Esophageal Ligation Research Articles

A Novel Deformable Self-Assembled Magnetic Anastomosis Ring (DSAMAR) for Esophageal Stenosis Recanalization without Temporary Gastrostomy in Beagle Dogs

BackgroundTo assess the feasibility of a deformable self-assembled magnetic anastomosis ring (DSAMAR) in the treatment of esophageal stenosis in beagle dogs via transoral access without temporary gastrostomy. MethodsExperimental esophageal stenosis was created in 10 beagle dogs by partial cervical esophageal ligation. The DSAMAR was inserted into the distal esophagus via the narrow section of the esophagus using a gastroscope. A circular DSAMAR was placed in the proximal esophagus. The magnetic rings on both sides of the experimental stenosis automatically attracted each other. We then recorded the operation time, postoperative complications, anastomotic formation time, and magnetic ring discharge time. The dogs were euthanized 4 weeks postoperatively; subsequently, we obtained the esophageal anastomotic specimens and observed the anastomotic formation via the naked eye and by light microscopy. ResultsOur esophageal stenosis model produced reproducible stenoses in all dogs, which was confirmed via endoscopy and esophagography. DSAMAR was successfully implanted in all experimental animals under endoscopic and X-ray monitoring, and all linear DSAMARs were successfully transformed into rings. The magnets at both ends of the esophageal stenosis were automatically attracted. All animals survived until euthanasia. No complications, including esophageal perforation, bleeding, and gastrointestinal obstruction, were noted during the perioperative period. The mean operation time of endoscopic magnetic anastomosis was 15.6 ± 2.41 (range, 12–19) min. The mean esophageal anastomotic formation time was 8.8 ± 1.03 (range, 7–10) days, and the mean expulsion time of DSAMAR was 13.94 ± 2.88 (range, 10–19) days. Gastroscopy and esophagography were performed at 4 weeks postoperatively; the esophageal patency was good. Macroscopic observation of the esophageal anastomotic specimens revealed that the esophageal mucosal layer of the anastomosis had good continuity and the anastomosis was smooth. ConclusionDSAMAR is a feasible option for magnetic recanalization of esophageal stricture via transoral access without temporary gastrostomy.

Impact of Portal Vein Thrombosis on Endoscopic Variceal Band Ligation in Liver Cirrhosis

Background. Portal vein (PV) thrombosis (PVT) is a common complication of liver cirrhosis and can refer to thrombosis within the PV that can extend to its left or right branches and in some cases to the superior mesenteric vein or the splenic vein (Chawla and Bodh, 2015). For severe PVT patients, there are possibilities of increasing PV resistance and reduction of the blood flow though PV towards liver, which exacerbate liver function damage meanwhile elevating the gastrointestinal variceal bleeding risk. Endoscopic Variceal band ligation (EVL) is often used to prevent esophageal variceal bleeding; postoperative complications such as severe gastrointestinal bleeding and bleeding-related death, fever, retrosternal pain, and esophageal stenosis may appear. There was absence of the research which evaluated the impact of PVT in liver cirrhosis on the complication of endoscopic Variceal band ligation for now. We herein aimed to compare cirrhosis patients with and without PVT of recent complications after EVL. Method. We established the retrospective investigation on 144 consecutive cirrhosis patients (excluding patients with hepatocellular carcinoma and who received portal vein-systemic circulation devascularization or shunt surgery, splenectomy, hepatectomy, liver transplantation, transjugular intrahepatic portal vein stent shunt (TIPS), endoscopic varices Variceal ligation, or sclerotherapy before) who have received first endoscopic esophageal varices band ligation in Gastrointestinal Endoscopy Center of the First Affiliated Hospital, College of Medicine, ZheJiang University, between January 2014 and December 2017. Portal vein Doppler ultrasonography, liver computerized tomography (CT), and angiography or liver-enhanced magnetic resonance imaging (MRI) were applied to evaluate the portal vein thrombosis of each patient before EVL. There were 18 patients confirmed with portal vein thrombosis while the other 126 patients without PVT. The primary end point for this research is the upper gastrointestinal hemorrhage and related death occurred from the date of ligation until leaving hospital, and the secondary end point is the appearance of postoperative fever and retrosternal pain. Results. There are no significant differences of gastrointestinal bleeding, bleeding-related death, fever, or retrosternal pain after EVL and the length of hospital stays between cirrhotic patients with or without PVT ( P = 0.34 , 0.51 , 0.58 , 0.61 , 0.88 ). Conclusion. Liver cirrhosis with portal vein thrombosis did not increase incidence of recent complications of the endoscopic Variceal band ligation.

