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1.
From a retrospective review of 156 patients with actively bleeding peptic ulcers, 61 patients had gastric ulcers and 95 patients had duodenal ulcers. Patients presented with hematemesis or melena or a combination of the two. Forty patients with gastric ulcers and 53 patients with duodenal ulcers were in shock. Twenty-five patients with gastric ulcers underwent surgery. Bleeding was controlled in all patients, but in the postoperative period five patients died of myocardial infarction, pulmonary embolism or septic multisystem organ failure. Of 36 patients who underwent endoscopic epinephrine sclerosis of the bleeding gastric ulcer, hemorrhage was controlled in 34. Two patients required reoperation for bleeding after surgery; both survived. Fifty patients with duodenal ulcers had surgery. Bleeding was controlled in all patients, but in the postoperative period 10 died of myocardial infarction and multisystem organ failure. Of 45 patients who underwent endoscopic sclerosis, bleeding was controlled in 40. Five patients required reoperation for bleeding after surgery; all survived. The authors conclude that endoscopic sclerosis should be the initial treatment for actively bleeding gastric and duodenal ulcers. If bleeding continues or recurs then surgery should be carried out. 相似文献
2.
Background: More should be known about the spectrum of endoscopic abnormalities and treatments in patients with upper gastrointestinal
(UGI) symptoms after laparoscopic bariatric surgery. Methods: Patients referred for endoscopic evaluation of UGI symptoms
after laparoscopic bariatric surgery were studied. Clinical manifestations, endoscopic findings and therapy were recorded
and correlated. Results: 76 patients who had undergone laparoscopic vertical banded gastroplasty (LVBG) and 28 who had undergone
laparoscopic Roux-en-Y gastric bypass (LRYGBP) underwent 160 instances of upper endoscopy. The symptoms included nausea or
vomiting (n=47, 29.4%), epigastric discomfort (n=44, 27.5%), UGI bleeding (n=26, 16.3%), heartburn or acid regurgitation (n=26,
16.3%), dysphagia (n=10, 6.3%) and anemia with dizziness (n=7, 4.4%). The endoscopic diagnosis consisted of normal findings
(n=57, 35.6%), marginal ulcer (n=39, 24.4%), erosive esophagitis or esophageal ulcer (n=21, 13.1%), food impaction (n=21,
13.1%), stenosis or stricture (n=14, 8.8%), gastric ulcer (n=7, 4.4%), and duodenal ulcer (n=1, 0.6%). Patients with UGI bleeding,
dysphagia and LRYGBP tended to have endoscopic abnormalities (P<0.001, P=0.09 and P=0.021, respectively). Endoscopic therapy was successful in resolving the complications including stenosis, UGI bleeding and
food impaction. Conclusions: Endoscopy is an essential method of combining relevant endoscopic findings and therapeutic intervention
in symptomatic patients following laparoscopic bariatric surgery. 相似文献
3.
Bleeding continues to be a significant cause of morbidity and mortality for patients with peptic ulcer disease. Recent advances have changed the management of this disease. Upper endoscopy with or without endoscopic therapy is the preferred procedure during the initial evaluation of upper gastrointestinal bleeding. With its excellent success rates, many patients are being cured with endoscopic therapy followed by eradication of Helicobacter pylori. H. pylori is now thought to have an important role in the pathogenesis of a majority of gastric and duodenal ulcers. This finding has led to the recommendation that patients with peptic ulcer disease be treated with regimens effective against this organism. Currently, patients who are older and who have more severe underlying medical conditions present a challenge. This review will address the options for treatment of peptic ulcer bleeding. In addition, knowledge gained regarding H. pylori infection and use of nonsteroidal anti-inflammatory drugs will be discussed. 相似文献
4.
