Incidence and Mortality Related to Gastrointestinal Bleeding, and the Effect of Tranexamic Acid on Gastrointestinal Bleeding.

BACKGROUND: Gastrointestinal bleeding is a common and potentially life-threatening condition. The incidence of gastrointestinal bleeding has not decreased despite new prophylaxis and treatments. Ulcer is still one of the most common etiologies for upper gastrointestinal bleeding. It is routinely treated with proton pump inhibitors (PPIs) and endoscopic interventions, sometimes endovascular procedures, and rarely today, open surgery with suture to stop the bleeding. The fibrinolytic tranexamic acid (TXA) has a role in bleeding treatment, and is routinely used for example within trauma care, postpartum bleeding and orthopedic surgery. The aim of this study is to assess the incidence of gastrointestinal bleeding. A further aim was to investigate if TXA has any role in medical treatment of gastrointestinal bleeding today. METHODS: We performed a retrospective cohort study with a review of medical records, involving patients with clinical signs of gastrointestinal bleeding and endoscopically verified ulcers between the years of 2010 and 2016 at the University Hospital of Linkoping, Sweden. The cities of Motala and Linkoping have the primary acute admissions at this Hospital. RESULTS: We found in total 1,331 patients with gastrointestinal bleeding. The overall incidence for patients with gastrointestinal bleeding was 98.6 (98.6/100,000 inhabitants and year). For those with endoscopically verified ulcer (386 patients), the incidence for peptic ulcer was 28.6/100,000/year. In the group with endoscopically verified ulcer, 25 patients died, giving the 30-day mortality of 6.4%. TXA is still used for treatment of bleeding ulcers. We had two groups, those with and without TXA treatment. They were equal in age, gender and comorbidity. Clinically we saw no major differences in respect to hemodynamic stability. There were more patients with overt bleeding symptoms in the TXA group. We also saw more patients in need of intensive care in the TXA group. CONCLUSIONS: The incidence of gastrointestinal bleeding has not significantly decreased during the last years. There was no significant positive effect of TXA in patients with upper gastrointestinal bleeding in this study. The difference between the two groups is probably more a question of whom we treat with TXA (e.g., the patients in worse condition or at higher risk) than a difference in drug effect. It is time to quit with TXA treatment in all patients with gastrointestinal bleeding, even those at intensive care unit (ICU).

Surgical Morbidity and Mortality From the Multicenter Randomized Controlled NeoRes II Trial: Standard Versus Prolonged Time to Surgery After Neoadjuvant Chemoradiotherapy for Esophageal Cancer.

OBJECTIVE: To investigate if prolonged TTS after completed nCRT improves postoperative outcomes for esophageal and esophagogastric junction cancer. SUMMARY OF BACKGROUND DATA: TTS has traditionally been 4-6 weeks after completed nCRT. However, the optimal timing is not known. METHODS: A multicenter clinical trial was performed with randomized allocation of TTS of 4-6 or 10-12 weeks. The primary endpoint of this sub-study was overall postoperative complications defined as Clavien-Dindo grade II-V. Secondary endpoints included complication severity according to Clavien-Dindo grade IIIb-V, postoperative 90-day mortality, and length of hospital stay. The study was registered in Clinicaltrials.gov (NCT02415101). RESULTS: In total 249 patients were randomized. There were no significant differences between standard TTS and prolonged TTS with regard to overall incidence of complications Clavien-Dindo grade II-V (63.2% vs 72.6%, P = 0.134) or regarding Clavien-Dindo grade IIIb-V complications (31.6% vs 34.9%, P = 0.603). There were no statistically significant differences between standard and prolonged TTS regarding anastomotic leak (P = 0.596), conduit necrosis (P = 0.524), chyle leak (P = 0.427), pneumonia (P = 0.548), and respiratory failure (P = 0.723). In the standard TTS arm 5 patients (4.3%) died within 90 days of surgery, compared to 4 patients (3.8%) in the prolonged TTS arm (P = 1.0). Median length of hospital stay was 15 days in the standard TTS arm and 17 days in the prolonged TTS arm (P = 0.234). CONCLUSION: The timing of surgery after completed nCRT for carcinoma of the esophagus or esophagogastric junction, is not of major importance with regard to short-term postoperative outcomes.

Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial.

BACKGROUND: Goal-directed therapy (GDT) is expected to be of highest benefit in high-risk surgery. Therefore, GDT is recommended during oesophageal resection, which carries a high risk of postoperative complications. OBJECTIVES: The aim of this study was to confirm the hypothesis that GDT during oesophageal resection improves outcome compared with standard care. DESIGN: A randomised controlled study. SETTING: Two Swedish university hospitals, between October 2011 and October 2015. PATIENTS: Sixty-four patients scheduled for elective transthoracic oesophageal resection were randomised. Exclusion criteria included colonic interposition and significant aortic or mitral valve insufficiency. INTERVENTION: A three-step GDT protocol included stroke volume optimisation using colloid boluses as assessed by pulse-contour analysis, dobutamine infusion if cardiac index was below 2.5 l min m and norepinephrine infusion if mean arterial blood pressure was below 65 mmHg. MAIN OUTCOME MEASURE: The incidence of complications per patient at 5 and 30 days postoperatively as assessed using a predefined list. RESULTS: Fifty-nine patients were available for analysis. Patients in the intervention group received more colloid fluid (2190 ±â€Š875 vs. 1596 ±â€Š759 ml, P < 0.01) and dobutamine more frequently (27/30 vs. 9/29, P < 0.01). The median [interquartile range, IQR] incidence of complications per patient 5 days after surgery was 2 [0 to 3] in the intervention group and 1 [0 to 2] in the control group (P = 0.10), and after 30 days 4 [2 to 6] in the intervention group and 2 [1 to 4] in the control group (P = 0.10). CONCLUSION: Goal-directed therapy during oesophageal resection did not result in a reduction of the incidence of postoperative complications. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01416077.

[Abdominal tuberculosis--still a diagnostic challenge. Two case reports and a literature review]. / Abdominell tuberkulos--en nygammal diagnostisk utmaning Två fallbeskrivningar och en litteraturgenomgång.

Abdominal tuberculosis (TB) is unusual in Sweden today. This paper presents two patients born 1981 and 1975, one with perforated duodenal ulcer due to Helicobacter pylori and/or Mycobacterium tuberculosis. Acute operation with suture was done, signs of granulomatous inflammation revealed culture positive for TB. The other was operated with appendectomy; the pathology was TB in the mesenteries and outside the caecum. Antituberculosis chemotherapy was given in both cases and neither patient suffered any major problems. These two cases show how important it is for surgeons to be aware of TB nowadays, particularly in patients born outside Sweden or those undergoing immune therapy.