Incidence Of Recurrent Bleeding Research Articles

Comparison of Law Enforcement Officer versus Emergency Medical Services Placed Tourniquets.

Tourniquet (TQ) use for hemorrhage control is a core skill for many law enforcement officers (LEO) and all emergency medical services (EMS) providers. However, LEO TQ training is not as intensive as EMS. Overuse of TQ can result in over triage. We hypothesize that LEO are more liberal than EMS with TQ placement. A seven-year retrospective, single center study of adult patients who had a TQ placed in the field was conducted. Data were stratified by provider who placed the TQ. Patient demographics, body location where the TQ was placed, hospital location where the TQ was removed, incidence of recurrent bleeding and need for operative control of bleeding, and name of injured vessel were recorded. Data were analyzed using student t-test and Chi-square tests. 192 patients had 197 TQ placed (LEO 77 (40%) and EMS 120 (63%). Most TQ were placed on the thigh. There was no difference in body mass index but the EMS cohort had a higher injury severity score (9.4 v 6.5, p = 0.03) and extremity abbreviated injury severity score (2.4 v 1.9, p = 0.007). LEO placed TQ were more commonly removed in the trauma bay (83% v 73%, p = 0.03). EMS placed TQ were more likely to require operative control of bleeding (23% v 6%, p = 0.003). There were no complications related to TQ use in either arm. LEO are more likely than EMS to place tourniquets without injury to a named vessel or the presence of severe bleeding. LEO need better training to determine when a TQ is needed. EMS should be allowed to remove TQ if appropriate. Studies on the impact of over triage based on TQ use are needed. Therapeutic/Care Management, Level III.

The impact of kidney function in patients on antithrombotic therapy: a post hoc subgroup analysis focusing on recurrent bleeding events from the AFIRE trial

BackgroundThe success of antithrombotic therapies is assessed based on thrombotic and bleeding events. Simultaneously assessing both kinds of events might be challenging, and recurrent bleeding events are often ignored. We tried to confirm the effects of kidney function on outcome events in patients undergoing antithrombotic therapy.MethodsAs a post hoc subgroup analysis of the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial, a randomized clinical trial with a median follow-up of 36 months, patients were divided into high and low estimated glomerular filtration rate (eGFR) groups with a cutoff value of 50 mL/min. The cumulative incidence of bleeding and crude incidence of recurrent bleeding per 100 patient-years were calculated. We used the Cox regression model with multiple failure time data for recurrent bleeding events.ResultsAmong 2092 patients, 1386 (66.3%) showed high eGFR. The cumulative bleeding events per 100 patients at 1 year were 5.4 and 6.2 in the high and low eGFR groups, respectively. The difference continued to increase over time. The hazard ratio for time to the first bleeding event in the high eGFR group was 0.875 (95% confidence interval 0.701–1.090, p = .234) and that for the first composite event was 0.723 (95% confidence interval 0.603–0.867, p < .000). The recurrent bleeding events per 100 person-years were 11.3 and 15.3 in the high and low eGFR groups, respectively, with a rate ratio of 0.738 (95% confidence interval 0.615–0.886, p = .001). During the observation period, the risk of bleeding changed with time. It peaked soon after the study enrollment in both groups. It decreased continuously in the high eGFR group but remained high in the low eGFR group.ConclusionsWe reaffirmed that kidney function affects bleeding events in patients on antithrombotic therapy, considering recurrent events. Patients should have detailed discussions with physicians regarding the possible bleeding events when continuing antithrombotic therapy, especially in patients with decreased kidney function.Trial registrationUMIN Clinical Trials Registry, UMIN000016612. ClinicalTrials.gov, NCT02642419. Registered on 21 October 2015.

