Transesplenic access in the treatment of varicose gastrointestinal bleeding. Case and technical report / Uso do acesso transesplênico no tratamento do sangramento gastrointestinal varicoso. Relato de caso e técnica

ABSTRACT Varicose gastrointestinal bleeding is one of the major causes of morbidity and mortality in patients with chronic liver disease. Endoscopic treatment is the first therapeutic line for these patients, however, for those whom this therapeutic modality fail, a broad knowledge of alternative treatment options may improve the prognosis. We describe a case of a patient who were successfully embolized from gastroesophageal varices via transsplenic access.

RESUMO O sangramento gastrointestinal varicoso está entre as maiores causas de morbimortalidade nos paciente com doença hepática crônica. O tratamento endoscópico é a primeira linha terapêutica neste pacientes, porém naqueles que apresentam falha nesta modalidade terapêutica, o amplo conhecimento de opções alternativas de tratamento pode melhorar o prognóstico. Descrevemos um caso de paciente submetido à embolização com sucesso de varizes gastresofágicas por acesso transesplênico.

The efficacy and safety of Rivaroxaban for elderly patients with thrombotic diseases / 中华老年医学杂志

Objective@#To investigate the efficacy and safety of Rivaroxaban for elderly patients with thrombotic diseases.@*Methods@#This was a retrospective study.A total of 301 elderly patients taking Rivaroxaban from October 2012 to November 2017 at the Second Medical Center of the Chinese PLA General Hospital were consecutively selected.The ages ranged from 60 to 102 years, with an average age of(86.5±8.4)years.Anticoagulation regimens were developed based on comprehensive evaluation of indications, creatinine clearance, ischemia and bleeding risk.Patients were divided into a Rivaroxaban 2.5-5.0 mg/d group(n=72), a 10.0 mg/d group(n=205), and a 15.0-20.0 mg/d group(n=24). Hepatic function, renal function, and coagulation indexes were measured before and after the administration of Rivaroxaban.Fatal bleeding, cardiovascular deaths, all-cause deaths, non-fatal bleeding and thromboembolic events were recorded during the follow-up period.@*Results@#The average dose of Rivaroxaban was(9.3±3.0)mg/d, and the minimum dose was 2.5 mg/d.The average follow-up time was(14.9± 13.9)months and the longest follow-up time was 48 months.One patient had intracranial bleeding.Twenty patients(6.6%)died with a cumulative incidence of 25.2%, three(1.0%)died of cardiac events, and 55.0% died of pneumonia and multiple organ failure.Forty patients(13.3%)had non-fatal hemorrhagic events with a cumulative incidence of 42.4%.Seven patients(2.3%)had thromboembolic events with a cumulative incidence of 16.0%, including 2 cases of non-fatal myocardial infarction, 3 cases of cerebral infarction and 2 cases of deep vein thrombosis.After treatment, levels of prothrombin time and fibrinogen significantly increased while levels of D-dimer significantly deceased(P<0.05).@*Conclusions@#Compared with previous reports, low-dose Rivaroxaban is safe and effective for elderly patients with thrombotic diseases.However, the risk of bleeding and ischemia should be comprehensively evaluated, and appropriate doses of Rivaroxaban should be selected individually.

The efficacy and safety of Rivaroxaban for elderly patients with thrombotic diseases / 中华老年医学杂志

