Comparison of heater probe coagulation and argon plasma coagulation in the management of Mallory-Weiss tears and high-risk ulcer bleeding.

BACKGROUND AND STUDY AIMS: Upper gastrointestinal (GI) bleeding is a common medical emergency. Endoscopic treatments often lead to better therapeutic outcomes than conventional conservative treatments. This study aimed to investigate and compare the use of heater probe coagulation (HPC) and argon plasma coagulation (APC) together with epinephrine injection for the treatment of Mallory-Weiss tears and high-risk ulcer bleeding. PATIENTS AND METHODS: A total of 97 patients (54 in the HPC group and 43 in the APC group) who were diagnosed with upper GI bleeding secondary to a Mallory-Weiss tear or high-risk gastric or duodenal ulcers were included in the study. Lesions were classified according to the Forrest classification. The HPC and APC groups were compared in terms of initial haemostasis, re-bleeding in the early period, need for surgery, average need for transfusion, and duration of hospital stay. RESULTS: There were no significant differences between the HPC and APC groups in terms of ensuring initial haemostasis (98% vs. 97.5%, p>0.05), re-bleeding rates (17% vs. 19%, p>0.05), need for surgery (2% vs. 9%, p>0.05), average need for transfusion (3.7±2.11 vs. 3.4±2.95 units, p>0.05), and average duration of hospital stay (4.6±2.24vs. 5.3±3.23days, p>0.05). CONCLUSION: There was no difference between HPC and APC when used together with epinephrine injection for the treatment of Mallory-Weiss tear and high-risk ulcer bleeding.

Effective endoscopic treatment of Mallory-Weiss syndrome using Glasgow-Blatchford score and Forrest classification.

OBJECTIVES: There is limited data on whether scoring systems can be used to predict clinical outcomes in patients with upper gastrointestinal bleeding due to Mallory-Weiss syndrome (MWS). We aimed to evaluate whether the Glasgow-Blatchford score (GBS) could be effective in predicting clinical outcomes of bleeding MWS and to investigate the predictive ability of the Forrest classification for rebleeding and assess the effective endoscopic modalities for bleeding control in MWS. METHODS: From January 2004 to December 2012 168 patients were diagnosed with MWS in the Asan Medical Center Emergency Department. We analyzed their clinical outcomes, including endoscopic treatment, transfusion and admission as well as the rates of rebleeding and mortality using GBS and the Forrest classification, retrospectively. RESULTS: Endoscopic treatment was applied to patients. The GBS was significantly higher in patients treated with endoscopic therapy than in the conservative treatment group (6.8 ± 3.7 vs 5.1 ± 4.7, P = 0.011). In patients with a GBS of >6 the rates of endoscopic treatment and rebleeding and the need for transfusion and admission were significantly higher (all P < 0.05). The Forrest classification was able to predict recurrent bleeding (area under the receiver operating characteristic curve 0.723, 95% confidence interval 0.609-0.836, P = 0.025). Hemoclip-based therapy and band ligation achieved higher success rates than did injection therapy alone in preventing rebleeding (96.4%, 88.9% and 71.4%, P = 0.013). CONCLUSION: In MWS, GBS might be useful for predicting clinical outcomes and the Forrest classification in predicting recurrent bleeding.

Outcomes of Propofol Sedation During Emergency Endoscopy Performed for Upper Gastrointestinal Bleeding.

BACKGROUND: Although propofol-based sedation can be used during emergency endoscopy for upper gastrointestinal bleeding (UGIB), there is a potential risk of sedation-related adverse events, especially in patients with variceal bleeding. AIM: We compared adverse events related to propofol-based sedation during emergency endoscopy between patients with non-variceal and variceal bleeding. METHODS: Clinical records of patients who underwent emergency endoscopy for UGIB under sedation were reviewed. Adverse events, including shock, hypoxia, and paradoxical reaction, were compared between the non-variceal and variceal bleeding groups. RESULTS: Of 703 endoscopies, 539 and 164 were performed for non-variceal and variceal bleeding, respectively. Shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding (12.2 vs. 3.5%, P < 0.001). All patients except one recovered from shock after normal saline hydration, and emergency endoscopy could be finished without interruption in most cases. The incidence of hypoxia and paradoxical reaction did not differ based on the source of bleeding (non-variceal bleeding vs. variceal bleeding: hypoxia, 3.5 vs. 1.8%, P = 0.275; paradoxical reaction interfering with the procedure, 4.1 vs. 5.5%, P = 0.442). CONCLUSIONS: Although shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding, most cases could be controlled without procedure interruption. Paradoxical reaction, rather than shock or hypoxia, was the most common cause of procedure interruption in patients with variceal bleeding, but the rate did not differ between patients with non-variceal and variceal bleeding.

