The value of liver fibrosis serum markers in predicting esophagogastric variceal re-bleeding after laparoscopic splenectomy and azygoportal disconnection: a prospective study / 中华消化外科杂志

Objective:To investigate the value of liver fibrosis serum markers in predicting esophagogastric variceal re-bleeding (EGVR) after laparoscopic splenectomy and azygoportal discon-nection (LSD).Methods:The prospective study was conducted. The clinical data of 155 cirrhotic portal hypertension patients with EGVR after LSD in the Clinical Medical College of Yangzhou University from September 2014 to January 2017 were selected. Observation indicators: (1) grouping situations of the enrolled patients; (2) risk factors analysis for postoperative EGVR; (3) prediction of postoperative EGVR; (4) follow-up. Follow-up was conducted using telephone interview, outpatient examination and hospitalization. Patients were followed up once every 3 months after operation to detect occurrence of EGVR and survival of patient up to January 2018. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data wite skewed distribution were represented as M(range), and comparison between groups was conducted using the non-parameter test. Count data were described as absolute numbers, and comparison between groups were conducted using the chi-square test or Fisher exact probability. Logistic regression model was used for multivariate analysis. The area under curve (AUC) of receiver operating characteristic (ROC) curve was used to estimate the diagnostic efficiency. The Youden index was used to determine the optimal cut-off point. Results:(1) Grouping situations of the enrolled patients. A total of 155 patients were selected for eligibility. There were 106 males and 49 females, aged (53±11)years. Of the 155 patients, there were 21 cases with EGVR in the postoperative 1 year and 134 cases without EGVR in the postoperative 1 year. The protein expression of laminin and collagen Ⅳ were 100.3(range, 16.1?712.2)μg/L and 68.4(range, 35.0?198.8)μg/L in patients with EGVR, vs 35.5(range, 2.0?521.2)μg/L and 43.5(range, 4.3?150.4)μg/L in patients without EGVR, showing significant differences between them ( Z=?4.55, ?4.52, P<0.05). (2) Risk factors analysis for postoperative EGVR. According to the Youden index, the optimal cut-off point of protein expression of laminin and collagen Ⅳ were 64.0 μg/L and 65.0 μg/L, respec-tively. Results of multivariate analysis showed that the protein expression of laminin ≥64.0 μg/L and the protein expression of collagen Ⅳ ≥65.0 μg/L were independent risk factors for postoperative EGVR ( odds ratio=9.69, 8.16, 95 confidence intervals as 3.05?30.82, 2.65?25.15, P<0.05). (3) Prediction of postoperative EGVR. Results of ROC curve showed that the AUC of laminin and collagen Ⅳ in predicting postoperative EGVR was 0.79 (95% confidence interval as 0.66?0.92), with sensi-tivity as 0.62 and specificity as 0.96. (4) Follow-up. All the 155 patients were followed up for 12(range, 1?12)months. During the follow-up, there were 21 of the 155 patients (13.55%) with post-operative EGVR, including 3 cases died of EGVR. Of the 21 patients with postoperative EGVR, there were 6 cases with postoperative EGVR during the first month after operation including 2 cases died, 5 cases with postoperative EGVR at postoperative 1?3 month, 6 cases with postoperative EGVR more than 3 month and less than 6 month after operation and 4 cases with postoperative EGVR at postoperative 6?12 months including 1 case died at postoperative 12 month. Conclusions:Laminin and collagen Ⅳ show satisfactory ability to predict EGVR after LSD.

Riesgo de resangrado en hemorragia digestiva alta según la escala de Glasgow-Blatchford: herramienta de triaje / Upper gastrointestinal hemorrhage re-bleeding risk according to the Glasgow-Blatchford scale: a triage tool