Objective To investigate the efficacy and safety of Rivaroxaban for elderly patients with thrombotic diseases.Methods This was a retrospective study.A total of 301 elderly patients taking Rivaroxaban from October 2012 to November 2017 at the Second Medical Center of the Chinese PLA General Hospital were consecutively selected.The ages ranged from 60 to 102 years,with an average age of(86.5 ± 8.4) years.Anticoagulation regimens were developed based on comprehensive evaluation of indications,creatinine clearance,ischemia and bleeding risk.Patients were divided into a Rivaroxaban 2.5-5.0 mg/d group(n=72),a 10.0 mg/d group(n=205),and a 15.0-20.0 mg/d group (n=24).Hepatic function,renal function,and coagulation indexes were measured before and after the administration of Rivaroxaban.Fatal bleeding,cardiovascular deaths,all-cause deaths,non-fatal bleeding and thromboembolic events were recorded during the follow-up period.Results The average dose of Rivaroxaban was(9.3±3.0)mg/d,and the minimum dose was 2.5 mg/d.The average follow-up time was(14.9± 13.9)months and the longest follow-up time was 48 months.One patient had intracranial bleeding.Twenty patients (6.6％)died with a cumulative incidence of 25.2％,three (1.0％)died of cardiac events,and 55.0％ died of pneumonia and multiple organ failure.Forty patients (13.3％)had non-fatal hemorrhagic events with a cumulative incidence of 42.4％.Seven patients (2.3％)had thromboembolic events with a cumulative incidence of 16.0％,including 2 cases of nonfatal myocardial infarction,3 cases of cerebral infarction and 2 cases of deep vein thrombosis.After treatment,levels of prothrombin time and fibrinogen significantly increased while levels of D-dimer significantly deceased (P ＜ 0.05).Conclusions Compared with previous reports,low-dose Rivaroxaban is safe and effective for elderly patients with thrombotic diseases.However,the risk of bleeding and ischemia should be comprehensively evaluated,and appropriate doses of Rivaroxaban should be selected individually.

Hemorragia masiva: una complicación tardía del reemplazo de la gastrostomía endoscópica percutánea. A propósito de un caso / Massive hemorrhage: a late complication of replacement percutaneous endoscopic gastrostomy: case report

La gastrostomía endoscópica percutánea (GEP) se utiliza como alternativa de la alimentación enteral/nasoenteral en situaciones en las que la alimentación por vía oral a largo plazo no es eficaz o no se tolera. Se prefiere principalmente en pacientes con afecciones neurológicas y, además, como apoyo de la nutrición en pacientes con enfermedades cardíacas congénitas, fibrosis quística, enfermedad intestinal inflamatoria y diversas enfermedades orofaríngeas. Si bien la colocación es sencilla en comparación con muchos procedimientos invasivos, presenta complicaciones, que incluyen desde la infección de la herida hasta la muerte. La GEP exige personal médico experimentado, antibióticos profilácticos adecuados e información exhaustiva para los pacientes o sus familias sobre el procedimiento y los cuidados posteriores. Presentamos una complicación rara, aunque importante, que surgió durante el reemplazo de la sonda de gastrostomía después del método de "corte y empuje". El tope, que debe llegar hasta el extremo distal del estómago, se desplazó hacia arriba, hasta el esófago proximal, y causó una úlcera profunda en la mucosa esofágica y una hemorragia masiva.

Percutaneous endoscopic gastrostomy (PEG) is used as an alternative to enteral/nasoenteral feeding in situations where long-term oral feeding is ineffective or not tolerated. It is mostly preferred in patients with neurological conditions and also to support nutrition in patients with congenital heart diseases, cystic fibrosis, inflammatory bowel disease, and various oropharyngeal diseases. Although it is easily applicable compared to many invasive procedures, it has complications ranging from wound infection to death. PEG requires experienced medical personnel, appropriate prophylactic antibiotics and exhaustive information to the patients or their families about the procedure and subsequent care. We present a rare but important complication during the replacement of the gastrostomy tube subsequent to the "cut and push" method. The bumper portions, which should move to the distal end of the stomach, moved upwards to the proximal esophagus, caused a deep ulcer in the esophageal mucosa and a massive hemorrhage.

Lower Gastrointestinal Bleeding: Is Urgent Colonoscopy Necessary for All Hematochezia?

Lower gastrointestinal bleeding (LGIB) is defined as acute or chronic abnormal blood loss distal to the ligament of Treitz. The incidence of LGIB is only one fifth of that of the upper gastrointestinal tract and is estimated to be 21 to 27 cases per 100,000 adults per year. Acute bleeding is arbitrarily defined as bleeding of <3 days' duration resulting in instability of vital signs, anemia, and/or need for blood transfusion. Chronic bleeding is defined as slow blood loss over a period of several days or longer presenting with symptoms of occult fecal blood, intermittent melena, or scant hematochezia. Bleeding means that the amounts of blood in the feces are too small to be seen but detectable by chemical tests. LGIB is usually chronic and stops spontaneously. Bleeding stop (80%), but male gender and older patients suffer from more severe LGIB. The optimal timing of colonoscopic intervention for LGIB remains uncertain. Urgent colonoscopy may serve to decrease hospital stay. However, urgent colonoscopy is difficult to control, and showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

