Use of neodymium YAG laser in endoscopic hemostasis in thoracic surgery]

YAG-laser radiation was used for endoscopic hemostasis in 33 patients with bleeding endobronchial carcinomas and in 4 patients with chest injury complicated by bleeding from wounds of the lung and chest wall. For conducting laser photocoagulation, the authors prefer a rigid bronchoscope and a thoracoscope and pulsed laser radiation with a power of up to 40 Wt. As the results of treatment, hemostasis was achieved in 24 patients with lung carcinoma and in 4 patients with trauma of the chest. In some patients with pulmonary carcinoma laser photocoagulation creates conditions for successful surgery or chemoradiotherapy. The performance of thoracoscopic laser operations in chest injuries and traumas allows wide thoracotomy to be avoided in some patients. Complications were not registered in endoscopic laser operations.     

evaluation of argon laser photocoagulation in a series of animal models of upper gastrointestinal bleeding

During the past five years we have evaluated argon laser photocoagulation in various canine models of upper gastrointestinal hemorrhage. In gastric erosions, the eight-watt argon laser was uniformly effective in stopping bleeding. In our standard acute ulcer model the seven-watt argon laser was effective in stopping bleeding from most ulcers and only occasionally produced deep injury. With the addition of a jet of CO₂ exiting the laser catheter coaxial to the laser beam, the argon laser was 100% effective and no deep injury resulted. The application of the argon laser in a more physiologic canine bleeding model using a single bleeding vessel in an ulcer base is currently under study. The development of improved animal models of gastrointestinal bleeding should contribute to the identification of effective and safe endoscopic hemostatic methods.     

Differential treatment of gastroduodenal ulcerous bleedings

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.     

Efficacy of Endoscopic Pure Ethanol Injection Method for Gastrointestinal Ulcer Bleeding

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.     

Non-surgical approach to bleeding gastric ulcer

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest's classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001 - December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them (31.1)-1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60% male and 40% female) with a mean age of 64.3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest's classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26.34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no--steroid antinflammatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.     

消化性溃疡出血的治疗现状

消化性溃疡出血是一个常见且潜在生命危险的临床症状。治疗上主要以药物治疗、内镜治疗和手术治疗为主。由于有效的内镜止血方法及抑酸药物的出现，消化性溃疡出血的治疗在过去20年里发生了很大的变化，药物联合内镜的治疗方法对消化性溃疡出血有很好的疗效，在很多医疗单位内镜治疗已被广泛采用作为一线治疗方案。而手术治疗，作为控制出血的最彻底的方法，多在上述治疗方法失败后采用。选择手术治疗或是重复内镜治疗可基于病人的并发症和溃疡的性质决定。     

Treatment of gastroduodenal ulcer bleedings in a general hospital of emergency care

Treatment of patients with gastroduodenal ulcer bleedings in a general hospital of emergency care is a complex of measures including of endoscopic diagnosis and stopping of bleeding, use of effective antisecretory drugs with obligatory laboratory control of acid-producing function of the stomach, surgical treatment and eradication of H. pylori. Up-to-date methods of endoscopic hemostasis - spirituous infiltration, argon-plasma coagulation, clipping of vessels in ulcer and also their combination in difficult cases - provide reliable hemostasis and allow to avoid urgent surgery. Recently we succeeded in reducing the rate of urgent surgeries performed at the height of bleedings from 70 to 40%. These methods can be recommended for clinical practice because they reduce significantly lethality rates in patients with severe conditions.     

Principles of medical care of patients with gastrointestinal ulcer hemorrhage]

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.     

Complications of peptic ulcer disease in children and adolescents: minimally invasive treatments offer feasible surgical options

Purpose

Surgery for complications of peptic ulcer disease (PUD) carries a significant morbidity and even mortality. The aim of this study was to determine the efficacy, safety, and outcome of children and adolescents undergoing minimally invasive treatment of bleeding and perforation complicating PUD.

Methods

One hundred thirty-two consecutive patients aged 6 to 17 years managed endoscopically for bleeding and laparoscopically for perforation from January 1999 to February 2006 were reviewed.