Risk factors for post-banding ulcer bleeding in cirrhotic patients undergoing elective esophageal varices band ligation

Risk factors for post-banding ulcer bleeding in cirrhotic patients undergoing elective esophageal varices band ligation

Thoracoscopic surgery for one neonate with broncho-esophageal fistula

Abstract This article is about a 6-day-old male infant admitted to the hospital presented with a 2-day history of worsening widespread spitting. After a series of treatments, we found that the diagnosis was “broncho-esophageal fistula”. So he was recommended to receive surgical treatment. After preoperative preparation, thoracoscopic ligation of esophagus and bronchospasm was performed.The fistula was 1.5 cm long. The broncho-esophageal fistula was often found in adults, which was often misdiagnosed as pneumonia with bad effective treatment, especially in a newborn, but the non-invasive CT three-dimensional imaging technology can provide a reliable basis for the clear diagnosis of esophageal bronchospasm.

Pancytopenia and Massive Gastroesophageal Bleeding Due to Hypersplenism Treated with Partial Splenic Embolization

Introduction: Portal hypertension may cause gastrointestinal complications; one of the most serious is a ruptured esophageal varices. Portal hypertension is also the main cause of hypersplenism, which in turn could lead to pancytopenia. Despite adequate therapy, some cases of hypersplenism could not be resolved. Partial splenic embolization (PSE) is an effective alternative method to treat this condition. Method: We reported two cases of hypersplenism treated with PSE. The first case was a 10- year-old girl with pancytopenia and a history of recurrent esophageal ligation. The second case was a 32-year-old man with recurrent episodes of hematemesis for two years before admission. Results: After the PSE procedure, the first patient’s white blood cell and platelet doubled in one month after procedure and stable at follow-up three months later, with no complaint of hematemesis. The second patient’s platelet doubled five days after the procedure. The first patient developed a complication of a splenic abscess, but after antibiotic administration and pus drainage, the condition was resolved. Conclusion: PSE is an effective method to treat hypersplenism secondary to the hypertensive portal. Treatment goals successfully achieved include improvement in blood count and control of bleeding. There are risks following PSE, but with adequate treatment, it can be overcome. Keywords: hypersplenism, partial splenic embolization, portal hypertension, pancytopenia

Comparative analysis of the results of the modified technique of esophageal varicose veins endoscopic ligation for the purpose of the primary and secondary prevention of bleeding

Comparative analysis of the results of the modified technique of esophageal varicose veins endoscopic ligation for the purpose of the primary and secondary prevention of bleeding

PWE-035 The Endoscopy and Endoscopic Therapy in Bleeding and Hypotension State of Upper Gastrointestinal Haemorrhage

Introduction The mortality of the cirrhotic patients with shock induced by esophageal varices (EV) rupture haemorrhage remains high despite all medical advances. The clinical study aims to exhibit the efficacy of endoscopic therapy using esophageal varicose ligation (EVL) in treating hypotension caused by upper gastrointestinal haemorrhage, as well as compare the long-term difference in effectiveness of single-band and multi-bands techniques for the patients. Methods sixty-seven patients with clinical diagnosis of cirrhosis were hospitalised in an emergency for massive hematemesis. The blood pressure (Bp) of the patients was between 60–82/30-55 mmHg, and the haemoglobin (Hb) was in the range of 50–87 g/L. As well as preparing blood protects, we take fluid resuscitation and apply somatostatin or terlipressin to reduce portal vein pressure of the patients, whose Hb was lower than 60 g/L were taken blood transfusion. When their Bp could stabilise between 78–86/50-55 mmHg and the Hb between 55–60 g/L, the emergency endoscopy examination and treatment were performed without narcosis. The patients with EV bleeding were randomly divided into single-band and multi-band ring ligation groups, while accompanying GV treated by injecting in the bleeding gastric varicose vein with sequential sclerosing agent, tissue adhesive, sclerosing agent, which is named sandwich method of GV injection therapy. The sixty-seven patients were found EV by gastroscoy, in whom there were fifty-three accompanying GV. In multi-bands treatment group with thirty-five patients, two, three, or four bands were applied on the varices according to the severity of EV. The single-band treatment group was consisting in thirty-two patients. Results Sixty-six cases were rescued successfully by emergency endoscopic treatment within 24 h of bleeding. Unfortunately, one person was still bleeding although EVL and sclerotherapy both being applied the bleeding oesophagus because it had been more than 24 hours since the bleeding and he had been treated with Sengtaken-Blakemore tube for three days, causing the erosion and ulcer of oesophagus. Two days after the endoscopic therapy, the patient died for the poor control of haemorrhage as he continually accepted comprehensive treatment. In the multi-bands ligation group, the number of patients with EV completely eradicated and mostly eradicated was eight and twenty-one respectively. The disappearance percents of varicose veins were 82.8%. In the single-band ligation group, the number of people with EV completely eradicated and mostly eradicated were five and fourteen, respectively, which the disappearance percent of the varicose veins was 59.4%. There were great significant differences between the two groups ( p p Conclusion The patients with EV and (or) GV rupture haemorrhage in bleeding and hypotension state can be rescued successfully by endoscopy and endoscopic therapy. The long-term efficacy of the multi-band ligation is superior to single-band EV ligation (EVL). Disclosure of Interest None Declared

