The results of the endoscopic diathermy coagulation of hemorrhaging gastroduodenal ulcers]

The authors analysed the results of endoscopic diathermy coagulation of bleeding acute gastroduodenal ulcers in 83 patients; in 47 of them the follow-up period ranged from 12 months to 9 years. A stable hemostatic effect was achieved in the early periods after coagulation of the acute ulcers in 76% of cases. The frequency of recurrent bleeding was found to be directly dependent on the degree of the blood loss. Recurrent bleeding from acute ulcerations of the gastric mucosa in the late-term period was discovered authentically in only one patient. It was linked with medication with brufen for a long duration. Thus, endoscopic diathermy coagulation produced good results in arresting bleeding from acute gastroduodenal ulcers, particularly in patients with a very high operative risk.     

Laser probe coagulation of bleeding canine ulcers

A nonlight-transmitting contact laser probe was used to treat acutely bleeding gastric ulcers in heparinized dogs. Thirty-five treated ulcers responded with complete hemostasis following 21-92 seconds (mean, 32 seconds) application per ulcer. Ten control ulcers left untreated bled for 5-30 minutes (mean, 11 minutes). Hemostasis was maintained at treated sites for the entire observation period (60 minutes). Perforations did not occur, and there was no evidence of full thickness injury. Histological assessment confirmed a limited (0.2-0.5 mm) zone of coagulation injury. The laser probe is effective for control of acute bleeding in this canine ulcer model.     

The role of gastrectomy in the treatment of hemorrhaging stomach ulcers

It is reported about 6 patients whose bleeding gastric ulcers required gastrectomy as ultima ratio. The operative technique depends on the individual case. Gastrectomy is indicated in patients with diffuse bleeding from erosions or multiple ulcers especially combined to coagulation disorders or in patients with recurrence bleeding after previous gastric resection. We saw no letal complication in spite of unfavourable initial conditions and major operating trauma. There were no essential postoperative complications except of one patient. The definite hemostasis seems to be most important for the prognosis of such critically ill patients.     

改良壁细胞迷走神经切断术治疗十二指肠溃疡穿孔45例体会

目的　探索治疗十二指肠溃疡穿孔简捷、有效的手术方法。方法　自 1993～ 1996年对壁细胞迷走神经切断术进行改良 ,手术不游离食道下段、不显露迷走神经、不分离切断胃大弯近侧网膜及胃底血管 ,对胃底浆肌层仅作部分切开 ,以此法治疗十二指肠溃疡穿孔 45例。结果　应用此法 (改良壁细胞迷走神经切断术 )使手术难度降低 ,手术时间缩短 ,适应范围扩大。 45例平均随访34 6个月 ,VisickⅠ、Ⅱ 41例 (41/ 45 ,91% )。基础胃酸排量 (basalacidoutput,BAO) (4 1± 2 1)mmol/h ,最高胃酸分泌量 (maximalacidoutput,MAO) (16± 6 )mmol/h ,溃疡复发 3例 (3/ 35 ,9% )。结论　改良壁细胞迷走神经切断术是治疗十二指肠溃疡穿孔的合理方法 ,对穿孔时间较长及老龄病人尤为适宜。     

The place of endoscopic treatment in hemorrhagic ulcers

INJECTIONS OF ADRENALINE: More than one third of upper gastrointestinal haemorrhages are still of ulcerous origin. In the case of active bleeding ulcers or ulcers with non-haemorrhagic visible vessels, endoscopy should be performed to stop bleeding. Injections of adrenaline, which combine efficacy, simplicity and absence of morbidity represent the treatment of choice for many. THE USE OF THERMAL METHODS: Spurting haemorrhages are probably the only haemorrhages that would benefit from injections of adrenaline combined with another haemostatic method, notably thermal. THE NEED FOR ASSOCIATED MEDICAL TREATMENT: Whatever the haemostatic method used, a powerful anti-secretory treatment administered intravenously must be associated since it will enhance the effects of endoscopic treatment.     

Laparoscopic and endoscopic management of perforated duodenal ulcers

BACKGROUND: Acid peptic perforation of the duodenum remains a surgical challenge. Plication alone may be satisfactory management if the ulcer diathesis is medically controlled. Laparoscopic management for plication has been safely applied in a variety of populations. This study assessed a combination of endoscopy and laparoscopy to manage early duodenal perforation. STUDY DESIGN: Forty-two patients with early (less than 12 hours) perforation were managed by laparoscopic plication and lavage. Endoscopy identified the site of perforation and guided repair in 35 of 42. All patients were followed with Helicobacter pylori treatment and examined by endoscopy at 3 months. Forty case control patients who had open procedures for duodenal perforation were evaluated for comparison. RESULTS: Endoscopic/laparoscopic management was completely effective and compared favorably with open procedures with regard to surgical time and complications. Endoscopic snaring of omentum and pulling into the defect proved to be an effective adjunct for plication. CONCLUSIONS: Endoscopic/laparoscopic repair of perforated duodenal ulcers is a safe and effective surgical tactic if followed by treatment for Helicobacter pylori.     

Safety of argon plasma coagulation for hemostasis during endoscopic mucosal resection

Showing the safety of argon plasma coagulation (APC) over mucosal defects during/after endoscopic mucosal resection (EMR), 2 studies using resected pig (ex vivo) and living minipig (in vivo) stomachs were performed. As an ex vivo study, APC was applied over mucosal defects in 2 groups; with prior submucosal saline injection and without injection. Only subtle tissue damage was observed in the injection group, whereas apparent damage was observed in the noninjection group. The damaged distances in depth significantly increased as the pulse duration increased and those at the pulse duration of 4 seconds, which might be maximal in clinical practice, were approximately 1 mm. As an in vivo study, APC was applied over mucosal defects immediately after EMR. Only subtle tissue damage was observed even at the pulse duration of 20 seconds as shown in the ex vivo study. APC can be performed safely over the mucosal defects during/after EMR.     