Ertekin C Yanar H Taviloglu K Guloglu R Alimoglu O 《Journal of laparoendoscopic & advanced surgical techniques. Part A》2004,14(3):147-152
BACKGROUND: Gastroduodenal ulcers are still a common cause of severe upper gastrointestinal bleeding. Endoscopy has gained popularity worldwide over conventional open surgery for the treatment of upper gastrointestinal bleeding. This study aims to assess the efficacy of endoscopic injection of epinephrine in the treatment of gastroduodenal ulcer bleeding. METHODS: This study was conducted between March 2000 and March 2003. We analyzed 107 consecutive patients admitted to our department of trauma and emergency surgery with upper gastrointestinal bleeding. Endoscopy was performed on all 107 patients and bleeding ulcers were treated with injection of diluted epinephrine. RESULTS: Recurrent bleeding was seen in 21 patients (19.6%), all of whom underwent a second endoscopy. Four patients (3.7%) required a third endoscopy session and nine patients (8.5%) needed surgery after endoscopy failed. There were two mortalities (1.9%). The nine patients who required surgery and the two patients who died were all in the Forrest Ia and Ib groups of acute UGI hemorrhage. DISCUSSION: Endoscopic injection therapy with epinephrine reduces operation rates and can be used safely in adequate hemostasis of gastroduodenal ulcers. 相似文献
5.
Results of treatment of 827 patients with bleedings from chronic gastric and duodenal ulcers are analyzed. Potentialities of various methods of endoscopic hemostasis were studied. Diathermocoagulation was the least effective method of hemostasis (59%). Irrigation of the bleeding source provided hemostasis in 88.7% patients, combined methods - in 94.1%. Methods of irrigation are appropriate in diffuse bleeding from ulcer (Forrest 1B). Stream bleeding (Forrest 1A) is indication for combined methods of hemostasis. It is demonstrated that type of endoscopic procedure does not influence rate of bleeding recurrences. The main element of conservative treatment of gastroduodenal ulcerous bleedings is antisecretory therapy. Proton pump blockers are more effective than H2-blockers; the rate of recurrences was 5.0 and 28.9%, respectively. Prediction of bleeding recurrences and preventive operations are the main way to treatment results improvement. 相似文献
6.
This study was undertaken to assess the role of fibrin sealant in achieving early hemostasis and wound healing following endoscopic injection in peptic ulcer hemorrhage. In an experimental study in Wistar-rats we looked at the healing rate and histological changes of laser-induced acute gastric ulcers and acetic acid-induced chronic gastric ulcers following injection of standard sclerosants as well as fibrin sealant. A statistically favourable result was observed in the fibrin treated group. We also treated 127 patients suffering from bleeding peptic ulcers with local injection of fibrin sealant (33 Forrest stage la, 40 Forrest lb, 54 Forrest Ila) in a prospective clinical trial during the period of 1. February 1988 to 31. January 1991. A primary recurrence was noticed in 19 (14.9%) patients. With a 2. injection the hemostasis was definite in 116 of 127 patients (91.3%). Only 11 patients (8.6%) needed surgery for hemostasis. The mortality was 6.3% (8 patients). 相似文献
7.
Laser photocoagulation of bleeding ulcer is one of the effective methods of endoscopic hemostasis. Experimental studies were carried out on resected stomach preparation. The preparations were studied histologically. Clinical trial was conducted in 43 patients with gastric and duodenal ulcer for hemostasis and prophylaxis of recurrent bleeding. Initial endoscopic hemostasis was successful in all the patients. Relapse of bleeding was seen in 4 patients. Overall efficacy of laser hemostasis was 90.7%. It is concluded that laser photocoagulation is one of effective and convenient methods of endoscopic hemostasis. 相似文献
8.
Korolev MP Fedotov LE Antipova MV Pavlova EA 《Vestnik khirurgii imeni I. I. Grekova》2006,165(6):47-50
The authors have analyzed their experiences with treatment of 61 patients using the method of endoscopic clipping: 24 of them had the source of bleeding in chronic ulcers of the duodenal bulb, 6 had chronic gastric ulcers, 15 had acute gastric ulcers, 2 had acute ulcers of the duodenal bulb, Mallory-Weiss syndrome was found in 2 patients, Dieulafoy syndrome in 10 patients and one patient had peptic ulcer of the gastro-entero-anastomosis. The endoscopic clipping was made in 11 patients, in 31 patients injections of adrenaline and coagulation were added, in 9 patients--coagulation only, in 2 patients--irrigation with caproferon, in 8--adrenaline injections. In 57 out of 61 patients reliable hemostasis was achieved. 相似文献
9.
