Topical Formalin for Management of Bleeding Malignant Ulcers

Hemorrhage, an infrequent but serious complication of malignant ulceration, can be difficult to manage. Although many methods exist for treatment, none is wholly satisfactory. The use of topical formalin was studied in a group of patients with bleeding from malignant ulcers, and the results show that the agent achieved control of bleeding in 86% of the patients after two applications. There were no significant complications arising from the treatment. Topical formalin is a safe, inexpensive, effective agent for control of bleeding from malignant ulcers.     

Percutaneous Endoscopic Treatment of Bleeding Gastric Ulcers

Bleeding gastric ulcers have a propensity to occur in the critically ill and elderly. Various treatments include endoscopic or surgical intervention. The endoscopic route may have as high as a 25 percent rebleeding rate and a 50 to 90 percent rebleeding rate if there is a visible vessel. Surgical intervention has a mortality rate of as high as 25 percent. Described is a procedure which combines endoscopic and surgical techniques for the treatment of bleeding gastric ulcers - the percutaneous endoscopic method.To evaluate the technique and efficacy of this procedure, a bleeding ulcer was created in a porcine stomach with multiple applications of standard biopsy forceps. After brisk hemorrhage developed, the percutaneous endoscopic method was employed and cessation of bleeding obtained.The entire procedure was completed within 20 minutes. There were no immediate complications. Overall costs were much less than those for routine general surgery and about the same as for placement of percutaneous gastrostomy tube.     

Surgical Management of Life Threatening Bleeding after Endoscopic Cystogastrostomy

ABSTRACT

Postprocedural bleeding is a rare but life threatening complication of endoscopic cystogastrostomy which may require surgical management in some patients. The presence of adhesions and inflammation due to antecedent acute pancreatitis, difficult location of the bleeding site and breach in the posterior wall of stomach pose significant challenges during the surgical management. Here we have described the surgical approach and technique that we used to manage three patients who required surgery for life threatening bleeding after endoscopic cystogastrostomy.     

Surgical Management of Acute Perforation of Peptic Ulcers. A Single Centre Experience

Introduction : Acute perforation may occur in gastric and duodenal ulcers. During the past decade, the need for elective operation for peptic ulceration has decreased as medical treatment has improved. However, emergency operations for acute complications such as perforation or bleeding remain constant. Actually, the treatment of choice is simple suture-closure, with or without omentoplasty, and peritoneal lavage or even omentoplasty alone, associated with a high intravenous dose of inhibitors of the proton pump and Helicobacter pylori eradication, if needed. Patients and method : The standard treatment in our team is to perform a peritoneal lavage and drainage and a simple closure of the ulcer with an omentoplasty. A first retrospective analysis was made on data collected from 1996 to 2001 and we completed a prospective study from 2001 to 2003 to compare our results with our old data and with data collected from other teams.

Results : The mean age and the mean ASA score were similar in the two groups. For the majority of the patients, the diagnosis was made from symptoms and the presence of free abdominal air. The delay between arrival in the emergency room and the operating room was significantly shorter in the second group, but operating time was longer in this group. Morbidity was more frequent in the first group but mortality remained quite similar.

Our results indicate that in a trained team the morbidity has decreased as the delay in surgery decreased and that the rate of diagnosis on plain abdominal film has increased. Laparoscopic suture of a perforated peptic ulcer is as safe as the open procedure but allows the surgeon to search for another cause of free air and offers the possibility, if conversion is needed, to perform a shorter laparotomy.     

Plasma Gastrin Activity and the Diagnosis of Bleeding Abomasal Ulcers in Cattle

The present study was designed to evaluate the usefulness of plasma gastrin determinations as a diagnostic aid and to review the clinical and haematological findings in cattle with bleeding abomasal ulcers. Twenty‐nine cows with bleeding abomasal ulcers and six healthy cows were used. Clinical and laboratory examinations, including plasma gastrin levels, were performed. Anorexia, depression, dark‐coloured to black faeces, pale mucous membranes, abdominal pain, moderate tachycardia and tachypnoea were the most pronounced clinical symptoms in the cattle with bleeding abomasal ulcers. Plasma gastrin concentration was significantly higher (P < 0.05) in the cattle with bleeding abomasal ulcers than in healthy cows. The mean plasma gastrin concentration in healthy cattle was 103.2 pg/ml, while the mean plasma gastrin concentrations in cattle with bleeding abomasal ulcers were found to be 213.6 pg/ml. Haemoglobin levels, packed cell volume, total white blood cell count and mean corpuscular volume were significantly lower (P < 0.05) in the cows with bleeding abomasal ulcer than in the healthy cattle. The results of this study show that measurement of plasma gastrin can be useful in the diagnosis of bleeding abomasal ulcers in cattle.     