The predictive value of endoscopic ultrasound for the recurrence of esophageal varices after endoscopic esophageal varix ligation

Objective To assess the relationship between the recurrence of esophageal varices following endoscopic esophageal varix ligation (EVL) and esophageal collateral veins(ECV)under endoscopic ultrasound (EUS), and analyze the predictive value of EUS for recurrence of esophageal varices. Methods Sixty patients with cirrhotic portal hypertension combined with esophageal varices underwent EVL for eradication of varices. Endoscopy and EUS were performed before ligation to detect and describe the type of esophageal varices, and grade, location, and the number of ECV. Over a 12-month period, variceal recurrence was examined. The statistical analyses were performed to assess the relationship between esophageal varices following EVL and ECV. Results Of the 60 patients, 29 (48.3%) had variceal recurrence within 12 months after EVL. Univariate logistic regression analysis showed that severe peri-ECV (OR=22.67; 95%CI: 4.37-117.47, P<0.001), severe para-ECV(OR=16.31; 95%CI: 0.84-108.14, P=0.018), multiple peri-ECV (OR=22.67; 95%CI: 4.37-117.47, P<0.001), and the presence of perforating veins (OR=6.67, 95%CI: 1.46-30.43, P=0.014) were significantly related to the variceal recurrence after EVL. Multivariate logistic regression model showed that severe peri-ECV (OR=24.39; 95%CI: 2.34-253.78, P=0.008) and multiple peri-ECV (OR=24.39; 95%CI: 2.34-253.78, P=0.008) severe para-ECV(OR=19.42; 95%CI: 4.84-148.54, P=0.012)remained independent prognostic factors for variceal recurrence. The sensitivity and specificity of multivariate logistic regression model in predicting variceal recurrence were 89.2% and 90.5%, respectively (prognostic value AUC=0.946). The sensitivity and specificity were 86.4% and 87.7% in predicting variceal recurrence(prognostic value AUC=0.871). Conclusion Recurrence rate of esophageal varices after EVL is high. EUS can clearly depict ECV. Severe peri-ECV and multiple peri-ECV are significant and independent prognostic factors associated with variceal recurrence risk. EUS before EVL will help predict variceal recurrence after EVL. Key words: Esophageal and gastric varices; Therapeutic endoscopy; Forecasting; Ultrasonic endoscope

Hospital-based Disparities in Care and Outcomes for Upper Gastrointestinal Bleeding