Surgical management of peptic ulcer disease today – indication, technique and outcome 总被引:1,自引:1,他引:0
T. T. Zittel E. C. Jehle H. D. Becker 《Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie》2000,385(2):84-96
Aims: The current surgical management of peptic ulcer disease and its outcome have been reviewed. Results: Today, surgery for peptic ulcer disease is largely restricted to the treatment of complications. In peptic ulcer perforation,
a conservative treatment trial can be given in selected cases. If laparotomy is necessary, simple closure is sufficient in
the large majority of cases, and definitive ulcer surgery to reduce gastric acid secretion is no longer justified in these
patients. Laparoscopic surgery for perforated peptic ulcer has failed to prove to be a significant advantage over open surgery.
In bleeding peptic ulcers, definitive hemostasis can be achieved by endoscopic treatment in more than 90% of cases. In 1–2%
of cases, immediate emergency surgery is necessary. Some ulcers have a high risk of re-bleeding, and early elective surgery
might be advisable. Surgical bleeding control can be achieved by direct suture and extraluminal ligation of the gastroduodenal
artery or by gastric resection. Benign gastric outlet obstruction can be controlled by endoscopic balloon dilatation in 70%
of cases, but gastrojejunostomy or gastric resection are necessary in about 30% of cases. Conclusions: Elective surgery for peptic ulcer disease has been largely abandoned, and bleeding or obstructing ulcers can be managed safely
by endoscopic treatment in most cases. However, surgeons will continue to encounter patients with peptic ulcer disease for
emergency surgery. Currently, laparoscopic surgery has no proven advantage in peptic ulcer surgery.
Received: 11 January 2000 Accepted: 12 January 2000 相似文献
10.
Bleeding duodenal and gastric ulcers continue to be a common and serious problem. Definition of the precise appearance and location of the ulcer by endoscopy gives important information about the source of bleeding and additional information about the risk of rebleeding and the indications for surgery. Several endoscopic hemostatic methods are available. The nonerosive contact probes (heater and BICAP) are preferred. Injection therapy with vasoconstrictors or sclerosing agents can also be recommended as a safe, efficacious, and economical means of treatment. Several hemostatic modalities should be available for use depending on the anatomic location and type of bleeding ulcers. The collaboration of skilled interventional endoscopists with their traditional surgical colleagues offers the patient with bleeding peptic ulcer disease the optimum probability of a successful outcome, with minimum treatment-associated morbidity. 相似文献
11.
de Manzoni G Ruzzenente A Pachera S Festini M Zerman G Guglielmi A Catalano F Rodella L 《Chirurgia italiana》2001,53(6):783-791
The aim of this study was to investigate the effects of endoscopic injection therapy on the clinical outcome of patients with gastric ulcer bleeding. Seven hundred and seventy-five patients with gastric ulcer bleeding were observed over a 10-year period (January 1990 to May 2000) in the First Division of General Surgery of the University of Verona. The prognostic and therapeutic implications of endoscopic treatment of acute severe gastrointestinal bleeding were analyzed on the basis of medical history and clinical and endoscopic findings. The ulcers were classified according to Forrest's classification of bleeding activity. Endoscopic therapy was performed in 500 patients with active bleeding. Haemostasis was initially obtained in all patients except one. Rebleeding occurred in 13%. All these patients were treated endoscopically at the first attempt. Multivariate analysis revealed that recent surgery, ulcer site and Forrest classification independently influenced the recurrence rate. The mortality of the entire cohort studied was 8.1%. Only 31 patients (4%) underwent surgical treatment with a higher mortality compared to unoperated patients (19.3% vs 7.7%). Endoscopic treatment is a safe procedure with a low mortality and cost, and, if successful, substantially reduces the need for emergency surgery. 相似文献
12.