ОТКРЫТАЯ ЭЗОФАГОГАСТРАЛЬНАЯ ДЕВАСКУЛЯРИЗАЦИЯ В СОБСТВЕННОЙ МОДИФИКАЦИИ. ПРЕДВАРИТЕЛЬНОЕ СООБЩЕНИЕ О СЕРИИ СЛУЧАЕВ

Introduction. Progress in surgical technologies and the presence of a category of patients with alcoholic cirrhosis of the liver and bleeding from esophageal varices who can not take nonselective beta-blockers and undergo repeated sessions of endoscopic ligation, allow to perform open esophagogastric devascularization as a reserve technique in surgical practice. Aim. Preliminary analysis of the results of performing open esophagogastric devascularization in its own modification. Material and methods. Open esophagogastric devascularization in its own modification was performed in five patients with Child-Pugh class B cirrhosis (3 men and 2 women) aged 44 to 59 years for delayed and planned indications after a repeated episode of bleeding from esophageal varices (from 2 up to 4 relapses). The technique included open esophagogastric devascularization with esophageal transection in combination with truncal vagotomy and pyloroplasty without splenectomy. Results. All patients underwent successful surgery. The duration of the operation (Me [min; max]) was 245 [230; 310] min. The time spent in the department of anesthesiology, resuscitation and intensive care was 2 [1; 5] days. During the postoperative follow-up of these patients for the period from 31 to 92 months, there were no recurrences of bleeding from esophageal varices. In all patients, endoscopic examination after a year showed regression of the degree of expansion of esophageal varices. Сonclusions. The use of the described methodology of multilevel stitching of submucosal esophageal varices in addition to hardware transection during open esophagogastric devascularization in its own modification enable to detect early all remaining significant varicose veins after hardware transsection of the esophagus and carry out their additional stitching without the need to open the esophagus and stomach potentially reduced the incidence of recurrent bleeding.

Transcatheter Arterial Embolization Treatment for Bleeding Visceral Artery Pseudoaneurysms in Patients with Pancreatitis or Following Pancreatic Surgery.

Simple SummaryTranscatheter arterial embolization (TAE) with coils is widely used to treat pseudoaneurysms; recently, the use of N-butyl cyanoacrylate (NBCA) in TAE has been reported as a feasible and effective approach. The purpose of our retrospective study was to evaluate the efficacy and safety of TAE with coils and NBCA for pseudoaneurysms associated with pancreatitis or pancreatic surgery. This retrospective study included 42 consecutive patients. The technical and clinical success rates, incidence of recurrent bleeding, complications, including pancreatitis, and overall survival after TAE were evaluated. All cases obtained hemostasis after TAE (the technical success rate was 100%). Complications were seen in only two patients. Clinical success rate that was evaluated in terms of 30-day mortality was 76.2%. TAE is then an effective treatment modality for pseudoaneurysms associated with pancreatitis or pancreatic surgery. Accurate diagnosis using angiography contributes to the proper choice of embolic agents and management of such hemorrhages.Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for pseudoaneurysms occurring secondary to pancreatitis or because of leakage of pancreatic juice after pancreatectomy. Materials and Methods: This retrospective study included 42 consecutive patients (38 males and 4 females; mean age, 60 years; range, 33–80 years) who underwent TAE for bleeding visceral artery pseudoaneurysms between March 2004 and December 2018. The technical and clinical success rates, incidence of recurrent bleeding, complications, including pancreatitis, and overall survival after TAE were evaluated. Results: Of the 42 enrolled patients, 23 had bleeding due to a complication of pancreatectomy and 19 had bleeding as a complication of pancreatitis. TAE with N-butyl cyanoacrylate (NBCA) or NBCA plus microcoils recurrent bleeding or inability to control bleeding was 15.8% (3 of 19) following TAE with NBCA and 17.4% (4 of 23) following TAE with coils. No clinically significant ischemic events of the pancreas or duodenum were observed in the embolized areas. Serum amylase did not increase compared with the initial levels after any of the procedures. At 30 days after TAE, 32 patients were alive. Conclusion: TAE has a high success rate for the management of hemorrhage, with few complications. The procedure appears to be safe and effective for pseudoaneurysms associated with either pancreatitis or pancreatectomy.

Gastroesophageal variceal bleeding in cirrhotic patients: the possibilities of effective hemostasis

To improve the results of treatment of gastroesophageal variceal bleeding (GEVB) in cirrhotic patients with thrombocytopenia. A total experience of the clinic includes 338 GEVB patients, endoscopic variceal ligation (EVL) and transjugular intrahepatic portosystemic shunt (TIPS) were performed in 162 and 157 cases respectively. Nevertheless, just the efficacy of initial pharmacological hemostatic therapy was analyzed. Administration of serotonin adipinate 30-50 mg/day during 3-5 days in addition to standard initial therapy allowed us to achieve permanent hemostasis during initial treatment if EVL was impossible. Serotonin adipinate induces thrombocytes' adhesion and improves fibrin clot strength. This therapy markedly decreases mortality (33.3% vs 46.7%), incidence of recurrent bleeding (46.4% vs 60.0%). Also it contributes successful hemostasis with endoscopic ligation and effective portal decompression by TIPS procedure.

Long-term prognosis in patients continuing taking antithrombotics after peptic ulcer bleeding.