Surgical Treatment of Complicated Duodenal Ulcers: Controlled Trials

Indications for surgery of duodenal ulcer (DU) have changed radically because of the efficacy of H₂-antagonists, endoscopic procedures, and eradication of Helicobacter pylorus. The aim of this study was to analyze the current literature to determine if definitive surgery is still relevant for complicated DU (bleeding, perforation, gastric outlet obstruction). Two studies have compared early to late surgery in terms of bleeding. One recommended early surgery (significant reduction in mortality) in the elderly, but no statistically significant difference was found when analyzed with “intention to treat.” In the other, mortality with early surgery was five times higher than with expectant therapy (when it was possible). Two studies comparing different surgical techniques for bleeding favored the radical procedure. Of at least 15 studies comparing endoscopic treatments, however, none has compared endoscopic therapy to surgical intervention for bleeding DU. One trial, comparing nonoperative to surgical treatment for perforation, found similar rates of morbidity, intraabdominal abscess, and mortality; but the hospital stay was longer (p < 0.001). Nonoperative treatment failed more often (p < 0.05) in patients over age 70. In three trials, postoperative morbidity (excepting wound sepsis in one) was not significantly increased by definitive surgery, with less ulcer recurrence (p < 0.05) compared with simple closure. Laparoscopy (versus laparotomy) was shown to take longer (p < 0.001) but required less postoperative analgesics (p < 0.03); there were no statistically significant differences as concerns the duration of nasogastric aspiration, intravenous drips, hospital stay, time to resume normal diet, Visual Analogous Scale pain scores for the first 24 hours after surgery, morbidity, reoperation rate, or mortality. Of 48 laparoscopic patients, 11 (23%) underwent conversion to open surgery. Three surgical techniques [highly selective vagotomy (HSU) + gastrojejunostomy (group 1), HSV + Jaboulay gastroduodenostomy (group 2), or selective vagotomy (group 3) + antrectomy) for gastric outlet obstruction (GOO)] showed that although postoperative results were similar (except wound sepsis in one trial), long-term Visick scores were significantly (p < 0.01) better in group 1 than in group 2, but not in group 3. Further studies are needed to determine the exact prevalence of Helicobacter pylori in complicated DU and to compare (1) definitive to minimal surgery (stop the bleeding or close the perforation) combined with antisecretory drugs and eradication of H. pylori; (2) surgery to endoscopic treatment combined with eradication of H. pylori; and (3) for GOO, surgery to balloon dilatation combined with eradication of H. pylori.     

Dermal Regeneration Template in the Surgical Management of Diabetic Foot Ulcers: A Series of Five Cases

Soft-tissue defects in the feet of patients with diabetes continue to pose a challenge because adequate debridement often leaves an extensive defect with exposed bone, tendon, and cartilage. The use of a dermal regeneration template followed by split-thickness skin grafts in the treatment of recalcitrant diabetic foot wounds was retrospectively reviewed. In a case series of 5 patients with diabetes and extensive tissue deficits of the foot, the use of a dermal regeneration template and split-thickness skin graft enabled closure of the lower-extremity defect. All patients completely healed and were able to resume ambulation with the aid of extradepth shoes and multidensity insoles. The take of the dermal regeneration template was excellent in all patients, and the grafts (dermal regeneration templates and split-thickness skin) were durable even when placed on difficult areas such as the plantar surface and heel. No infections occurred. Exposed bone, tendon, cartilage, and fascia were successfully covered. The experience in this case series suggests that the use of the dermal regeneration template followed by split-thickness skin graft offers an option for patients with diabetes with chronic wounds that have foot defects as a result of extensive tissue loss resulting from infection.     