Abordaje temporopolar para la cirugía de aneurismas intracraneales de la circulación posterior: Informe de 2 casos / Temporopolar approach to intracraneal aneurysms surgery of the posterior circulation: to cases report

Los aneurismas intracraneales de la circulación posterior representan un reto para la neurocirugía contemporánea y para la neurorradiología intervencionista, debido a la complejidad anatómica de su topografía que predispone a la aparición de complicaciones. La oclusión endovascular representa la opción más acertada para el tratamiento de estas lesiones, pero al no existir una cobertura adecuada para todos los pacientes, la microcirugía representa una alternativa para el manejo de los pacientes con esta compleja enfermedad. En el presente trabajo se presentan dos casos intervenidos quirúrgicamente, uno con un aneurisma del tope de la basilar y otro con uno de la arteria cerebelosa superior izquierda, en los que se utilizó un abordaje temporopolar descrito por Sano, con resultados satisfactorios. Se concluye que este abordaje representa una alternativa adecuada al resto de las técnicas usadas para el tratamiento quirúrgico de estas lesiones

Intracranial aneurysms of the posterior circulation represent a challenge for contemporary neurosurgery and interventional neuroradiological procedures due to the anatomical complexity of its topography that predispose on the occurrence of complications. The endovascular occlusion represents the best option for the treatment of these injuries, but at not existing a coverage suitable for all patients, microsurgery continues representing an alternative for the management of patients with this complex disease. In this paper we present two cases operated, one with a basilar tip aneurysms and another one in the left superior cerebellar artery in which a temporopolar approach described by healthy, with successful results was used. We conclude that this approach represents an alternative to the rest of the techniques used for the surgical treatment of these injuries

Hemorragia post-parto: embolización terapéutica / Postpartum hemorrhage: therapeutic embolization

Paciente de 29 años, puérpera, que presenta importante hemorragia postparto, con comprimiso hemodinámioco, que no cede a los tratamientos gineco-obstétricos habituales. Por su condición de primiparidad se decide intentar terapia endovascular, efectuándose embolización selectiva de ramas cérvico-uterinas, lograndose detener el sangramiento en forma exitosa.

29 year old patient, which presents a major postpartum hemorrhage, with hemodynamic involvement, that did not respond to the usual obstetric gynecological treatments. For its status of primiparity, it is decided to try endovascular theraphy; performing a selective embolization of cervical-uterine branches, that was successful.

Effect of Minimally invasive drainage of hematoma on hypertensive cerebral hemorrhage in patients with neurological functional recovery / 中国基层医药

Objective To evaluate the efficacy of minimally invasive drairage of hematoma in treatment of hypertensive cerebral hemorrhage. Methods 60 patients with hypertensive cerebral hemorrhage were randomly divided into two groups,including the observation group of minimally invasive hematoma drainage, the control group 30 cases, a small bone window intracranial hematoma,observe and compare the two groups of hypertensive cerebral hemorrhage the neurological function recovery. Results The operative time was significantly shorter than that used in the control group. Postoperative mortality, the difference was significant (P <rate,the difference was significant( P < 0.05 ). Hematoma drainage time of the observation group was significantly shorter than that in the control group,two groups of neural function in SSS score comparison showed that 21 daysafter treatment ,SSS score in observation group was significantly higher in the observation group than the control group. Observation group MRS scores and BI scores were significantly improved, and the ADL rating was significantly beffer than the control group( P < 0.05 or P < 0.01 ). Conclusion The minimally invasive hematoma drainage in the treatment of hypertensive cerebral hemorrhage with a short time, could significantly promote the recovery of neurological function in patients and reduce patient complications and mortality ,but also be neficial to activities of daily living (ADL) recovery.

Colite cística profunda: relato de caso / Colitis cystica profunda: case reporte

A colite cística profunda consiste na presença de cistos submucosos, contendo muco, principalmente no reto e no cólon esquerdo. De etiologia controversa, com pouco mais de 200 casos relatados na literatura mundial. Tem importância pela capacidade de mimetizar neoplasia maligna colorretal. Descreveremos um caso de colite cística profunda localizada no reto e submetida a tratamento cirúrgico, seu acompanhamento pós-operatório e revisão da literatura.

