Lower gastrointestinal hemorrhage: etiologic assessment and surgical concept

Due to its occurence in patients at higher ages with comorbidities, lower gastrointestinal bleeding remains a challenge in terms of diagnostic and therapeutic strategies. In this series (1994-1997, n = 40) the source of bleeding was in the upper gastrointestinal tract in 38% and in the lower gastrointestinal tract in 62%. The source of bleeding could be localized in 58%. Bleeding stopped spontaneously in 40% of all patients but 60% required intervention (54% radiologic or endoscopic intervention, 46% surgery). Segmental resection was the procedure most frequently employed (8/11 patients), 3 patients underwent a subtotal colectomy. In-hospital mortality and surgical morbidity were 0/11 each. Following a staged diagnostic approach and segmental surgical resection, lower gastrointestinal bleeding can be treated with a low morbidity, mortality and a low rebleeding rate.     

Management of gastrointestinal bezoars: an analysis of 23 cases

Bezoars (BZs) represent the most common foreign bodies of the gastrointestinal tract. Clinical symptoms varying from no symptoms to acute abdominal obstruction. Our goal is to present our experience with a review of the literature. In this study, 23 patients with BZs of the upper gastrointestinal system (GIS) were treated in the surgical department of two generals hospitals in northwest Greece. The size of BZs, localization, predisposing factors, clinical symptoms, morbidity, and mortality were analyzed. Conservative treatment, endoscopic procedures, and surgical treatment were also parameters under consideration. Nineteen patients presenting with phytobezoars and four female patients presented with psychological disorders and mental retardation with trichobezoars. More than one half of them (57%) had previous gastric surgery. Surgical morbidity rate was 28%, whereas the endoscopic morbidity was 11%. Mortality was 4% and 0% for the surgical and endoscopic groups, respectively. The differences in morbidity and mortality rates between the two groups were not statistically significant. BZs are commonly found in the stomach and small intestine, especially in patients who underwent previous gastric surgery. Small bowel obstruction is the most common complication. When uncomplicated, endoscopic or surgical removal of the BZs can be performed easy and effectively.     

Surgical Endoscopic Vacuum Therapy for Anastomotic Leakage and Perforation of the Upper Gastrointestinal Tract

Introduction

Emergency operations for perforations and anastomotic leakage of the upper gastrointestinal tract are associated with a high overall morbidity and mortality rate. An endoscopic vacuum therapy (EVT) has been established successfully for anastomotic leakage after rectal resection but only limited data exist for EVT of the upper GI tract.

Methods

We report on a series of nine patients treated with EVT for defects of the upper intestinal tract between March 2011 and May 2012. In four patients, initial endoscopic sponge placement was performed in combination with open surgical revision. Median follow-up was 189 (range, 51?C366) days.

Results

In total, 52 vacuum sponges were placed in upper GI defects of nine patients. Indication for EVT were anastomotic leakage after esophageal resection or gastrectomy (n?=?5) and iatrogenic or spontaneous esophageal perforations (n?=?4). The mean number of sponge insertions was six (range, 1?C13) with a mean changing interval of 3.5?days (range, 2?C5). A successful vacuum therapy for upper intestinal defects was achieved in eight of nine patients (89?%).

Conclusion

EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. If necessary the endoscopic procedure can be combined with operative revision for better control of the local septic focus.     

Evidence‐based Review of Gastrointestinal Bleeding in the Chronic Kidney Disease Patient

Patients with end‐stage renal disease are more likely to suffer from gastrointestinal (GI) problems, including bleeding from upper and lower sources. Peptic ulcer disease is the most common cause of upper GI bleeding, and although there is some debate in the literature regarding whether the frequency of ulcer disease is higher in patients with kidney disease, it is well established that outcomes are worse in patients with compromised renal function. Angioectasias can be found throughout the GI tract and are another common cause of bleeding; management can be divided into localized endoscopic therapy and systemic hormonal treatment, or surgery for refractory cases. The most frequent causes of lower GI bleeding in this population, in addition to angioectasias, are diverticulosis, hemorrhoids, and ischemic colitis.     