Introduction: Major teaching hospitals and urban centers are often recognized for offering advanced treatment options, but whether these centers provide better care for common illness than non teaching and rural hospitals is not clear. The objective of this study is to examine the association of location and hospital teaching status with outcomes for patients with acute upper gastrointestinal bleeding (UGIB). Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients who presented with upper gastrointestinal bleeding between 2003 and 2010. Data was collected on the utilization of surgical intervention and diagnostic procedures based on hospital location and hospital teaching status. Logistic regression models were used to evaluate the outcomes disparities based on hospital characteristics. Results: Of the 478,921 patients included in the study, 76.2% of patients received an EGD while 1.9% had some form of surgical intervention. Patients treated at rural hospitals were less likely to receive an EGD (68.9%) than those treated at urban institutions (77.7%) (p < 0.001). Of those patients treated at rural institutions 1.2% received surgical intervention while 2% received surgical intervention at urban institutions, with gastrostomy being less commonly performed at rural vs. urban institutions (p=0.005). Patients receiving care at teaching hospitals were more likely to undergo an EGD than patients in non teaching hospitals (77.7% v. 75.3%, p < 0.001). They were also more likely to have intervention at time of EGD including esophageal ligation or injection (p=0.042). At teaching institutions 2.2% of patients underwent surgical intervention, with more laparoscopy/laparotomies being performed at teaching hospitals vs. non teaching institutions (p=0.021). At rural and non teaching hospitals patients were more likely to receive blood transfusions during their inpatient course (p < 0.001 & p < 0.001, respectively). Patients at urban and teaching hospitals were more likely to have a longer length of stay (p < 0.001) and increased health care cost (p < 0.001). Conclusion: Treatment for patients with UGIB including rate of surgical intervention, rate of blood transfusion, length of stay and care cost are dependent on hospital characteristics. Recognizing disparities of care and addressing possible causes are essential to ensure that all patients admitted for acute gastrointestinal bleeding receive access to high quality care.

Prediction of Esophageal Variceal Bleeding in Liver Cirrhosis: Is There a Role for Hemostatic Factors?

Variceal bleeding is a frequent and ominous complication of liver cirrhosis. Fortunately, primary prophylaxis with β blockers or esophageal band ligation effectively reduces the risk of variceal bleeding and its associated mortality. Periodic endoscopic surveillance of esophageal varices (EV) is currently recommended in every patient with cirrhosis for early detection of EV and initiation of primary variceal bleeding prophylaxis is indicated for high-risk patients. During the last decades several noninvasive tests have emerged, aiming to facilitate access, reduce cost, and avoid unnecessary risk associated with endoscopic EV surveillance. In addition, several hemostatic abnormalities have been described in cirrhosis, and their role in variceal bleeding pathogenesis is yet to be defined. In this article, we review and critically analyze the accuracy of noninvasive EV predictors and utility of hemostatic factors to predict individual variceal bleeding risk. In addition, we summarize available data regarding the therapeutic role of hemostatic factors in primary prevention of variceal bleeding and early recurrence after an initial episode of variceal hemorrhage.

Management of Esophageal Perforations in Elderly Patients

Limited data are available on the management of esophageal perforations in elderly patients. The aim of this study is to analyze the characteristics and treatments of esophageal perforations in elderly patients. Data on patients with esophageal perforations and older than 65 years of age were retrospectively reviewed from January 2001 to November 2012. Surgery-related and caustic-induced perforations were excluded in this study. Disease-related parameters, such as sex, bacteriology, locations, time to treatment, treatment types, and outcomes, were analyzed. A new method, cervical esophageal ligation and T-tube diversion following repair of esophageal perforations, was introduced. A total of 61 patients, 24 females and 37 males, were eligible for this study. Heterogeneous presentations were noted following diagnosis of esophageal perforations. Esophagoscopy was the most frequently used method for diagnosis of esophageal perforations. Different sites of perforations would induce heterogeneous complications, among which thoracic perforations were most lethal. In this study, disease-related mortality rate was 13.1% (8 patients). Thoracic and abdominal perforations ( p < 0.001) and delayed treatments > 48 hours ( p = 0.002) were two significant factors responsible for mortality of patients esophageal perforations. The suggested new diversion method can be used as a salvage treatment option for complicated perforations. Early diagnosis and prompt treatments are the important determinants to reduce mortalities of elderly patients with esophageal perforations. Cervical esophageal ligation combined with T-tube diversion can be considered as a salvage method for complicated perforations.

P0206 : Prevention of bleeding following invasive procedures in cirrhotic patients: A single center experience