Colitis cystica profunda comprises submucous mucus-filled cysts, located mainly in rectum and left colon. Its etiology is controversial, with about 200 cases reported in the literature. This disease is important clinically in that mimics colorectal malignancies. We report a case of colitis cystica profunda localized in rectum treated surgically, its follow-up and review of the literature.

The treatment of the fissuration of pancreatojejunal stoma by the bridge-crossing internal drainage / 中华内分泌外科杂志

Objective The purpose of this study was to discuss the therapies for hemorrage caused by the fissuration of pancreatojejunal stoma and pancreatic leakage after pancreatoduodenectomy.Methods After three cases of pancreatoduodenectomy,the disruptions of pancreatojejunal stoma resulted in serious pancreatic leakage and the hemorrage in abdominal cavity.During all the second operations,the drainage-tube insertions into the main pancreatic ducts were used to lead the pancreatic juice into the neighboring loop of jejunum.Results Afer the operations,the supportive treatment,continuous irrigation of peritoneal cavity and pancreatic enzyme inhabition were given to the patients of these cases and all of the patients were successfully cured.Conclusions The bridge-crossing internal drainage which inserts drainage-tube into the main pancreatic duct was a convenient and effective therapy and method to rescue the hemorrage caused by the fissuration of pancreatojejunal stoma and pancreatic leakage after pancreatoduodenectomy.While the patients' lives were saved,their functions of pancreas were preserved and the qualities of life were improved after the operations.

Packing pelviano retroperitoneal en fracturas inestables de pelvis: reporte de un caso y descripción de la técnica / Retroperitoneal packing in unstable pelvic fractures: case report and description of the technique

Pelvic fractures in hemodynamically unstable patients are associated with high rates of morbidity and mortality. The optimal management strategy for hemorrhage control remains controversial. We present a clinical case that was successfully treated with retroperitoneal pelvic packing. The technique is described and discussed.

Las fracturas de pelvis con inestabilidad hemodinámica se asocian a altas tasas de morbilidad y mortalidad. No existe consenso sobre la mejor manera de controlar hemorragia asociada. Se presenta un caso manejado exitosamente mediante la realización de un packing pelviano retroperitoneal. Se describe la técnica quirúrgica y se discuten sus alcances.

Branch Retinal Vein Occlusion with Progressive Intraretinal Hemorrhage

PURPOSE: To evaluate the clinical feature and visual prognosis of branch retinal vein occlusion (BRVO) with progressive intraretinal hemorrhage that we happened to meet them in rare incidence. METHODS: Medical records of 91 patients who were diagnosed as BRVO from October 1997 to September 2001, were reviewed retrospectively. Ninety-eight eligible BRVO eyes were assigned to either progression group or control group according to their clinical feature of intraretinal hemorrhage. RESULTS: BRVO with progressive intraretinal hemorrhage was observed at 7 of 98 eyes (7.1%). Interval between initial presentation and progression was variable from 1 week to 3 months. In control group, 50 out of 91 eyes (54.9%) showed improvement of visual acuity at least two lines from the baseline. However, no one got improved visual acuity in progressive group (p=0.005). Final visual acuity of 0.5 or more was achieved in 54 eyes (59.34%) of control group and 1 eyes (14.3%) of progression group (p=0.041). Above data suggest that visual prognosis of progressive BRVO is poorer than that of non-progressive one. CONCLUSIONS: Because of the poor prognosis of BRVO with progressive intraretinal hemorrhage, this portions of BRVO patients might be considered more aggressive treatment such as surgical interventions. Also, additional prudent explanation about visual prognosis and special care must be given to the BRVO patients with progressive intraretinal hemorrhage.