AIMTo investigate the long-term prognosis in peptic ulcer patients continuing taking antithrombotics after ulcer bleeding, and to determine the risk factors that influence the prognosis.METHODSAll clinical data of peptic ulcer patients treated from January 1, 2009 to January 1, 2014 were retrospectively collected and analyzed. Patients were divided into either a continuing group to continue taking antithrombotic drugs after ulcer bleeding or a discontinuing group to discontinue antithrombotic drugs. The primary outcome of follow-up in peptic ulcer bleeding patients was recurrent bleeding, and secondary outcome was death or acute cardiovascular disease occurrence. The final date of follow-up was December 31, 2014. Basic demographic data, complications, and disease classifications were analyzed and compared by t- or χ2-test. The number of patients that achieved various outcomes was counted and analyzed statistically. A survival curve was drawn using the Kaplan-Meier method, and the difference was compared using the log-rank test. COX regression multivariate analysis was applied to analyze risk factors for the prognosis of peptic ulcer patients.RESULTSA total of 167 patients were enrolled into this study. As for the baseline information, differences in age, smoking, alcohol abuse, and acute cardiovascular diseases were statistically significant between the continuing and discontinuing groups (70.8 ± 11.4 vs 62.4 ± 12.0, P < 0.001; 8 (8.2%) vs 15 (21.7%), P < 0.05; 65 (66.3%) vs 13 (18.8%), P < 0.001). At the end of the study, 18 patients had recurrent bleeding and three patients died or had acute cardiovascular disease in the continuing group, while four patients had recurrent bleeding and 15 patients died or had acute cardiovascular disease in the discontinuing group. The differences in these results were statistically significant (P = 0.022, P = 0.000). The Kaplan-Meier survival curve indicated that the incidence of recurrent bleeding was higher in patients in the continuing group, and the risk of death and developing acute cardiovascular disease was higher in patients in the discontinuing group (log-rank test, P = 0.000 for both). Furthermore, COX regression multivariate analysis revealed that the hazard ratio (HR) for recurrent bleeding was 2.986 (95%CI: 067-8.356, P = 0.015) in the continuing group, while HR for death or acute cardiovascular disease was 5.216 (95%CI: 1.035-26.278, P = 0.028).CONCLUSIONAfter the occurrence of peptic ulcer bleeding, continuing antithrombotics increases the risk of recurrent bleeding events, while discontinuing antithrombotics would increase the risk of death and developing cardiovascular disease. This suggests that clinicians should comprehensively consider the use of antithrombotics after peptic ulcer bleeding.

Determination of the Risk of Recurrent Gastroduodenal Ulcer Bleeding

Despite the advances in endoscopic haemostasis, the incidence of recurrent ulcer bleeding remains to be high. It necessitates further search for its prognosis and methods of treatment.The objective of the research was to analyse risk factors for recurrent gastroduodenal ulcer bleeding.Materials and methods. The study included 203 patients with gastroduodenal ulcer bleeding. There were 135 (66.5%) males and 68 (33.3%) females. All the patients were examined and received conservative treatment according to treatment protocols.Results. Duodenal ulcer was diagnosed in 127 (62.3%) patients, gastric ulcer was found in 68 (33.3%) patients, gastroduodenal ulcer was seen in 9 (4.4%) patients. The recurrence of bleeding was observed in 24 (11.8%) cases. Most cases of recurrent bleeding (n=11 (45.8%) occurred within 2-3 days after the admission. 9 (37.5%) patients developed the recurrence of bleeding later. The lowest number of recurrent bleeding occurred within the first day - 4 (16.7%) cases. The incidence of recurrent bleeding was higher in men rather than in women - 17 (70.8%). Recurrent bleeding was observed in 9 (64.29%) patients with blood type O; 4 (28.57%) patients with blood type A; 1 (7.14%) patient with blood type B; 1 (7.14%) patient with blood type AB. The majority of recurrences (n=15 (62.5%) occurred in patients without ulcer in anamnesis. There was found no clear connection between ulcer location and the rate of recurrent bleeding.Conclusions.The scales of predicting recurrent bleeding that are known today do not consider a number of important clinical and pathogenetic factors as a basis of recurrence.The improvement of the results of treating bleeding ulcers is possible only on the basis of the complex of factors determining the effectiveness of regeneration.

Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Coil or Plug Embolization Ineffectively Attain Gastric Variceal Decompression or Occlusion: Results of a 26-Patient Retrospective Study

PurposeTo assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs). Materials and MethodsIn this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization. ResultsGVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1–1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4). ConclusionsIn this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration.

Treatment of epistaxis without the use of nasal packing, a patient study

We questioned how many patients with epistaxis can be treated by cautery without the use of nasal packing, as cautery is more effective and efficient. To investigate this, we performed a retrospective study of a cohort of 418 patients with epistaxis who presented to one ENT consultant at the ENT department of Medisch Centrum Leeuwarden (the Netherlands) between 1997 and 2007. Main outcomes were the treatment modality (cautery and/or nasal packing), recurrence of epistaxis and need for hospitalization. In 98% of all patients the bleeding site could be found and treated by cautery. The incidence of recurrent bleeding was 6%. Two percent of all patients had to be admitted to the hospital. This is considerably lower compared with recurrence rates and hospitalization after treatment by nasal packing known from the literature. Therefore we concluded that nearly all patients can be effectively treated by cautery with a low recurrence rate. In addition, this method of treatment is very cost effective. Because cautery requires skill and appropriate facilities, we recommend special attention for this in ENT training programs.