Results

Thirty children had significant endoscopic stigma of recent hemorrhage. Primary endoscopic hemostasis was achieved in most cases except one requiring further endoscopic hemostasis. Seventeen patients with perforation underwent laparoscopic patch repair. Four patients were converted to open repair because of technical difficulty and the large size of the ulcer. All patients had a course of proton pump inhibitors postoperatively. Ninety percent of patients had Helicobacter pylori infestation. Triple therapy was given. Two patients defaulted triple therapy and presented later with recurrent ulcer bleeding. All others remained asymptomatic on follow-up (average, 32.6 months).

Conclusions

Endoscopic hemostasis of bleeding peptic ulcer is effective and safe in children. With stringent criteria, laparoscopic patch repair of perforation can be applied safely to most pediatric patients. Eradication of H pylori and subsequent antiulcer medication are integral in the management of complicated PUD.     

Endoscopic Nd:YAG laser therapy in upper gastrointestinal bleeding

Between 1983 and 1986 thirty-seven patients with upper gastrointestinal bleeding or stigmata of acute bleeding were treated at the Second Department of Surgery with endoscopic laser therapy. The non-contact method was used. The cause of bleeding was gastric ulcer in 13 cases and duodenal ulcer in 5. Two patients had anastomotic ulcer, 6 had a simple ulcer, 7 had telangiectases (Mb. Osler), 2 had Mallory Weiss tears and 2 bled after gastric biopsy. Twenty-one patients bled during endoscopy and 16 had signs of recent bleeding. During acute bleeding laser treatment was effective in 95% (1, 3). However, 41% of all patients (15/37) rebled within a week after laser therapy and in 30% (11/37) an emergency operation was necessary. The overall mortality rate was 10.8% (4/37). Endoscopic laser coagulation is successful in the initial treatment of acute upper GI-bleeding. However, there is a considerable risk of rebleeding. Acute laser therapy may change an emergency operation into an elective one, provided that the group at risk of rebleeding can be anticipated at first endoscopy.     

不同内镜止血方法治疗老年消化性溃疡出血的效果比较

目的：评价不同内镜止血方法治疗老年消化性溃疡出血的效果。方法回顾性分析2008年1月～2013年12月在北京大学首钢医院住院并接受内镜治疗的80例老年消化性溃疡出血患者的临床及内镜检查资料,病变出血征象采用Forrest分级。内镜止血治疗方法包括内镜下肾上腺素注射（54例）和金属钛夹治疗（26例）。结果进行内镜治疗的病变均为Forrest Ⅰa～Ⅱb级。与内镜下肾上腺素注射组相比,金属钛夹治疗组的内镜治疗成功率更高（96.2％与87.0％）,再出血发生率更低（7.7％与14.8％）,临床症状消失时间更短[（2.3±0.6）d与（3.4±1.1）d],住院天数更短[（7.8±0.9）d与（11.5±2.4）d],差异均有统计学意义。结论内镜下金属钛夹止血治疗老年消化性溃疡出血的有效性和安全性均优于肾上腺素注射治疗。     

The application of gastro-duodeno-fibroscopy in the diagnosis and treatment of ulcers complicated by gastroduodenal hemorrhage

The results of gastrofibroscopic investigation were analyzed in 1491 patients with gastroduodenal ulcer, complicated by hemorrhage. Comparative analysis of the endoscopic hemostasis efficacy was conducted in 327 patients with persisting hemorrhage and for prophylactic hemostasis--in 158 patients with stopped hemorrhage and unstable hemostasis. The most effective method of coagulation, mechanical hemostasis is that, using the clips and combined methods. Performance of endoscopic hemostasis manipulations had promoted the lowering of general lethality down to 3.6%, and the postoperative one--to 1.8%.     