Risk Factors for Aspiration Pneumonia After Endoscopic Hemostasis.

BACKGROUND: Although all types of endoscopic procedures harbor risk of aspiration, little is understood about risk factors for aspiration pneumonia developing after endoscopic hemostasis. AIMS: The present study aimed to identify risk factors for aspiration pneumonia after endoscopic hemostasis. METHODS: Charts from consecutive patients with upper gastrointestinal bleeding that had been treated by endoscopic hemostasis at a single center between January 2004 and January 2015 were retrospectively reviewed. Patient information and clinical characteristics including cause of hemorrhage, established prognostic scales, laboratory data, comorbidities, medications, duration of endoscopic hemostasis, vital signs, sedative use, and the main operator during the procedure were compared between patients who developed aspiration pneumonia and those who did not. RESULTS: Aspiration pneumonia developed in 24 (4.8%) of 504 patients after endoscopic hemostasis. Endotracheal intubation was required for three of them, and one died of the complication. Multivariate analysis revealed that age >75 years (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.5-13.6; p = 0.0073), procedural duration >30 min (OR 5.6; 95% CI 1.9-18.2; p = 0.0023), hemodialysis (OR 3.6; 95% CI 1.2-11; p = 0.024), and a history of stroke (OR 3.8; 95% CI 1-14; p = 0.041) were independent risk factors for developing aspiration pneumonia. CONCLUSIONS: Specific risk factors for aspiration pneumonia after endoscopic hemostasis were identified. Endoscopists should carefully consider aspiration pneumonia when managing older patients who are on hemodialysis, have a history of stroke, and undergo a longer procedure.

Upper gastrointestinal bleeding.

Upper gastrointestinal (GI) bleeding remains a commonly encountered diagnosis for acute care surgeons. Initial stabilization and resuscitation of patients is imperative. Stable patients can have initiation of medical therapy and localization of the bleeding, whereas persistently unstable patients require emergent endoscopic or operative intervention. Minimally invasive techniques have surpassed surgery as the treatment of choice for most upper GI bleeding.

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy.

BACKGROUND: Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. OBJECTIVE: To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). DESIGN: Secondary analysis of prospectively collected data from 3 national databases. SETTINGS: Community and teaching hospitals. PATIENTS: Consecutive patients admitted for acute nonvariceal UGIB. INTERVENTIONS: Early endoscopy, medical and endoscopic treatment as appropriate. MAIN OUTCOME MEASUREMENTS: Thirty-day mortality, recurrent bleeding, and need for surgery. RESULTS: A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001). LIMITATIONS: No data on the American Society of Anesthesiologists class score in the Prometeo study. CONCLUSIONS: Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

[Etiology and pathogenesis of Mallory-Weiss syndrome].

Treatment results of 405 patients with Mallory-Weiss syndrome, X-ray gastric investigation in patients with severe bloating reflex were analyzed. Experimental part of the study involved rats and pigs, modeling esophageal and gastric rupture. Cardioesophageal and gastric cardial rupture happen in case of simultaneous sudden intragastric and intraabdominal hypertension, following the rule of Laplace.

[Mallory-Weiss lesions]. / Mallory-Weiss laesioner.