Radiologic evaluation before gastric bypass for morbid obesity

During a 4 year period, 69 patients received gastric bypass with stapling and Roux-Y gastrojejunostomy for morbid obesity. The results of 67 preoperative radiologic evaluations of the gastrointestional tract were analyzed. Of these patients, 17.9 percent (12 of 67) had previous cholecystectomy for cholelithiasis; 14.6 percent (10 of 67) had cholelithiasis found on preoperative evaluation. This gave an overall incidence of gallbladder disease of 32.8 percent. The upper gastrointestinal examination revealed four patients with hiatal hernia, three with reflux, and one with evidence of reflux esophagitis. Two patients had one duodenal diverticulum each. Ten small bowel follow-through examinations were performed, six of which revealed no abnormalities and four of which were consistent with previous jejunoileal bypass. Results of air-contrast barium enema showed 1 patient with a cecal mass which was subsequently found to be a fatty iliocecal valve and 16 patients had diverticulosis without evidence of diverticulitis. The remainder of the findings of all studies were unremarkable. When all is considered, including radiation dose, difficulty in performing examinations, and cost, we conclude that because of the low incidence of significant abnormalities, routine preoperative evaluation of these patients should only include radiographic or sonographic evaluation of the gallbladder. Other examinations should be obtained if the patients have current symptoms or previous gastrointestinal disease or gastric surgery.     

Radiologic, endoscopic, and surgical considerations of melanoma metastatic to the gastrointestinal tract

Malignant melanoma is the most common malignancy to metastasize to the gastrointestinal tract. In a retrospective computer-assisted data search of over 2500 patients with melanoma registered over the past 10 years, 110 patients have been identified to have premortem gastrointestinal metastatic disease (metastatic disease identified at least 6 months before death). The small intestine (35%), colon (14.5%), and stomach (7%) are the most common sites for metastases. Polypoid or ulcerating masses and intramucosal nodules are typical radiologic presentations for gastric and colonic lesions, while over 50% of the small bowel metastases are polypoid masses that many times act as leading points for intussusception. Endoscopic studies are helpful in the preoperative diagnosis of these lesions. In a subset of 38 patients with symptomatic small bowel metastatic disease, complete resections were performed in 26% of patients, with palliative bypasses being performed in 40%, despite the fact that over 50% of the patients had documented visceral metastasis in other body sites. The operative morbidity rate was 15% with no operative deaths. Ninety percent of patients gained relief of symptoms, and overall survival from the time of confirmed small bowel disease averaged 17.3 months, with a range of 6 months to 9 years. It would seem that patients with melanoma with gastrointestinal metastatic disease can benefit from aggressive radiologic and endoscopic procedures for diagnosis and staging. Only through surgical interventions for symptomatic gastrointestinal disease can the quality of life be improved and life expectancy be extended.     

乙型肝炎相关性终末期肝病肝移植受者术后上消化道疾病的初步调查

目的调查乙型肝炎相关性终末期肝病肝移植(以下简称乙肝肝移植)受者上消化道疾病的发生情况,并对其影响因素进行初步探讨。 方法对2006年7月至2018年12月青岛大学附属医院符合入选标准的63例乙肝肝移植受者进行电子胃镜检查。同时,以年龄和性别作为匹配因素,按1 ∶3进行倾向性评分匹配,选取于本院行电子胃镜检查的慢性乙型肝炎患者和健康体检者各189例作为对照。比较3组受者消化系统症状和胃镜检出疾病情况,并进一步分析乙肝肝移植受者上消化道疾病发生的危险因素。 结果乙肝肝移植组受者术后经胃镜检出的上消化道疾病主要包括慢性萎缩性胃炎(36/63,57.1%)、反流性食管炎(13/63,20.6%)及食管静脉曲张和/或胃底静脉曲张(10/63,15.9%)。乙肝肝移植受者慢性萎缩性胃炎发生率高于慢性乙型肝炎组和体检组(P均<0.017),幽门螺旋杆菌感染发生率低于慢性乙型肝炎组和体检组(P均<0.017)。肝移植受者中,慢性萎缩性胃炎组年龄高于非慢性萎缩性胃炎组,分别为(58±8)岁和(51±7)岁,差异有统计学意义(t＝2.232,P<0.05)。 结论乙肝肝移植受者术后上消化道疾病发生率高且种类多,其中慢性萎缩性胃炎和反流性食管炎最为常见,应重视肝移植受者术后电子胃镜定期筛查。     

Endoscopic and Pathologic Findings Associated with Clinical Outcomes of Melanoma in the Upper Gastrointestinal Tract

Background

Melanoma that involves the upper gastrointestinal (GI) tract is rare and studies relating to endoscopic and pathologic findings with clinical outcomes are lacking. We reviewed the gross and microscopic patterns of the upper GI tract in primary and metastatic melanoma, and examined their association with clinical outcomes.