Infarto del epiplón mayor como causa de hemorragia interna. A propósito de un caso / Infarction of the major eplioon as a cause of internal hemorrhage. Case study

Se presentó el caso de un paciente de 58 años con antecente de infarto agudo del miocardio 15 años atrás, acude a la consulta de urgencia en cirugía general deambulando. Refiere estado catarral desde una semana atrás, tos, fiebre 37½-38ºC, dolor en el abdomen que se focaliza en el hipocondrio derecho, pulso al inicio de 86 por minuto que se acelera después a 100 por minuto. Se analizan los datos aportados por el paciente, se realiza examen físico, exámenes complementarios y se interpreta como una colecistitis aguda. Con ese criterio se opera, pero el acto operatorio demuestra lo contrario: hemorragia interna por infarto del epiplón mayor y hematoma grande que se localiza en el estómago-duodeno-ángulo hepático del colon transverso e hígado, que comprimía la vesícula comprometiendo la irrigación del órgano. Se realiza omentomía parcial y reposición de volumen.

The study of 58 years patient with antecedent of acute infarction of myocardium during 15 years is presented he attended the general surgery deparment of the emergency service. He refers influenza during a week , counghing, fever 37 1/2 o C - 38 o C, abdominal pain focused to rigth hypochondrium, pulse begimming with 86/min which accelerates later to 100/min. Date collected were analyzed: physical examination, complementary test, and it is interpreted as acute cholecystitis but the operatory procedure shows the contrary, internal hemorrhage due to infarction of the major eplioon and a huge hematoma localized beteween the stomach-duodenum-hepatic angle of transverse colon and liver which compressed the gall-bladder, affecting the irrigation of this organ. Partiot omentectomy and volume reposition is performed. Literaturerelated with this topic is reviewed.

EFFECT OF PAPAVERINE ON CEREBRAL VASOSPASM FOLLOWING CEREBRAL ANEURYSM OPERATION / 解放军医学杂志

To evaluate the effect of papaverine administered via different routes following cerebral aneurysm operation, 43 cerebral aneurysm patients were divided randomly into two groups: A and B. Patients of group A were placed with a silicagel tube in cerebral ventricle and lavaged repeatedly with papaverine solution during operation and following 3 days after operation, those of group B were intramuscularly injected with papaverine 30mg, 3 times per day,for one week. By analysis of clinical features and TCD data, both A and B could cure cerebral vasospasm, but group A was obviously superior to group B. Our conclusion is that papaverine solution lavaged locally can effectively prevent cerebral vasospasm after cerebral aneurysm operation .

CT Findings of Late Onset Intracranial Hemorrage in Vitamin K Deficiency / 实用放射学杂志

Objective To study the CT findings of late onset intracranial hemorrhage in vitamin K(Vit K) deficiency.Methods 56 cases of late onset intracranial hemorrhage in Vit K deficiency proved clinically were presented.There were 42 male and 14 female,age ranging 28～60 days.Brain CT scans were obtained in all 56 cases. Results Subarachnoid hemorrage(SAH) in 33 cases,subdural hemorrage(SDH) in 32 cases,intracerebral hemorrage(ICH) in 19 cases and inraventricular hemorrage(IVH) in 8 cases were found.The hemorragic amount was ranged 2～150 ml.Simple hemorrage was demonstrated in 26 cases,and multiple mixed hemorrage in 30 cases.The cerebral edema was displaied in 16 cases.Conclusion SAH,SDH and multiple mixed hemorrage are common seen in the late onset intracranial hemorrage in Vit K deficiency.

Percutaneous transhepatic variceal obliteration in patients with severe hepatic cirrhosis / 介入放射学杂志

Objective To evaluate the effects of percutaneous transhepatic variceal obliteration in the treatment of acute bleeding from gastroesophageal varices in patients with severe cirrhosis.Methods 19 patients with Child C cirrhosis suffered from active bleeding from gastroesphageal varices. Emergency procechures of percutaneous transhepatic variceal obliteration were performed in all 19 patients. Results Successful catheterization and obliteration of the varices in all of the 19 cases. Active bleeding were controlled in 18 cases with only one failure and TIPSS was performed. During a follow up peroiod ranging from one to 12 months, 14 cases bled recurrently during 3 to 12 months. 15 cases died within the follow up period. 4 cases were alive. Severe complication of intraperitoneal bleeding occurred in 1 case, and laparotomy was performed. Conclusions Percutaneous transhepatic variceal obliteration is effective in controlling acute bleeding from gastroesophageal varices in patients with Child C cirrhosis. It could be used as the first choice treatment method for emergency when TIPSS is contraindicated.