INTRODUCTION: Mallory-Weiss syndrome (MW) has been know since 1929. Only few studies exist which focus on the prognosis of the lesion. No Danish MW data are available. The purpose of the study was to describe the demographics of patients admitted with an MW to a Danish surgical unit during a 5-year period and to investigate the prognosis of these patients. MATERIAL AND METHODS: Data from the patient records of 49 patients with endoscopically verified MW admitted through a five-year period were analysed. At follow-up, 35 patients were alive and contacted. A total of 29 responded. The mean time to follow-up from admittance was 42.7 months (range: 10.1-77.1). RESULTS: Haemostasis was achieved in all 49 patients. Sixteen received active therapy during the endoscopic procedure. Haemoglobin at admittance was lower (p = 0.008), the presence of bleeding stigmata higher (p < 0.0001) and the number of patients receiving blood transfusion higher (p = 0.01) among those receiving active therapy than among the group receiving no therapy at the time of their endoscopy. At follow-up, 50% of those receiving active therapy were dead (eight of 16) compared with 18% (six of 33) in the no-therapy group (p = 0.02). In the follow-up period, 10% of the patients admitted with an MW were re-admitted for a new gastrointestinal bleeding. CONCLUSION: Our data suggests that an attitude change is needed toward MW with bleeding stigmata. The course of the disease may not be as benign as generally believed. Further prospective studies designed to resolve this matter are needed.

[The treatment of patients with Mallory-Weiss syndrome].

Results of treatment of 345 patients with Mallory-Weiss syndrome were analyzed. Classification of the disease with a glance on stages and bleeding activity was given. Methods of hemostasis and indications for the surgical interference were discussed. The importance of consideration and respective treatment of the concomitant gastrointestinal diseases or alcohol intoxication was stressed.

The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding.

Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.

Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding.

AIM: To compare the hemostatic efficacy and safety of two mechanical endoscopic methods: endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in patients with actively bleeding Mallory-Weiss syndrome (MWS). METHODS: A prospective randomized study to compare the efficacy and safety of EHP with EBL was performed from January 2002 to August 2005. Forty-one patients with active bleeding from MWS were treated with EHP (n = 21) or EBL (n = 20). RESULTS: There were no significant differences between groups with respect to clinical and endoscopic characteristics. The mean number of hemoclips applied was 3.2 +/- 1.5 and the mean number of bands applied was 1.2 +/- 0.4. Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient from the EHP group and two from the EBL group. Patients with recurrent bleeding were treated by the same modality as at randomization and secondary hemostasis was achieved in all. There were no significant differences between the two groups in total transfusion amount or duration of hospital stay. No complications or bleeding-related death resulted. CONCLUSION: EHP and EBL are equally effective and safe for the management of active bleeding in patients with Mallory-Weiss syndrome, even in those with shock or comorbid diseases.

[Therapy and course of disease in spontaneous esophageal perforations]. / Chirurgische Therapie und Verlauf nach spontaner Osophagusruptur.

INTRODUCTION: Esophageal perforations occur spontaneously or as a complication of endoscopic procedures. Especially in spontaneous perforation there is ongoing debate regarding the best treatment options. METHODS: 24 patients that were treated at two surgical centers (University Halle, City-hospital Bielefeld) after spontaneous esophageal perforations between 1996 and 2005 were analysed retrospectively. RESULTS: All patients but one underwent surgical treatment with in 2 cases additional stent implantation. Average stay in hospital was 53 days. In-hospital-lethality was 25% (overall lethality 37.5%). Concerning the therapeutic outcome there was no link between patients' age, localization or size of the perforation and the time interval between perforation and treatment. In 22 patients diagnosis was made > 12hrs after the event. CONCLUSIONS: Main problem of the Boerhaave-syndrome is the septic-toxic disease. Prognostic criteria are the patients' health-state and not factors like size of perforation, time of delay or localization of the perforation. Since in case of survival esophageal resection shows good long-term-results, in doubt a radical surgical procedure should be recommended as primary option. Implanting an esophageal stent might become a useful mean of treating patients with spontaneous perforations.

The role of endoscopy in early postoperative haemorrhage.