Methods

Twenty-nine cases of primary esophageal (n = 19) and metastatic gastric and/or duodenal melanoma (n = 10) that were detected during upper GI endoscopy between 1995 and 2011 were retrospectively analyzed.

Results

Three types of gross patterns were recognized—nodular pattern in 7 cases, mass-forming pattern in 18 cases, and flat pigmented pattern in 4 cases. In primary esophageal melanoma, 13 patients (68.4 %) underwent surgery and 9 received palliative therapy. Of all cases, 22 patients (75.9 %) died of disease progression; the median overall survival period was 12 months (interquartile range [IQR] 4.5–24.5 months), and from recognition of upper GI tract melanoma the median overall survival period was 9 months (IQR 3.5–17.0 months). In primary esophageal cases, skin melanoma stage better discriminated the patients with good prognosis than the esophageal cancer stage. The flat pigmented gross pattern proved to be a good prognostic factor in primary and metastatic GI tract melanomas (p = 0.016 and p = 0.046, respectively).

Conclusions

Melanoma of the GI tract is a highly aggressive disease with a poor prognosis, both in primary and metastatic cases. However, in primary esophageal melanoma, careful inspection of the mucosa during endoscopic examination followed by surgical resection may result in extended survival.     

Simultaneous upper and lower endoscopic biopsy in the diagnosis of intestinal graft-versus-host disease

Graft-versus-host disease in the upper gastrointestinal tract presents with anorexia, vomiting, and abdominal discomfort. Because these symptoms are not specific, we have proposed that a diagnosis of upper GI GVHD requires histologic confirmation. However, the utility of upper endoscopy in the diagnosis of upper GI GVHD has not been examined. We report a retrospective analysis of 77 allogeneic bone marrow transplantation recipients who received simultaneous upper and lower GI tract biopsies. Upper GI GVHD was found in 44% of patients, of whom 59% also had a positive lower GI tract biopsy (P less than 0.001). Thirty-five percent of the patients with no clinical evidence of lower GI tract GVHD had symptomatic upper GI GVHD confirmed histologically. Patients with and without upper GI GVHD had no significant difference in their clinical symptoms or in their endoscopic findings. We found an association between upper GI and skin GVHD greater than stage I (P = 0.05), a trend to concordance between upper GI GVHD and clinical GVHD in the lower GI tract (P = 0.08), and with the overall clinical GVHD grade (P = 0.08) but no association with clinical liver involvement. Of these 77 patients, 16% had their treatment for acute GVHD changed to include systemic immunosuppression as a result of the upper GI endoscopic biopsy. In addition, 71% had other enteric pathology identified that required specific therapy. These data suggest that upper GI GVHD cannot be diagnosed accurately from its clinical presentation nor inferred from lower GI symptoms or from extraintestinal GVHD. Upper GI endoscopy with biopsy is an important tool in the diagnosis of intestinal GVHD.     

Clinical features, diagnosis and treatment of benign nonepithelial tumors of stomach

The results of treatment of 24 patients with benign nonepithelial tumors of the stomach (BNTS) are presented. The majority of the tumors were leiomyomas (42%). The preoperative diagnostic algorithm included x-ray examination of upper gastrointestinal tract, endoscopic examination with histologic study (biopsy), ultrasound examination and CT. The best results were obtained in CT. The operation of choice in BNTS are wedge-resection of the stomach and enucleation (78.3% of patients).     

Upper urinary tract filling defects: flexible ureteroscopic diagnosis

There were 62 patients referred to our institution for evaluation of upper urinary tract filling defects. These patients had undergone any of several diagnostic evaluations, including computerized tomography, B-mode ultrasound scanning and urinary cytology studies with or without upper tract brush biopsy. In all cases a conclusive diagnosis could not be formulated. With the use of flexible ureteropyeloscopy complete evaluations of the upper tract lesions were performed. The upper tract endoscopic procedure provided the diagnosis in all patients, as well as allowed for therapeutic intervention in 19. There was no significant morbidity associated with any procedure. We advocate the continued development of flexible ureteropyeloscopic instrumentation and procedures. We suggest the inclusion of ureteropyeloscopy with tissue sampling of neoplasms in the evaluation of all upper urinary tract lesions, except when diagnostic ultrasound correlates the characteristics and position of the lesion as calculous disease.     