Background: Risk of bleeding in cirrhosis has predominantly been associated with coagulopathy and thrombocytopenia due to impaired liver function and splenomegaly. The evaluation of the actual bleeding risk in cirrhotic patientsundergoing invasiveprocedures is a critical point to optimizemanagement in termsof platelet (Plt) or plasma prophylactic transfusions. Methods: During 2013, 480 cirrhotic patients underwent diagnostic or therapeutic invasive procedures at our Liver Unit (Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy). Plt transfusion was performed when Plt count less than 50,000/mmc while fresh frozen plasma was infused when international normalized ratio (INR) >1.5, except those undergoing paracentesis. Low-molecular-weight-heparin was discontinued 24h before any procedure while antiaggregant therapy was interrupted five days before any procedure except oesophageal varices band ligation and paracentesis. Major hemorrhagic events were those requiring hospitalisation or blood transfusion; minor events was a haemoglobin decline >1.5 g/dl post procedure without clinical relevance. Results: 174 Transarterial Chemo-Embolization (TACE), 16 Radio-Frequency Termal Alblation (RFTA), 214 paracentesis, 59 oesophageal varices banding, 6 trans-jugular liver biopsy (LB) and 11 Percutaneous Ethanol Injection (PEI) were performed. Overall, 61 procedures met the criteria for plasma or Plt infusion and major bleeding complications occurred in 3 patients (0,6%). In 2 patients, anemia-related paracentesis was treated by blood transfusions whereas one patient following variceal band ligation had to be hospitalized for severe anemia. Major complications rate was 1.6% in Plt/plasma infusion exposed patients versus 0.47% in unexposed (p=0.28).Minor eventswith a>1.5 g/dl haemoglobindecline occurred in 17 patients (15 paracentesis and 2 band ligations), rate was 3.2% in Plt/plasma infusion exposed patients versus 3.5% in unexposed (p=0.9). Conclusion: Pre-treatment platelet transfusion in cirrhotic patients with Plt count 1.5, was associated with a negligible risk of bleeding and appeared as a safe, cost/effective strategy.

Oral, nasal and pharyngeal exposure to lipopolysaccharide causes a fetal inflammatory response in sheep.

BackgroundA fetal inflammatory response (FIR) in sheep can be induced by intraamniotic or selective exposure of the fetal lung or gut to lipopolysaccharide (LPS). The oral, nasal, and pharyngeal cavities (ONP) contain lymphoid tissue and epithelium that are in contact with the amniotic fluid. The ability of the ONP epithelium and lymphoid tissue to initiate a FIR is unknown.ObjectiveTo determine if FIR occurs after selective ONP exposure to LPS in fetal sheep.MethodsUsing fetal recovery surgery, we isolated ONP from the fetal lung, GI tract, and amniotic fluid by tracheal and esophageal ligation and with an occlusive glove fitted over the snout. LPS (5 mg) or saline was infused with 24 h Alzet pumps secured in the oral cavity (n = 7–8/group). Animals were delivered 1 or 6 days after initiation of the LPS or saline infusions.ResultsThe ONP exposure to LPS had time-dependent systemic inflammatory effects with changes in WBC in cord blood, an increase in posterior mediastinal lymph node weight at 6 days, and pro-inflammatory mRNA responses in the fetal plasma, lung, and liver. Compared to controls, the expression of surfactant protein A mRNA increased 1 and 6 days after ONP exposure to LPS.ConclusionONP exposure to LPS alone can induce a mild FIR with time-dependent inflammatory responses in remote fetal tissues not directly exposed to LPS.

Use of proton pump inhibitors in the management of gastroesophageal varices: a systematic review.

To review the efficacy and safety of proton pump inhibitors (PPIs) in gastroesophageal varices (GEVs). MEDLINE (1946 to September 2014), EMBASE (1974 to September 2014), International Pharmaceutical Abstracts (1970 to September 2014), Cochrane Central Register of Controlled Trials (1991 to September 2014), Google, and Google Scholar were searched using the following terms: esophageal varices, gastroesophageal varices, variceal hemorrhage, variceal bleeding, banding ligation, endoscopic variceal ligation, sclerotherapy, proton pump inhibitor, PPI, omeprazole, pantoprazole, lansoprazole, dexlansoprazole, rabeprazole, and esomeprazole. Published and unpublished studies evaluating the clinical outcomes of PPI use for GEVs were included regardless of study design. Non-English and nonhuman studies were excluded. Of 1156 studies, 20 were included after assessment. There was wide methodological heterogeneity and moderately high risk of bias among studies. Level I evidence suggests that PPIs reduce esophageal ulcer size post-elective esophageal ligation; the clinical importance of such findings is not known given the self-limiting nature of esophageal ulcer. Available evidence does not support a role of PPIs for long-term prophylaxis of portal hypertension-related bleeding and high-dose infusion for acute management of GEV hemorrhage. Retrospective data demonstrate a potential increase in the incidence of spontaneous bacterial peritonitis in patients with cirrhosis receiving PPIs. The best available evidence supports the use of short-course (10 days) PPI post-endoscopic variceal ligation to reduce ulcer size if ulcer healing is a concern. Practices such as high-dose infusion and prolonged use should be discouraged until evidence of benefit becomes available.