Raffaele Manta Giuseppe Galloro Benedetto Mangiavillano Rita Conigliaro Luigi Pasquale Alberto Arezzo Enzo Masci Gabrio Bassotti Marzio Frazzoni 《Surgical endoscopy》2013,27(9):3162-3164
Background
Through-the-scope clips are commonly used for endoscopic hemostasis of gastrointestinal (GI) bleeding, but their efficacy can be suboptimal in patients with complex bleeding lesions. The over-the-scope clip (OTSC) could overcome the limitations of through-the-scope clips by allowing compression of larger amounts of tissue, allowing a more efficient hemostasis. We analyzed the use of OTSC in a consecutive case series of patients with acute GI bleeding unresponsive to conventional endoscopic treatment modalities.Methods
In a retrospective analysis of prospectively collected data in tertiary referral centers, patients undergoing emergency endoscopy for severe acute nonvariceal GI bleeding were treated with the OTSC after failure of conventional techniques. All patients underwent repeat endoscopy 2–4 days after the procedure. Data analysis included primary hemostasis, complications, and 1-month follow-up clinical outcome.Results
During a 10-month period, 30 patients entered the study consecutively. Bleeding lesions unresponsive to conventional endoscopic treatment (saline/adrenaline injection and through-the-scope clipping) were located in the upper and lower GI tract in 23 and 7 cases, respectively. Primary hemostasis was achieved in 29 of 30 cases (97 %). One patient with bleeding from duodenal bulb ulcer required emergent selective radiological embolization. Rebleeding occurred in two patients 12 and 24 h after the procedure; they were successfully treated with conventional saline/adrenaline endoscopic injection.Conclusions
OTSC is an effective and safe therapeutic option for severe acute GI bleeding when conventional endoscopic treatment modalities fail. 相似文献13.
Radiowave hemostasis was used for endoscopic stopping of bleeding from gastric and duodenal ulcers in 96 patients. Primary single radiowave hemostasis permitted to achieve stable effect in 80 (83.3%) patients. After repeated radiowave hemostasis bleeding was completely stopped in 14 (14.6%) patients, 2 (2.1%) patients of this group underwent urgent surgery. On day 10 after radiowave hemostasis 95% of mucosal defects epithialized. 相似文献
14.
This report describes four patients with NSAID-induced esophageal ulcers documented by endoscopy. The cause of injury was
ibuprofen alone in two patients, aspirin in one patient, and a combination of aspirin and ibuprofen in one patient. The most
common findings were anemia, retrosternal pain, and dysphagia. Three patients had bleeding esophageal ulcers requiring blood
transfusions. One patient had massive bleeding which was controlled by endoscopic hemostasis. Three patients were followed
up by endoscopy, which showed healing in 3–4 weeks. These NSAID-induced ulcers had characteristic endoscopic features, namely,
a large, shallow, discrete ulcer in the midesophagus near the aortic arch with normal surrounding mucosa. These findings suggest
that the injury resulted from mucosal contact with NSAIDs. A precise history and immediate endoscopic examination were most
important in establishing the diagnosis of esophageal ulcer. Healing occurs if drug-induced injury is recognized early and
treatment is appropriately started with antacids and H2 blockade. Offending medication should be discontinued and patients should be counseled to take pills in an upright posture
with liberal amounts of fluids well before retiring for the night.
Received: 5 April 1996/Accepted: 28 May 1996 相似文献
15.
Efficacy of Endoscopic Pure Ethanol Injection Method for Gastrointestinal Ulcer Bleeding 总被引:1,自引:0,他引:1
Asaki S 《World journal of surgery》2000,24(3):294-298
We reviewed endoscopic hemostatic effects of the pure ethanol injection (PEI) method for reducting emergency operations and
deaths due to gastroduodenal ulcer bleeding. During 17 years beginning in June 1979 in Tohoku University Hospital, 331 patients
underwent endoscopic hemostasis by the PEI method. Initial hemostasis was successfully obtained in all cases. Rebleeding occurred
in about 4% of the patients, and rehemostasis was obtained successfully in all of them. Complete hemostasis was obtained in
330 of 331 patients (99.7%) using the PEI method; there were no deaths. Only one patient required emergency operation after
hemostasis because of repeated neogenetic bleeding complicated with a perforation and another because of an unidentifiable
neogenetic ulcer bleeding located just above the Vater papilla. None required other endoscopic hemostasis or interventional
radiology. Moreover, after introduction of “second-look” endoscopy, the rebleeding rate decreased to about 1% with PEI hemostasis.
Based on these excellent hemostatic effects of the PEI method, we believe that a comparative study with other hemostatic methods
is not needed. 相似文献
16.
