Portal venous pressure in non-cirrhotic bilharzial patients undergoing elective splenectomy, can it affect mortality? A prospective study.

BACKGROUND AND STUDY AIMS: To evaluate the impact of intraoperatively measured portal vein pressure (PVP) on mortality in non-cirrhotic bilharzial patients undergoing splenectomy. METHODS: The present study is a prospective study that was conducted in Egypt from April 2014 to April 2018. Adult patients with non-cirrhotic bilharziasis who were scheduled to undergo splenectomy were included. Studied cases were divided into a survival cohort and a non-survival cohort. The main objective was the correlation between the incidence of mortality and intraoperative PVP. RESULTS: The present work comprised 130 cases with a mean age of 51.8 ± 6.4 years old. The in-hospital mortality rate was 22.3%, with sepsis as a major cause of death (37.9%). In term of the association between preoperative variables and mortality, survivors had statistically significant lower portal vein diameter (13.6 ± 1.8 versus 15.2 ± 1.8mm; p<0.001) and higher portal vein velocity (14.2 ± 1.8 versus 10.4 ± 2.3 cm/sec; p<0.001) than nonsurvivors. The survived patients had significantly lower PVP (13.9 ± 1.1 versus 17.7 ± 2.7; p<0.001). A cut-off value of ≥14.5 mmHg, the PVP yielded a sensitivity of 86.2% and a specificity of 69% for the prediction of mortality. The association analysis showed a statistically significant association between mortality and postoperative liver function parameters. CONCLUSIONS: High intraoperative PVP is linked to early postoperative death in non-cirrhotic cases undergoing splenectomy. Our study showed that PVP > 14.5mmHg was an independent predictor of death and showed good diagnostic performance for the detection of early postoperative mortality.

High- versus low-dose proton pump inhibitors post endoscopic hemostasis in hemodialysis cases with peptic ulcer bleeding.

Post-endoscopic hemostasis treatment is not adequately addressed in high-risk patients on regular hemodialysis (HD) with emergency peptic ulcer bleeding. This study aimed to compare post-endoscopic high- versus low-dose proton pump inhibitors (PPIs) for peptic ulcer bleeding in patients undergoing regular HD. This prospective study comprised 200 patients on regular hemodialysis having emergency peptic ulcer bleeding confirmed at endoscopy and managed with endoscopic hemostasis. Half of the patients received high-dose intensive regimen and the other half received the standard regimen. Patients who were suspected to have recurrent bleeding underwent a second endoscopy for bleeding control. The primary outcome measure was rate of recurrent bleeding during period of hospitalization that was detected through second endoscopy. Rebleeding occurred in 32 patients ; 15 in the High-Dose Cohort and 17 in the Low-Dose Control (p = 0.700). No significant differences between the two dose cohorts regarding the time of rebleeding (p = 0.243), endoscopic hemostasis mode (p = 1.000), and need for surgery (p = 0.306). The highdose regimen Inhospital mortality in high-dose group was 9.0% compared to 8.0% in the low-dose group (p = 0.800). Apart from the pre-hemostatic Forrest classification of ulcers, there were no significant differences between patients with re-bleeding ulcers (n=32) and those with non-rebleeding (n=168). Rebleeding was more common in class Ia, i.e. spurting bleeders (p < 0.001). Endoscopic hemostasis followed by the standard low-dose PPI regimen of 40 mg daily IV boluses is safe and effective option for bleeding peptic ulcers in the high-risk patients under regular hemodialysis.

Long-term outcome after endoscopic ligation of acute esophageal variceal bleeding in patients with liver cirrhosis.

Endoscopic variceal ligation (EVL) has been the standard treatment for acute variceal bleeding (AVB). However, reports of long-term prognosis after EVL are scarce. Therefore, the current work aimed to investigate the long-term outcome and prognostic modifiers of cirrhotic cases presented with acute esophageal variceal bleeding and managed with EVL. The current prospective work comprised primarily 276 consecutive grown-up cirrhotic cases presenting with AVB and managed with EVL. Two-hundred patients who completed the study till death or 3-year follow-up were enrolled in final analysis. The primary outcome measure was occurrence of rebleeding and all-cause mortality. By the end of follow up 56 patients (28%) developed rebleeding and 78 (39%) died. The independent factors associated with rebleeding were lacking follow up EVL (OR: 4.8, 95%CI: 1.9-12.2), BMI > 30 kg/m2 (OR: 0.-, 95%CI: 0.2-0.9), Child class C (OR: 3.8, 95%CI: 1.8-7.8), and grade IV varices (OR: 2.6, 95%CI: 1.3-5.3). The independent factors associated with mortality were: Age > 65 years (OR: 32.4, 95%CI: 8.7-120.3), rebleeding (OR: 98.4, 95%CI: 27.9-347.0), coexistence of HCC (OR: 7.4, 95%CI: 2.0-27.4), and lacking follow up EVL (OR: 6.1, 95%CI: 1.2-31.1). Recurrent bleeding after emergency endoscopic ligation of acute esophageal variceal bleeding in cirrhotic cases is a rather common complication that significantly increases the mortality rate. The liver condition, lack of follow up endoscopy, old age, and severity of esophageal varices are independent prognostic indicator of rebleeding and morality.