Effects of different drugs on patients undergoing endoscopic variceal ligation

Objective To study the sedative and analgesic effects of different drugs on patients under-going endoscopic variceal ligation( EVL). Methods Sixty patients undergoing selective EVL were randomly assigned to three groups:pethidine group( A),propofol-fentanyl group( B)and dexmedetomidine-fentanyl group(C). Data concerning blood pressure,heart rate,peripheral oxygen saturation,Ramsay score,endo-scopic operation and anesthesia time,surgeons' satisfaction and adverse reactions were recorded. Follow-up was done 24 hours later to confirm the patients' satisfaction and incidence of intraoperative awareness. Results The Ramsay scores of group B(5. 2 ± 0. 3)and C(3. 5 ± 0. 4)were significantly higher than group A (1. 6 ± 0. 4)(P<0. 05). There was no cough,body movement and high blood pressure during the EVL in group B or C,while the incidences of these symptoms in group A(40%,40% and 30%)were obviously higher (P<0. 05). The surgeons'satisfaction of group B(9. 2 ± 0. 3)and C(9. 6 ± 0. 4)were significantly higher than that of group A(5. 0 ± 0. 4)(P<0. 05). The patients' satisfaction scores of group B(9. 6 ± 0. 3)and C (9. 6 ± 0. 4)were also markedly higher than that of group A(5. 4 ± 0. 3)(P<0. 05). There was no difference of operation time among the three groups. The anesthesia time of group A(44 ± 6)was obviously longer than those of group B(35 ± 4)and C(36 ± 5)(P<0. 05). There was no difference in patients'or surgeons'satis-faction,or anesthesia time between group B and C. But the incidences of bradycardia( 40%),hypotension(30%)and hyoxemia(30%)in group B were obviously higher than those of group C(5%,0,0)(P<0. 05). There was no intraoperative awareness in group B or C. Conclusion Both dexmedetomidine and propofol com-bined with fentanyl are superior to pethidine for patients undergoing EVL,while dexmedetomidine provides bet-ter hemodynamics and respiratory conditions compared with propofol. Key words: Endoscope ; Pethidine ; Propofol ; Dexmedetomidine ; Esophageal varices liga-tion ;

Is There a Role for Antibiotic Prophylaxis in Cirrhotics with Poor Dentition Undergoing Esophageal Band Ligation?

Is There a Role for Antibiotic Prophylaxis in Cirrhotics with Poor Dentition Undergoing Esophageal Band Ligation?

365 Success of Two Different Endoscopic Submucosal Resection Methods in Gastric Subepithelial Lesions

Success of Two Different Endoscopic Submucosal Resection Methods in Gastric Subepithelial Lesions Cetin Karaca*, Ozlem Mutluay Soyer, Filiz Akyuz, Bulent Baran, Asli Ormeci, Suut Gokturk, Kadir Demir, Sadakat Ozdil, Fatih Besisik, Sabahattin Kaymakoglu Istanbul University, Istanbul School of Medicine, Istanbul, Turkey Aim: Gastric subepitelial lesions (GSL) are incidentally detecting during gastroscopy. Endoscopic ultrasound’s (EUS) success is limited in accurate diagnosis. Endoscopic submucosal resection (ESMR) is needed for accurate diagnosis of GSL’s. In this study, we evaluated the usefulness of ESMR with a esophageal band ligation device and saline solution-assisted and snare technique in GSL. Materials and Methods: We analysed gastroscopically detected and ESMR applied GSL cases, retrospectively. GSL’s characterising executed using EUS before ESMR. ESMR executed using saline solution-assisted and snare technique in %50 of cases and using band ligation in rest of cases. Results: A total of 16 patients (10 women, mean age 52.4 years) with an endoscopically resected GSL were included. In EUS examination lesions found %62.5 submucosal, %12.5 mucosal, %25 muscularis propria oriented. The mean size of the 16 lesions was 11mm (range 5-20mm). An endoscopic cap band mucosectomy device was used to resect 8 (50%) lesions, whereas 8 (50%) were resected with a saline solutionassisted and snare technique. ESMR was successfully performed in all 16 GSLs. The en bloc resection rate was 100% (16/16). Lesions pathological diagnosis are found as; ectopic pancreas 3 (%18.7), inflammatory fibroid polyp 3 (%18.7), leiyomyoma 2 (%12.5), lipoma 2 (%12.5), neuroendocrine tumour 1 (%6.3), foveolar epihtelium hyperplasia 3 (%18.7), lymphangiectasia 1 (%6.3), maltoma 1 (%6.3). There were no complications developed during EMR applications using saline solution-assisted and snare technique however endoscopy required bleeding developed in 1 patient during EMR applications using esophageal band ligation. Questioning patient revealed aspirin usage. Conclusions: EMR using adrenaline or band ligation is effective technique with low complication ratio in diagnosis and treatmentof GSL’s smaller than 2cm diameter.