Camprodon RA Al-Ghnaniem R Camprodon R 《Archives of surgery (Chicago, Ill. : 1960)》2003,138(7):757-61; discovery 762
HYPOTHESIS: A transgastric approach may be used succesfully for the treatment of posterior juxtacardial ulcers presenting with massive bleeding. METHODS: Eight patients were admitted during a 6-year period with acute massive upper gastrointestinal bleeding caused by posterior juxtacardial ulcers. All patients had signs of profound hypovolemic shock, and initial endoscopic control was achieved in 3 patients. They all underwent surgery after endoscopy. At operation, the ulcer was approached through an anteromedial gastrostomy and hemostasis was achieved by transfixing stitches. Ulcers were excised whenever possible, or excluded if adherent posteriorly. Four-quadrant biopsy was taken for frozen section to exclude malignancy. Both anterior and posterior gastric walls were then closed with nonabsorbable suture material. RESULTS: There were 6 men and 2 women with a mean age of 73 years. Hemoglobin levels ranged from 5.2 to 8.0 g/dL. Five patients underwent emergency surgery within 28 hours of admission. The diameter of the ulcers ranged from 2 to 5 cm. Ulcerectomy was performed in 6 cases. In the remaining 2 patients, the crater of the ulcer was adherent to the diaphragm and required exclusion from the gastrointestinal tract. None of the ulcers proved to be malignant, and there were no operative deaths. Patients were followed up for a mean of 3 years with no complications. CONCLUSIONS: Satisfactory results can be achieved with a transgastric approach to these rare ulcers. This allows definitive treatment while avoiding major gastric resection with its potential complications. 相似文献
17.
目的探讨透明帽在消化内镜止血治疗中的作用及护理配合方法。方法对86例消化道出血患者实施内镜止血治疗,均于内镜下找到出血点后安装透明帽,其中32例消化道溃疡底部动脉或Dieulafoy病出血者选用带侧孔的透明帽电凝止血,21例贲门黏膜撕裂综合征出血者选用不带侧孔的透明帽以金属夹止血,33例食管胃静脉曲张者选用带侧孔的透明帽注射硬化剂止血,同时加强术前准备、术中配合及术后观察护理。结果 86例均顺利完成内镜治疗并取得较好的止血效果,无相关并发症发生;术后3~6个月内镜复查,出血部位瘢痕形成,2例食管胃静脉曲张患者再出血,第2次给予硬化剂注射联合套扎治疗止血成功;余84例无复发出血。结论透明帽用于消化内镜止血治疗效果好,并发症少,护理人员熟练掌握其性能和操作,能缩短操作时间,提高治疗效果。 相似文献
18.
Mikinori Kataoka Takashi Kawai Yasutaka Hayama Kei Yamamoto Masaya Nonaka Takaya Aoki Kenji Yagi Mari Fukuzawa Masakatsu Fukuzawa Fuminori Moriyasu 《Surgical endoscopy》2013,27(8):3035-3038
Background
We previously reported on the safety and efficacy of bipolar hemostatic forceps for treating nonvariceal upper gastrointestinal (UGI) bleeding. However, no prospective or randomized studies have evaluated the efficacy of bipolar hemostatic forceps. The aim of this study was to evaluate the hemostatic efficacy of using bipolar hemostatic forceps compared with the hemostatic efficacy of the commonly used method of endoscopic hemoclipping for treating nonvariceal UGI bleeding.Methods
A total of 50 patients who required endoscopic hemostasis for UGI bleeding were divided into two groups: those who underwent endoscopic hemostasis using bipolar hemostatic forceps (Group I) and those who underwent endoscopic hemostasis by endoscopic hemoclipping (Group II). We compared the two groups in terms of hemostasis success rate and time required to achieve hemostasis and stop recurrent bleeding.Results
All (100 %) of 27 patients in Group I and 18 (78.2 %) of 23 patients in Group II were successfully treated using bipolar hemostatic forceps or by endoscopic hemoclipping alone, respectively, indicating a significantly higher success rate for Group I than for Group II (p < 0.05). The time required to achieve hemostasis was 6.8 ± 13.4 min for Group I and 15.4 ± 17.0 min for Group II. One patient in Group I (3.7 %) and four patients in Group II (22.2 %) experienced recurrent bleeding.Conclusion
Bipolar hemostatic forceps was more effective than endoscopic hemoclipping for treating nonvariceal UGI bleeding. 相似文献19.