Enteral nutrition of patients with a severe trauma

An analysis of results of using different kinds of nutritional care of 257 patients with severe injuries has been made. Effects of different variants of the nutritional care were estimated by the character of changes in infusion therapy, dynamics of changes of the content of total protein and albumin in blood of the patients, the endoscopic picture of the upper parts of the gastrointestinal tract in dynamics of the trauma disease. At early terms after trauma a combination of parenteral and enteral methods of feeding is thought to be most rational. The probe nutrition allows the volume of intravenous infusions to be reduced. Enteral nutrition results in a less frequency and degree of errosive-ulcerous damages of the mucosa of the upper parts of the gastrointestinal tract.     

Lasers in endoscopic gastrointestinal surgery

Lasers have been used for endoscopic gastrointestinal surgery at our institution since 1977. The argon and Nd-YAG lasers are valuable for coagulating upper gastrointestinal hemorrhage, arteriovenous malformations, and benign and malignant lesions, as well as a variety of anatomic anomalies. Between December 1977 and September 1983, 222 procedures were performed in 122 patients. Hospital charts were reviewed and a scale constructed to assess the results of treatment. When information was available, a comparison of transfusion requirements before and after laser therapy was made. Success was achieved in 84 percent of the patients regardless of initial diagnosis. Laser therapy was not effective in 12 patients (10 percent). In 27 patients with gastrointestinal atrioventricular malformations, transfusion requirements fell from a mean of 17 +/- 5.9 units in the year before laser therapy to 1 +/- 0.8 units in the year after laser phototherapy (p less than 0.01). Complications rarely occurred (6 percent of all procedures). There were no perforations of the gastrointestinal tract and only one death (0.8 percent) partially attributable to laser application. Endoscopic laser surgery is minimally invasive and can be performed on an outpatient basis without anesthesia. It is especially valuable in patients with a high operative risk.     

Open surgical partial nephrectomy for upper tract urothelial carcinoma

We aimed to determine the ability of partial nephrectomy to prevent end‐stage renal disease and tumor recurrence or progression in patients with upper tract urothelial carcinoma. Retrospectively, eight patients undergoing partial nephrectomy for upper tract urothelial carcinoma were identified and their medical records reviewed. All patients had imperative indications for nephron sparing, and diagnosis of upper tract urothelial carcinoma not adequately amenable to endoscopic management. Although three patients suffered acute tubular necrosis, only one required postoperative hemodialysis. During the follow‐up period 25% (2/8) developed end‐stage renal disease, including the one patient who had received postoperative hemodialysis. Recurrences occurred in five of seven patients with adequate oncological surveillance. Recurrences were successfully treated endoscopically in 80% (4/5) patients, and one patient had metastases. Of the eight patients, four have died. Death occurred 4 months, 1 year, 1.2 years and 3.5 years after partial nephrectomy. Of these patients, one succumbed to metastatic disease; the exact cause of death is unknown in the other three, but there was no documentation of metastatic cancer. The mean duration of follow up in the remaining four patients, all without evidence of metastatic urothelial cancer, is 71 months (range 22–108 months). In summary, partial nephrectomy for upper tract urothelial carcinoma in patients with imperative indications averts end‐stage renal disease in most patients, and appears to be associated with acceptable disease‐specific survival. Partial nephrectomy is a sparingly used option in patients with upper tract urothelial carcinoma refractory to endoscopic management who have imperative indications for nephron sparing.     

Is endoscopic injection hemostasis of bleeding gastrointestinal ulcers obsolete in 1995?

Bleeding non-neoplastic lesions of the upper gastrointestinal tract, not due to portal hypertension, are a frequent cause of emergency admission. In the present paper we report our retrospective experience in hemostatic injection treatment of these lesions. From May 1990 to May 1994, 164 patients were admitted to our institution for a bleeding gastrointestinal lesion. In 124 cases an ulcer classified according Forrest's criteria was detected. Four patients underwent immediate surgery. The second group of 86 patients (FIIa/FIIb/FIII) were treated conservatively. The third group of 34 patients (FIa/FIb/FIIa) underwent perilesional injection of adrenaline 1:10,000 and polidocanol 1% saline solution during endoscopic examination; 29% (25 pts) of the second group re-bled during the first 72 h vs 8.8% (3 pts) of the third group. The postoperative morbidity in the rebleeding patients was higher in the second group: 38.4% vs 0%. The importance of immediate, inexpensive, and simple hemostatic treatment extended to Forrest IIa lesions is emphasized.     