Esophageal variceal band ligation in Dakar, Senegal

After a preliminary study in the gastrointestinal endoscopy center of the Aristide-Le-Dantec Teaching Hospital in Dakar, Senegal, demonstrated the feasibility and effectiveness of endoscopic ligation of esophageal varices, this procedure entered regular use for management of patients admitted for upper digestive tract bleeding due to these varices. This study sought to assess its effectiveness. Patients and method. This study, conducted from July 2005 through January 2010, included all patients with upper digestive tract bleeding due to rupture of esophageal varices. Results. In all, 140 patients with a mean age of 36 years [range: 16-75] were admitted for this diagnosis and included in the study: 93 men and 47 women (sex-ratio = 1.98). The presence of at least one clinical sign of portal hypertension was noted in 72% of cases. Esophageal varices were graded as stage III in 75.7% of cases. The underlying cause of portal hypertension was cirrhosis in 94.3%, presumptively due to hepatitis B virus among 37.1%. The varices were successfully eradicated in 64 patients (45.7%). The mean number of sessions required was 2 [range: 2-4] in patients with stage II and 3.4 [range, 3-8] in patients with stage III varices, and the mean number of bands applied per session was 5.1 [range: 2-6] and 5.6 [range: 2-10], respectively. The interval between sessions was 4 weeks [range: 3 -12]. Bleeding recurred in 8 patients (5.7%) before eradication was achieved; 4 (2.8%) of them died. Conclusion. Esophageal variceal ligation is an effective therapeutic and prophylactic procedure for management of esophageal varices in Senegal.

Successful Treatment of Atrioesophageal Fistula by Cervical Esophageal Ligation and Decompression

Atrioesophageal fistula is a rare yet devastating complication of transcatheter ablation for atrial fibrillation. This condition requires urgent intervention, but the optimal treatment strategy is yet to be defined. Reported therapies range from endoscopic stenting to direct atrial repair or reconstruction while on cardiopulmonary bypass. Here, we describe the successful management of an atrioesophageal fistula by cervical esophageal ligation and decompression, along with gastric drainage.

Pharmacokinetics of propofol when combined with remifentanil in patients with liver cirrhosis

Objective To investigate the pharmacokinetics of propofol when combined with remifentanil in patients with liver cirrhosis.Methods Ten patients (5 males, 5 females) with liver cirrhosis scheduled for endoscopic esophageal varix ligation (test group) and 10 cases (5 males, 5 females) with normal liver function scheduled for gastroscopy (control group), aged 18-55 yr, weighing 40-75 kg, were studied. The patients were unpremedicated. All the patients received iv injection of propofol 1.5 mg/kg and remifentanil 0.5 μg/kg, and 5 min later propofol 0.5 mg/kg and remifentanil 0.2 μg/kg was given again. Blood samples were taken from radial artery before administration and at 2, 5, 10, 15, 20, 30, 45, 60, 80 and 120 min after administration for determination of the plasma propofol concentration using gas chromatography-mass spectrography. The pharmacokinetic parameters were calculated using DAS 2.0 software.Results The pharmacokinetics of propofol was best described by a three-compartment open model. There was no significant difference in the distribution half-life, elimination halflife , terminal half-life, area under the curve and transfer rate constant between the two groups ( P ＞ 0.05) . The apparent volume of distribution of propofol and clearance were significantly increased in test group compared with control group (P ＜0.01) .Conclusion When propofol combined with remifentanil is used in patients with liver cirrhosis, the apparent volume of distribution of propofol and clearance are significantly increased, while no changes in the other pharmacokinetic parameters are found. Key words: Propofol; Piperidines; liver cirrhosis; Pharmacokinetics