The experience in diagnosis and treatment of 469 patients with gastroduodenal ulcer bleedings is presented. Sensitivity of endoscopy in detection of bleeding source was 98.8%, in detection of ulcer size -- 93.4%, specificity -- 80.6%. It is demonstrated that the most frequently recurrence of bleeding occurs when ulcer size is more than 1 cm. Location of ulcer on posterior, posterior-superior and posterior-inferior walls of the duodenal bulb is an unfavorable prognostic symptom (rebleeding occurs in 17.1, 30.0 and 12.5% cases, respectively). Types Forrest-Ia and Forrest-IIa are especially dangerous for recurrence (21.4 and 15.6%, respectively). In types Forrest-Ib and Forrest-IIb rebleeding occurs less frequently (4 and 6%, respectively). In types Forrest-Ia and Forrest-Ib rebleeding occurs mainly on the first day, rebleeding in types Forrest-IIa occurs more often on the first-second day, however it is possible up to day 7. Rebleeding in types Forrest-IIb occurs also mainly during the first two days. Endoscopic hemostasis (electrocoagulation and injection therapy) was performed in 40 patients. In 6 (15%) cases hemostasis was not achieved. In 8 (20%) cases endoscopic hemostasis led to a temporary effect, i.e. rebleeding was seen within 24-72 hours after endoscopic procedure. Stable hemostasis with endoscopy was achieved in 26 (65%) patients. 相似文献
20.
Di Carlo I Toro A Sparatore F Primo S Barbagallo F Di Blasi M 《Minerva chirurgica》2006,61(4):325-332
AIM: In elderly the incidence of the emergency gastric ulcer complications, perforation and bleeding are increasing, with a difficult management of these patients for their concomitant diseases. The aim of this work is to analyze the therapeutical approach of emergency gastric ulcer complications in elderly patients, in order to establish the factors affecting the morbidity and mortality. METHODS: Patients older than 70 years, presenting gastric ulcer, observed in a tertiary University Hospital from 1995 to 2003, have been considered for the present study. Two groups of diseases have been examined: ulcer perforation and bleeding ulcer. Age, sex, risk factors, comorbidity, methods of diagnosis, ulcer characteristics, treatment, morbidity, mortality, hospitalization time and follow-up have been considered in each group. RESULTS: Thirteen elderly patients with perforated gastric ulcer have been observed: 9 (69.2%) females and 4 (30.8%) males with a mean age of 80.5 years (range 70-90). Four patients were hospitalized in suburban hospital with an average time between the diagnosis and the surgery of 36 h, while the remnants were hospitalized directly in our Department with a medium waiting time of about 2 h. The surgical procedures were: simple closure with omentum patch in 11 cases (84.6%), and antrectomy in 2 cases (15.4%), in which the antrum was multiply perforated. Two patients presented an ulcer larger than 2 cm treated with simple suture and omental patch without morbidity and mortality. Three patients (23%) died postoperatively, due to septic shock, ventricular fibrillation and intraoperative massive haemorrhage, 2 of these patients came from other hospitals. Twenty-eight elderly patients with bleeding gastric ulcer have been observed during the same period: 13 (46.4%) females and 15 (53.6%) males with a mean age of 79.6 years (range 71-91). Except 2 patients submitted to endoscopic treatment both with adrenaline injection, all the remnant patients were managed with medical therapy (H2-receptor antagonist or proton pump inhibitors and in 7 patients [24.1%] antihaemorrhage drugs), and clinical observation, with a endoscopic control 3-4 days after from the first endoscopy. One of the 2 patients endoscopically treated developed a ulcer perforation after 11 days, and the other one rebled, without possibility of any kind of treatment due to his instable condition of health. Three patients (10.7%) died during their hospital stay not for causes strictly due to the gastric haemorrhage. CONCLUSIONS: Our results suggest that the early diagnoses and early treatment are 2 basic factor on the prognosis of elderly patients with perforated gastric ulcer. The choice between simple closure, with or without vagotomy, or gastrectomy depends from preoperative and operative health conditions of the patient. In patients with ulcer larger than 2 cm, Graham's technique can be performed safely if the preoperative and intraoperative conditions are favourable. Elderly patients with gastric ulcer bleeding show an high risk of morbidity and mortality, related to the risk factors like non steroid anti-inflammatory drugs (NSAIDs) intake or smoke. Repeated endoscopy and antiulcer drugs can manage the high stage patients of Forrest's classification with a low rate of morbidity and mortality. According to literature surgical treatment should be reserved after the second failure of endoscopic treatment. 相似文献