Role of endoscopic ultrasound in staging upper gastrointestinal cancers

The key clinical management points in this article are that (i) endoscopic ultrasound is the most accurate imaging method for local staging of oesophageal, gastric and pancreatic neoplasms; (ii) addition of fine-needle aspiration biopsy to the technique is safe and well tolerated and increases diagnostic accuracy for nodal staging purposes; and (iii) endoscopic ultrasound +/- fine-needle aspiration has the capacity to influence significantly, the management of patients with malignancies of the upper gastrointestinal tract, particularly with respect to selection for surgery. The learning objectives were that at the end of this paper the reader should be able to (i) understand the usefulness and limitations of various imaging methods in the staging of upper gastrointestinal cancers; and (ii) incorporate the various imaging methods, particularly endoscopic ultrasound, into management algorithms for oesophageal cancer, gastric cancer, mucosa-associated lymphoid tissue lymphomas, gastrointestinal stromal tumours, pancreatic cystic lesions and pancreatic cancer.     

Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needleknife dissection

Background  

Zenker’s diverticulum (ZD) is the most common diverticulum of the upper gastrointestinal tract. Various flexible endoscopic techniques have been used for division of the septum. However, the learning curve associated with these techniques might be difficult to overcome given the overall rarity of this condition. This can lead either to complications or to potential recurrence of symptoms. The authors hypothesized that a flexible bipolar hemostasis forceps developed for natural orifice translumenal surgery (NOTES) procedures would facilitate precise endoscopic diverticulotomy and simultaneously enable sealing of divided tissue edges.     

Endoscopy in the diagnosis and treatment of gastroduodenal hemorrhage]

An experience of work of the department of general surgery with the course of endoscopy is presented. The endoscopic diagnosis and treatment of 2931 patients for 6 years were performed for bleedings from the upper parts of the gastrointestinal tract. Errors in endoscopic diagnosis made 5%. The authors divided them into three groups: methodical (preparing the patients, methods of examination), diagnostic (assessment of the substrate and type of bleeding, probability of recurrences), tactical (medical policy, dynamics of observations). Hemostasis in endoscopic arrest may be complete or temporary (stable or unstable). The most effective methods are thought to be coagulation, clipping and a combination of the methods. Medicamentous means are less effective. The authors recommend to be aware of the endoscopic possibilities and not to try to stop bleeding by any means thereby wasting time.     

Agenesis of the gallbladder without extrahepatic biliary atresia

Agenesis of the gallbladder without extrahepatic biliary atresia is a rare disorder. At the UCLA-affiliated hospitals, 12 patients were classified in the following groups: (1) multiple fetal anomaly, (2) asymptomatic, and (3) symptomatic. All four patients in the multiple fetal anomaly group died of their other congenital defects. In the three patients in the asymptomatic group, the absent gallbladder was an incidental finding at autopsy. The five patients in the symptomatic group underwent operations for symptoms suggestive of biliary tract disease, with no gallbladder found; all were symptom free postoperatively. Operative strategy should include a complete exploration, operative cholangiography, and common bile duct exploration as necessary. Possible mechanisms responsible for symptoms include primary duct stones, biliary dyskinesia, or nonbiliary disorders. Computed tomography, biliary manometry, upper gastrointestinal tract endoscopy, and endoscopic cholangiography (with or without sphincterotomy) could be employed if symptoms continue.     

Treatment of acute ulcerations of the upper part of the gastrointestinal tract in patient with a neuroreanimation profile

A success in treatment of acute ulcerations of the upper parts of the gastrointestinal tract in patients with a severe neurosurgical pathology can be achieved only with a complex approach to treatment of the intensive care patients. The application of antiulcerous medicines in combination with pyrokinetics and medicines improving the regeneratory ability of the gastrointestinal tract mucosa allowed to considerably decrease risk of the development of gastroduodenal bleedings against the background of erosive-ulcerous lesion of the mucosa. The endoscopic methods of arresting bleedings in such patients in combination with the correction of homeostasis by infusions and local hemostatic therapy in most cases result in reliable hemostasis of the upper parts of the gastrointestinal tract. The program of active measures is completed with the early enteral feeding with balanced nutritional mixtures.