Novel endoscopic delivery modality of infrared coagulation therapy for internal hemorrhoids

Background

A novel endoscopic delivery system for infrared coagulation therapy (IRC) has been designed recently. IRC is a well-established treatment for symptomatic internal hemorrhoids. Patients frequently undergo lower endoscopy before hemorrhoid treatment to eliminate other sources of bleeding. Current treatment options are difficult to perform without an anal retractor, adequate lighting, and specialized instruments. Endoscopic IRC is an attractive alternative to standard IRC, because it can be performed during the lower endoscopy.

Technique

Endoscopic IRC utilizes infrared radiation generated by a control box, which is applied to the tissue through a flexible, fiber optic light guide (Precision Endoscopic Infrared Coagulator?). The light guide is placed through the colonoscope or flexible sigmoidoscope in the same chamber as other endoscopic instruments.

Methods

A retrospective review was performed using a prospectively collected database. A standardized protocol was utilized in all patients. Patients graded their symptoms before and after therapy by using the visual analog symptom severity scoring system (range, 0–10). These results were analyzed by using the nonparametric Wilcoxon signed-rank test. Exact P values were computed by using the R function wilcox.exact.

Results

A total of 55 patients underwent endoscopic IRC for predominately grade II and grade III symptomatic internal hemorrhoids (71?%). There were 22 (40?%) female patients. Posttherapy results indicated a significant improvement in global symptoms (pretreatment average global score?=?2.24 vs. posttreatment average global score?=?0.28; P?<?0.0001). There have been no adverse events reported to date.

Conclusions

Endoscopic IRC provides improved visibility and efficiency, allowing simultaneous treatment of symptomatic internal hemorrhoids at the time of lower endoscopy. Patients experienced significant improvement in their symptoms after a single session of endoscopic IRC. There are a variety of additional endoscopic IRC therapeutic utilities: endoscopic management of angiodysplasia, inflammation, hemostasis, and NOTES applications.     

Modified extraperitoneal endoscopic separation of parts for abdominal compartment syndrome

Background Standard therapy for abdominal compartment syndrome (ACS) is laparotomy and temporary abdominal wall closure with significant morbidity. The component separation technique allows for difficult abdominal closure. We studied a modified extraperitoneal endoscopic separation of parts technique on an animal model of ACS. Methods Twelve anesthetized pigs were instrumented for measurement of central venous pressure, arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, and intraabdominal pressure (IAP). ACS to 25 mmHg was created by infusing saline into an intraabdominally placed bag. Animals were divided in two equal groups. Pigs in group A underwent minimally invasive resection of the nerves supplying the rectus muscles bilaterally. Pigs in group B underwent minimally invasive modified component separation technique bilaterally. Change in IAP and other physiological parameters were recorded. Results (Group A) IAP increased significantly from 7.3 mmHg ± 3.8 to 25.2 mmHg ± 1.5 with infusion of saline. Following nerve transection on the right side there was a nonsignificant decrease in IAP from 25.2 mmHg ± 1.5 to 22.3 mmHg ± 1.4 and following nerve transection on the left side there was a further decrease in IAP to 20.3 mmHg ± 1.9. (Group B) IAP increased significantly from 3.8 mmHg ± 0.4 to 24.7 mmHg ± 0.5 with infusion of saline. Following separation of parts on the right side there was a significant decrease in IAP from 24.7 mmHg ± 0.5 to 15.0 mmHg ± 1.7 and there was a further decrease in IAP to 11.3 mmHg ± 1.4 following separation of parts on the left side. The only significant change in the physiological parameters measured was observed in CVP in both groups. Conclusion We present a porcine model of extraperitoneal endoscopic release of abdominal wall components as a treatment option for ACS. Podium presentation at the 2004 meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Denver, CO, USA, 31 March–3 April 2004     

Controlled trial of heater probe treatment in bleeding peptic ulcers

A prospective randomized controlled trial of endoscopic heater probe therapy in bleeding peptic ulcers was performed to determine whether probe therapy can reduce rebleeding rates. Of 630 patients endoscoped for suspected upper gastrointestinal haemorrhage over a 16-month period, 166 (26 per cent) were found to have a peptic ulcer. Either minor or no stigmata of recent haemorrhage were found in 115 patients at the time of endoscopy. A single peptic ulcer with either active haemorrhage or a visible vessel was found in 51 patients, 43 of whom were entered into the trial. There were eight exclusions: four were inaccessible, one was a torrential haemorrhage and three were excluded for non-technical reasons. Patients were randomized to receive either heater probe (n = 20) or sham (n = 23) therapy. In actively bleeding ulcers, immediate haemostasis was achieved following probe therapy in 14 of 18 patients (78 per cent) compared with none of 21 having sham treatment (P less than 0.002). No rebleeding occurred in the probe therapy group (n = 20) compared with rebleeding in five of 23 sham treated patients (P = 0.05). Urgent surgery for haemostasis was required in three of the five sham treated patients who rebled. It is concluded that heater probe therapy may be effective in reducing rebleeding rates in peptic ulcers accessible to the endoscope.