Resumen Introducción: Con la escala de Glasgow-Blatchford (EG-B) se califica mediante datos clínicos, el riesgo de resangrado después de hemorragia del tubo digestivo alto (HTDA); y con las escalas de Forrest y Dagradi, mediante endoscopia. Objetivo: Evaluar la capacidad de la EG-B para identificar riesgo de resangrado a 30 días después de una HTDA; el estándar de oro de comparación fue la endoscopia. Método: Se analizaron 129 expedientes de pacientes con HTDA y endoscopia. Se cuantificaron las escalas de Glasgow-Blatchford, Forrest y Dagradi; se calculó sensibilidad, especificidad y área bajo la curva ROC (ABC-ROC) del riesgo de resangrado reportado por EG-B. Resultados: La EG-B identificó a 53 pacientes con riesgo bajo de resangrado (41.09 %) y 76 con riesgo alto (58.91 %). Con la endoscopia se identificó a 107 pacientes con hemorragia no variceal (82.94 %), 98 con riesgo bajo (89.9 %) y 11 con riesgo alto (10.09 %); además, 22 pacientes con hemorragia variceal (17.05 %), 12 con riesgo bajo (54.54 %) y 10 con riesgo alto (45.45 %). La EG-B mostró sensibilidad de 0.857, especificidad de 0.462 y ABC-ROC de 0.660. Conclusiones: La EG-B es sencilla, objetiva y útil para identificar riesgo de resangrado después de HTDA; se sugiere como herramienta de triaje en urgencias.

Abstract Introduction: The Glasgow-Blatchford scale (GBS) classifies the risk of re-bleeding after upper gastrointestinal bleeding (UGIB) using clinical data, whereas the Forrest and Dagradi scales do it by endoscopy. Objective: To assess GBS’s ability to identify re-bleeding risk within 30 days of an UGIB, using endoscopy as the gold standard for comparison. Method: 129 medical records of patients with UGIB and endoscopy were analyzed. The Glasgow-Blatchford, Forrest and Dagradi scales were quantified; sensitivity, specificity and area under the ROC curve (AUC-ROC) of GBS-reported re-bleeding risk were calculated. Results: GBS identified 53 patients with low re-bleeding risk (41.09 %) and 76 with high risk (58.91 %). Endoscopy identified 107 patients with non-variceal bleeding (82.94 %): 98 with low risk (89.9 %) and 11 with high risk (10.09 %); in addition, it identified 22 patients with variceal hemorrhage (17.05 %): 12 with low risk (54.54 %) and 10 with high risk (45.45 %). GBS showed a sensitivity of 0.857, specificity of 0.462 and an AUC-ROC of 0.660. Conclusions: GBS is simple, objective and useful to identify the risk of re-bleeding after UGIB; it is suggested as a triage tool in the emergency department.

Application of the doctor-nurse integration care mode after EVL in liver cirrhosis patients / 现代临床护理

ObjectiveTo explore the effect of doctor-nurse integration mode in treating patients with liver cirrhosis treated with endoscopic variceal ligation (EVL).Methods According to the random number table,74 patients were randomly divided into control group and experiment group with 37 in each group.The control group was given routine nursing,while the experiment group was managed by doctor-nurse integration nursing mode.The two groups were compared in respect of early re-bleeding after EVL and mastery of health knowledge.Result The mastery of health-related knowledge in the experiment group was better than the control one and the rate of re-bleeding was significantly lower (P<0.05).Conclusion The doctor-nurse integration care mode can reduce the early postoperative re-bleeding after EVL in patients with liver cirrhosis and enhance the health education awareness.

Consenso Baveno V: ¿Qué hay de nuevo en hipertensión portal? / Baveno V consensus workshop: what is new in portal hypertension?

In patients with cirrhosis and portal hypertension, variceal bleeding is a severe complication, and still a major cause of death. From 1986 to 2010 (Baveno V), several consensuses related to this topic have been carried out. The main purposes of these meetings were to develop clear definitions and therapeutic recommendations aimed at the standardization and increased ease of interpretation among different studies, to be homogeneous, which is essential for meta-analysis. This applies both to the definition of events related to variceal hemorrhage and therapeutic behaviour. In Baveno V some definitions were modified such as criteria for failure to control bleeding, and failure of secondary prophylaxis, while other definitions were validated. As in Baveno IV, the level of evidence (1 being the highest, 5 being the lowest) and the grades of recommendation (‘A’ the strongest, ‘D’ the weakest) were assessed according to the Oxford System. Particular emphasis was placed on management of non-cirrhotic portal hypertension, especially on the Budd-Chiari syndrome and extra-hepatic portal vein obstruction. Areas requiring further study include mechanism in the development and progression of portal hypertension; the development of non-invasive techniques to identify patients with clinically significant portal hypertension; the assessment of the impact of the management of chronic liver disease in the development of this condition; the role of regular control of portal hypertension in the prevention of the development and progression of gastroesophageal varices. Finally more information about non-cirrhotic portal hypertension is needed, especially on the frequency, primary prophylaxis of variceal bleeding, factors associated with treatment failure, progression and thrombosis recurrence.

