction

RecentadvancesinthemanagementoferectiledysfunctionSKrishnamurti(AndromedaAndrologyCenter,POBox1563,Hyderabad500082,India)overthepasttwodecades,ithasbecomeincreasinglyclearthatphysical(organic)factorspreponderateintheetiopathogenesisofmaleerectiledysfunction(MED).Researchhasfocusedonbothbasicandclinicalaspectsinanendeavortobetterunderstandcausalmechanismsandsubsequentlyevolveeffectivediagnosticandtherapeuticmodalitiesforthemanagementofthiscondition.Thecurrentstatusofourunderstandingofthesu…     

Recent advances in the management of Hirschsprung's disease

BACKGROUND: Major advances have occurred in the management of Hirschsprung's disease since Swenson described his definitive operation in 1948. These advances have occurred in the following areas: genetics, neurophysiology, definitive management in the newborn, total colonic aganglionosis (TCA), Hirschsprung's-associated enterocolitis (HAEC), intestinal neuronal dysplasia (IND), and laparoscopic and perineal approaches for definitive pull-through and redo pull-through operations. METHODS: This paper will focus on the definitive management of the newborn, TCA, and HAEC, areas in which we have had considerable experience at our institution. RESULTS: We have treated almost 90 newborns with the definitive pull-through with minimum morbidity. We have managed 25 patients with TCA, of whom 5 had total intestinal involvement and died. The remaining 20 have undergone a total colectomy and endorectal pull-through (ERPT), with zero mortality and a very acceptable stooling pattern and continence rate. Our experience with more than 350 patients with Hirschsprung's disease over the past 25 years has demonstrated an incidence of HAEC of between 20% and 30%. During this period, we have performed 19 redo pull-through operations, the majority of which were ERPTs, with results comparable with those seen with a primary pull-through operation. CONCLUSIONS: The major advances that have occurred in the management of Hirschsprung's disease include the definitive management of the newborn, our understanding of Hirschsprung's-associated enterocolitis and the treatment of this entity, and the recent successful management of the very complex form of this disease, total colonic aganglionosis.     

Recent advances in urinary stone management

The treatment of urolithiasis is one of the branches of urological surgery that has undergone great changes during the last decade. Since all the new modalities will soon be available to patients in this country an overview of the different treatments and overseas trends in urinary stone management is presented.     

Recent advances in airway management devices

As a variety of new airway devices has been introduced, the practice of airway management has seemingly become more complex. Among them laryngeal mask airway (LMA) is the single most important development in the past 10 years. It has become a commonly accepted device for routine and rescue airway management, and is now listed in the American Society of Anesthesiologists (ASA) Difficult Airway Management Algorithm as an airway and a conduit for tracheal intubation. The ASA Task Force on Management of the Difficult Airway recommends us to have a portable storage unit that contains specialized equipment including LMA for difficult airway management. This article focuses on several of the newly developed and the ordinary devices that are listed by the Task Force, with particular emphasis on the difficult airway. Recent information about standardization work of ISO for rigid laryngoscopes, tracheal tubes and supralaryngeal airway devices are also discussed. Each airway devices has unique properties that may be advantageous in certain situations but disadvantageous in others. Choice and combination of device based on experienced clinical judgment may be crucial to their application.