Experimental Study of Laser Photocoagulation in the Treatment of Bleeding Canine Gastric Ulcers

We report experimental results obtained by laser photocoagulation on hemorrhagic lesions induced in dogs. The aims of this study were 1) to evaluate the real efficiency of the YAG laser to ensure hemostasis of briskly bleeding lesions; 2) to determine the minimum energy density necessary to ensure hemostasis; 3) to assess the damage depth inside the gastric wall after photocoagulation; 4) to compare reepithelialization of treated ulcers with that of control ulcers; 5) to evaluate the safety margin for the clinical use of the YAG laser.     

Surgical Management of Pressure Ulcers During Inpatient Neurologic Rehabilitation: Outcomes for Patients With Spinal Cord Disease

Background/Objective:

To study efficacy of surgery in the management of pressure ulcers and evaluate the effect of simultaneous comprehensive rehabilitation in improving outcome.

Method:

Prospective, follow-up study.

Setting:

Neurologic rehabilitation unit of a tertiary care center.

Participants:

Patients with spinal cord diseases who had stage III/IV pressure ulcers underwent surgical reconstruction and inpatient rehabilitation in 2005 with a minimum follow-up duration of 1 year.

Outcome Measures:

Ulcer healing rate, postoperative complications, ulcers recurrence rate, and neurologic (ASIA grade), and functional recovery (Barthel Index).

Statistical Analysis:

Frequency analysis and paired t test on SPSS 13.0.

Results:

Surgical intervention was carried out in 25 participants (19 men, 6 women), having a total of 39 ulcers (13 Stage III, 23 Stage IV, 3 unstaged). Surgeries performed were debridement (3), split skin grafting (13), and flap mobilization and closure (23). Only 4 participants (16.6%) had initial complications: wound dehiscence (2) and delayed graft healing (2). Follow-up rate was 92.0% (23/25 patients), with a duration of 12 to 21 months (mean, 15.4 ± 7.45 months), and only 4 participants (17.3%) had ulcer recurrence. The majority of participants (13 of 25; 56.5%) improved neurologically on ASIA grade and functional evaluation on Barthel Index, suggesting statistically significant improvement (P < 0.005).

Conclusions:

All outcome variables showed significant improvement at follow-up with good ulcer healing rate (87.0%), low initial complication (16.6%) and recurrence rates (17.3%), and good neurologic (56.5%) and functional (P < 0.005) recovery. Timely surgical interventions are necessary for Stage III to IV pressure ulcers, and simultaneous inpatient rehabilitation significantly improves outcome of patients with spinal cord disease.     

Surgical Management of Pressure Ulcers During Inpatient Neurologic Rehabilitation: Outcomes for Patients With Spinal Cord Disease

Background/Objective: To study efficacy of surgery in the management of pressure ulcers and evaluate the effect of simultaneous comprehensive rehabilitation in improving outcome.

Method: Prospective, follow-up study.

Setting: Neurologic rehabilitation unit of a tertiary care center.

Participants: Patients with spinal cord diseases who had stage lll/IV pressure ulcers underwent surgical reconstruction and inpatient rehabilitation in 2005 with a minimum follow-up duration of 1year. Outcome Measures: Ulcer healing rate, postoperative complications, ulcers recurrence rate, and neurologic (ASIA grade), and functional recovery (Barthel Index).

Statistical Analysis: Frequency analysis and paired t test on SPSS 13.0.

Results: Surgical intervention was carried out in 25 participants (19 men, 6 women), having a total of 39 ulcers (13 Stage III, 23 Stage IV, 3 unstaged). Surgeries performed were debridement (3), split skin grafting (13), and flap mobilization and closure (23). Only 4 participants (16.6%) had initial complications: wound dehiscence (2) and delayed graft healing (2). Follow-up rate was 92.0% (23/25 patients), with a duration of 12 to 21 months (mean, 15.4 ± 7.45 months), and only 4 participants (17.3%) had ulcer recurrence. The majority of participants (13 of 25; 56.5%) improved neurologically on ASIA grade and functional evaluation on Barthel Index, suggesting statistically significant improvement (P < 0.005).