Diagnostic and therapeutic treatment policy in ulcerous gastroduodenal bleedings

Results of treatment of 796 patients with ulcerous gastroduodenal bleedings (UGDB) are analyzed. The study group consisted of 676 patients who have undergone endoscopic hemostasis. The control group consisted of 120 patients treated with traditional therapy. Endoscopic hemostasis in the study group was effective in 628 (92.8%) patients, recurrence of bleeding was seen in 21 (3.3%) patients. Effective hemostasis in the control group was achieved in 92 (76.6%) patients, recurrence of bleeding occurred in 13 (14.1%) patients. Positive result of Helicobacter pylori detection was in 600 (88.7%) patients. It is concluded that local treatment of ulcer with glue applications reduces 3 times number of bleeding recurrences.     

Laser photocoagulation of bleeding gastroduodenal ulcers: A morphological study

The efficacy of photocoagulation by the neodymium-doped yttrium aluminium garnet (Nd-YAG) laser in the endoscopic control of upper gastrointestinal bleeding has been demonstrated previously. Yet rebleeding remains possible. In the present report the results are presented of a histological study of resection specimens from patients who required emergency surgery for recurrent upper gastrointestinal bleeding after endoscopic laser treatment. The study was set up in order: (1) to describe the changes induced by laser treatment and (2) to identify possible causes of recurrent bleeding. The findings show that laser photocoagulation can induce major vascular changes but that these may be incomplete. Incomplete photocoagulation may be responsible for the rebleeding and may itself be caused by poor accessibility to the bleeding site.     

Plastic filling of bleeding duodenal ulcers in the course of truncal vagotomy with pyloroplasty according Finney

The procedure of plastic filling of bleeding ulcer of the duodenum during vagotomy procedure and pyloroplasty by Finney was developed and used in 26 patients. The study of early postoperative results showed steady hemostasis in all patients and no recurrences of bleeding. Follow-up results up to 3 years were studied in 22 patients. No relapses of ulcer disease were recorded. Thus truncal vagotomy with pyloroplasty by Finney and plastic filling of bleeding ulcer is an effective method for hemostasis and adequate treatment of duodenal ulcer.     

Endoscopic electrohemostasis of active upper gastrointestinal bleeding.

Emergency esophagogastroduodenoscopy for active upper gastrointestinal bleeding was performed in 160 patients. Endoscopic electrocautery for control of bleeding was considered in the last ninety patients and performed in seventy-one patients. All lesions except esophageal varices were candidates for electrohemostasis. The indications for endoscopic electrocautery were active hemorrhage and precise identification of the bleeding point. The preendoscopic blood loss ranged from 1,500 to 6,000 ml. All seventy-one patients had initial hemostasis and sixty-five (92 per cent) had permanent hemostasis after one treatment. Six patients rebled, and four of these had permanent hemostasis after a second endoscopic electrocauterization. Only two of seventy-one patients had emergency operations for bleeding. There were no complications. Endoscopic electrohemostasis is still an experimental technic which requires further laboratory study and testing before broad general clinical application. This clinical trial suggests that endoscopic electrocautery is an attractive method of controlling active upper gastrointestinal bleeding because it can be safe, effective, and rapid, and is available in most medical communities.     

透明帽用于消化内镜止血治疗的护理配合

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。     

Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques

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.     

Endoscopic control of upper gastrointestinal bleeding

One important objective in managing patients with upper gastrointestinal hemorrhage is to control the bleeding until the patient's condition is stable and definitive therapy can be carried out. Endoscopic techniques are now available to attain this goal. Endoscopic sclerosis has become an accepted treatment for bleeding esophageal varices, especially in patients with Child's class B or C cirrhosis. Control of nonvariceal bleeding by endoscopic techniques is now feasible and involves laser photocoagulation and electrocoagulation. Clinical experience with endoscopic laser photocoagulation has demonstrated that it can successfully arrest bleeding in gastric and duodenal ulcers. Endoscopic electrocoagulation has been successful in stopping bleeding from Mallory-Weiss tears, acute gastric erosions, and gastric, duodenal and stomal ulcers. Use of an endoscopic heater probe, now in the development stage, to control bleeding gastric and duodenal ulcers will be an important addition.     

The role of endoscopy in diagnosis and treatment of gastroduodenal bleedings

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.