Diagnostic as well as therapeutic endoscopy has a decisive role in management of early postoperative haemorrhage. Endoscopy combines easy access to the upper and lower gastrointestinal tract and application of an array of interventional tools. In near future, even the small bowel will be accessible for diagnostic and therapeutic measures due to the advent of double-balloon enteroscopy. Thus, the endoscopist increasingly replaces the surgeon for diagnosis and therapy of postsurgical bleeding. Published data on frequency and aetiology of postoperative haemorrhage are scarce and mainly casuistic. Sources of gastrointestinal bleeding associated with surgery may be: anastomotic ulcers, mucosal ischaemia, 'stress' ulcers, reflux-induced lesions, coagulopathies (e.g. in sepsis or after organ transplantation) and aortoenteric fistula after bypass surgery. The endoscopist will frequently identify the culprit lesion and guide further management of the patient (e.g. endoscopic approach, repeated surgery, interventional radiology). All accessible lesions in postoperative haemorrhage should primarily be treated by endoscopic means, except aortoenteric fistulas. There is even a place for repeated endoscopy in recurrent bleeding. In the face of lacking controlled data, the endoscopist often has to rely on his personal experience in the selection of therapeutic options.

[Selfexpandable metal stent for the treatment of a large anastomotic insufficiency after esophageal resection]. / Minimalinvasives Management einer ausgedehnten mediastinalen Anastomoseninsuffizienz nach Osophagusresektion mit einem gecoverten selbstexpandierbaren Metallstent.

Mediastinal anastomotic leaks are still catastrophic events following surgical procedures and are still a therapeutic challenge. A variety of conservative and surgical procedures have been proposed for the management of this conditions. An aggressive surgical approach is associated with considerable morbidity and lethality. A conservative approach is indicated only in a few selected patients with minimal anastomotic leaks. With advances in minimally invasive techniques, interventional endoscopic procedures have become an established therapeutic approach in the treatment of anastomotic insufficiencies. Our case report demonstrates that transesophageal placement of a selfexpandable metal stent in combination with interventional drainage of the paraesophageal space is a safe and effective procedure in the management of a mediastinal anastomotic leaks.

Endoscopic ligation for patients with active bleeding Mallory-Weiss tears.

BACKGROUND: Only a few patients with active nonesophageal variceal upper gastrointestinal bleeding have been treated with endoscopic ligation. To further address this issue, four patients with active bleeding Mallory-Weiss tears who underwent endoscopic band ligation are presented. PATIENTS AND METHODS: Endoscopic ligation was performed in four patients with a median age of 52 years (range, 40-93 years) after a diagnosis of active bleeding Mallory-Weiss tears (MWTs). A 45-year-old man with massive persistent upper gastrointestinal bleeding as a cause of a MWT underwent therapeutical endoscopic band ligation after an unsuccessful endoscopic injection trial. On the contrary, injection therapy should have been performed on a 93-year-old woman with multiple myeloma because of an actively bleeding MWT caused by the fibrotic tissue after an unsuccessful endoscopic ligation trial, although her other actively bleeding MWT lesion had been ligated successfully. RESULTS: After endoscopic ligation, all patients achieved complete hemostasis, and rebleeding did not occur. They were discharged without complications after a control endoscopy. CONCLUSIONS: Endoscopic ligation can be performed easily and without any complications such as perforation or delayed hemorrhage in patients with actively bleeding nonfibrotic MWTs.

Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome.

BACKGROUND: Endoscopic hemoclipping is known to be highly effective as hemostatic treatment for upper gastrointestinal bleeding. However, the efficacy and safety of hemoclipping for Mallory-Weiss syndrome (MWS) have not been reported. Thus, the aim of the present study was to assess prospectively the usefulness of endoscopic hemoclipping for MWS bleeding. METHODS: This study was conducted from January 1994 to August 1999. Hemoclipping was performed when active bleeding (spurting, streaming or oozing), visible vessels or fresh adhesive clots were found on endoscopic examination. Patients who did not have any of these findings were conservatively treated. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the procedure. RESULTS: MWS was diagnosed in a total of 58 patients during the study. Hemoclipping was performed in 26 patients and was technically successful in all cases. The average number of hemoclips used was 2.8 +/- 1.6 (range 1 to 8). The number of hemoclips required for hemostasis depended on the nature of the bleeding. No complications, recurrent bleeding, or deaths resulted. Follow-up endoscopy showed no evidence of hemoclip-induced tissue injury and no impairment of Mallory-Weiss tears. CONCLUSION: Endoscopic hemoclipping provided an effective and safe modality for obtaining hemostasis when bleeding is due to MWS.