Conclusions: All outcome variables showed significant improvement at follow-up with good ulcer healing rate (87.0%), low initial complication (16.6%) and recurrence rates (17.3%), and good neurologic (56.5%) and functional (P < 0.005) recovery. Timely surgical interventions are necessary for Stage III to IV pressure ulcers, and simultaneous inpatient rehabilitation significantly improves outcome of patients with spinal cord disease.     

护理会诊在压疮管理中的应用

目的 对压疮护理进行规范化管理,降低压疮发生率,提高已发生压疮的治愈率.方法 于2006年在压疮管理制度的基础上,建立压疮护理会诊制度,选拔合适的会诊人员,确立会诊范围及职责,规定护理会诊时间及程序,考评压疮护理质量.结果 实施后住院患者压疮发生率显著降低,已发生压疮的治愈率显著提高(P＜0.05,P＜0.01).结论 压疮护理会诊制度的建立,提高了压疮护理质量,能有效降低住院患者压疮的发生,提高压疮治愈率.     

Management of Peptic Ulcers: Emerging Issues

Most peptic ulcers are caused by Helicobacter pylori infection. The infection is best diagnosed by a radiolabeled carbon urea breath test, which also can prove that eradication therapy was successful. Serologic testing is useful for establishing prior or present infection but not to determine if the infection has been eradicated. Endoscopic tests usually are not needed to establish a diagnosis. Modern ulcer treatment consists of H. pylori eradication in infected patients. A combination of a proton pump inhibitor plus clarithromycin and amoxicillin or a proton pump inhibitor plus bismuth, metronidazole, and tetracycline are the most effective regimens. Reinfection is less than 2% per year in developed countries. Evidence suggests that H. pylori eradication may foster the development of erosive esophagitis, but confirmatory studies are needed. Studies also suggest an interaction between H. pylori infection and peptic ulcers related to the use of nonsteroidal antiinflammatory drugs (NSAIDs). However, the studies are conflicting: One shows that H. pylori eradication protects against NSAID-related ulcers; another suggests protection afforded by the infection. Non-H. pylori peptic ulcers remain a challenge, especially in the United States, where one study showed that 42% of peptic ulcers were not due to the infection. Some non-H. pylori ulcers are refractory to usual doses of antisecretory drugs.     

Octreotide in the Control of Post-Sclerotherapy Bleeding from Oesophageal Varices,Ulcers and Oesophagitis

Bleeding from oesophageal varices, oesophageal ulcers or oesophagitis is occasionally massive and difficult to control. Octreotide, a synthetic analogue of somatostin lowers portal pressure and collateral blood flow including that through varices, increases lower oesophageal sphincter pressure, and inhibits the gastric secretion of acid as well as pepsin. Our current experience suggests it is effective in controlling acute variceal haemorrhage. Therefore we have examined the efficacy of octreotide in the control of postsclerotherapy bleeding from oesophageal varices, oesophageal ulcers and oesophagitis. During the study period 77 patients experienced a significant gastrointestinal bleed (blood pressure < 100 mm Hg, pulse > 100 beats per min or the need to transfuse 2 or more units of blood to restore the haemoglobin level) following injection sclerotherapy of oesophageal varices. The source of bleeding was varices in 42 patients, oesophageal ulcers in 31 and oesophagitis in 4. All patients received a continuous intravenous infusion of octreotide (50 μg/h) for between 40–140h. If bleeding was not controlled in the first 12h after commencing octreotide hourly bolus doses (50 μg) for 24h were superimposed on the continuous infusion. Haemorrhage was successfully controlled by an infusion of octreotide in 38 of the 42 patients with bleeding from varices, in 30 of 31 patients with oesophageal ulceration, and all patients with oesophagitis. In the 1 patient with persistent bleeding from oesophageal ulceration and in 2 of the 4 with continued haemorrhage from varices, haemostasis was achieved by hourly boluses of 50 μg octreotide for 24h in addition to the continuous infusion. No major complications were associated with octreotide administration. The results of this study clearly indicate that octreotide is a safe and effective treatment for the control of severe haemorrhage after technically successful injection sclerotherapy.