La hipertensión portal (HP) constituye un alteración hemodinámica severa, responsable de las principales complicaciones de la cirrosis, entre las cuales está la hemorragia por várices gastroesofágicas. Desde el año 1986 y hasta el 2010 (Baveno V), se han efectuado diferentes reuniones de consensos, cuyos objetivos han sido estandarizar criterios, haciéndolos simples y reproducibles, de tal forma de homogeneizar los resultados de estudios clínicos y meta-análisis. Esto es válido tanto para la definición de eventos relacionados con hemorragia variceal, como de conductas terapéuticas. En Baveno V se han modificado algunas definiciones como los criterios de falla en el control de la hemorragia, y de falla en la profilaxis secundaria, mientra que otras se validaron. Al igual que en Baveno IV, se utilizó el Sistema Oxford, para representar el nivel de evidencia (1 el mayor; 5 el menor) y de recomendación (‘A’ la más fuerte y ‘D’ la de menor peso). Especial hincapié se ha hecho en el manejo de la HP de origen no cirrótica (Síndrome de Budd-Chiari y obstrucción de la vena porta extra-hepática). Finalmente, las áreas con desafíos en investigación clínica incluyen mecanismos en el desarrollo y progresión de la HP; empleo de medidas no invasivas para identificar pacientes con HP de significación; evaluación del impacto que tiene el manejo de la enfermedad hepática de base, en el desarrollo de esta complicación; el papel de la medición de la presión portal en la prevención del desarrollo y progresión de las várices gastroesofágicas. Finalmente, se recomienda realizar estudios prospectivos sobre prevalencia y evolución clínica de la HP no cirrótica y profilaxis primaria de la hemorragia variceal; identificación de la población de riesgo y de factores asociados con falla al tratamiento, progresión de la enfermedad y recurrencia.

Indications of Postoperative Angiography after Surgical Treatment of Intracranial Aneurysms

OBJECTIVE: Subarachnoid hemorrhage(SAH) is still one of the most serious disease with high morbidity and mortality in the neurosurgical field. Clipping of the aneurysmal neck is the gold standard of the surgical treatment of aneurysmal SAH. The purpose of this study was to investigate the role of the postoperative angiography and to assess the risk factors related to the incomplete clipping. MATERIALS AND METHODS: From July 1995 to June 1998, the pre- and postoperative angiography were performed in 50 patients among total 81 patients who have underwent the aneurysmal surgery. We reviewed the various contributing factors including age, sex, Hunt-Hess grade, Fisher grade and the premature rupture of aneurysm during operation retrospectively. Careful evaluation of pre- and postoperative angiography focusing on the size, shape, and remnant neck of the aneurysms and vasospasm was performed. According to the angiographic findings, the patients were divided into two groups; a complete clipping group and an incomplete clipping group. The data were analyzed by using unpaired independent sample t test after F-test to compare the significance between two groups. RESULTS: Incomplete clipping of aneurysms was found in 6(12%) patients through the evaluation of postoperative angiography. Among them, three cases were located on the middle cerebral artery territory. Whereas the patient age, sex, Hunt-Hess grade, and Fisher grade were not significant(p<0.05), an intraoperative premature rupture had a statistical significance(p<0.05). A severe vasospasm occurred in 24(48%) cases and one patient with anterior communicating aneurysm was reoperated due to residual sac. CONCLUSION: According to our experience, the surgeons' judgement is the most reliable factor in deciding the postoperative angiography. During the aneurysmal surgery, the premature rupture always disturbs a complete clipping of aneurysms. Therefore, the temporary clipping of parent arteries is considered essential for a successful clipping. We believe that the postoperative angiography has a role in decreasing the re-bleeding risk due to clip migration and an inaccurate clipping only in the selected cases.