Clinical Profile and Outcome of Non-Variceal Upper Gastrointestinal Bleeding in Relation to Timing of Endoscopic Procedure in Patients Undergoing Elective Endoscopy

Background: Endoscopy is the most accurate method for diagnosing the source of upper gastrointestinal bleeding. This study was aimed to evaluate the correlation between the timing of elective endoscopy and the length of hospital stay, the amount of transfusion given and incidence of recurrent bleeding or patient mortality. Method: A retrospective study was conducted in all patients with non-variceal upper gastrointestinal bleeding who had experienced elective endoscopy at Cipto Mangunkusumo Hospital between January 2007 and August 2008. Identification of clinical risk using clinical Rockall score was performed at the emergency room. Persistent bleeding, recurrent bleeding, surgical treatment and death were the outcome variables. Statistical analysis was performed using Chi-square/fisher exact test and linear regression. Results: There were 40 eligible cases with mean age of 53 ± 13 years; the greatest occurrence was at the age group of 50-59 years (12%), male (52.5%) and those who had clinical symptom of melena (52.5%). Twenty seven (67.5%) patients had Rockall score of 1-3 points and 13 (32.5%) had 4-6 points. There was only one patient who had adherent clots (Forrest grade II B). Endoscopy results revealed that the most common cause of bleeding was gastric ulcer, which occurred in 12 (30%) patients. There was no correlation between the timing of endoscopic procedures and outcome variable; however the length of hospital stay had a significant correlation with timing of endoscopic procedures. Conclusion: Elective endoscopy does not affect the variables of mortality and recurrent bleeding; however, it affects the length of hospital stay. Further prospective studies are required to find causal relation between them. Keywords : non-variceal upper gastrointestinal bleeding, Rockall score, elective endoscopy, outcome variables

Predictors of Rebleeding and Mortality in Patients with High-Risk Bleeding Peptic Ulcers

Patients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality. A prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes. Bleeding recurred in 46 patients (11.8%) within 3 days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3 days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level<10 g/dl (OR 3.3) and ulcer>or=2 cm (OR 2.0). In-hospital bleeding was the only independent risk factor for mortality (OR 8.3). The study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.

Comparison of ChitoFlex®, CELOX™, and QuikClot® in Control of Hemorrhage

Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested. To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS+™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds. Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS+™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma. Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found. In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access.

CT Angiography of a Gonadal Artery Collateral from an Inferior Accessory Right Renal Artery

stay was unremarkable, without any recurrence of bleeding. To date, the patient has not had any therapeutic complications or recurrent bleeding. The small intestine presents a challenge when bleeding occurs as a result of its approximate length of 5 meters, which limits endoscopic imaging. Several treatment options exist for the treatment of small-bowel AV malformations. Endovascular methods include localized vasopressin injection, coil embolization, and polyvinyl alcohol embolization. Before the development of embolization treatments, medical treatments with vasopressin and/or subsequent resection were the gold-standard treatment methods. The use of vasopressin to induce vasoconstriction and thereby arrest bleeding was found to be as low as 36% effective (1), and the incidence of recurrent bleeding was as high as 71% (1). Therefore, vasopressin is used temporarily for stabilization and preparation for surgery, and has been replaced in most institutions with superselective embolization of mesenteric vessels. The aim of embolization of AV malformations is to completely obliterate the entire network of abnormal vasculature comprising the malformation, as partial treatment may allow recurrence (2).The use of NBCA adhesive, a liquid monomeric agent that polymerizes and solidifies when in contact with blood, has been shown to be effective in the management of AV malformations in the cranium. It has a low viscosity and can therefore be delivered through microcatheters within diminutive vessels. NBCA has been used to treat acute arterial hemorrhage from gastrointestinal and other pathologic processes (3). Kish et al (3) used NBCA in one of 16 patients for treatment of a rectal carcinoma pseudoaneurysm. NBCA has been shown to be successful in the treatment of gastrointestinal bleeding from a jejunal artery pseudoaneurysm secondary to intestinal tuberculosis (4). Additionally, the combination of microcoils and cyanoacrylate glue has been used to embolize an AV malformation of the superior pancreaticoduodenal artery supplying the duodenum (5).The difficulties associated with the use of NBCA include nontarget delivery, failure to satisfactorily obliterate the nidus, and catheter adhesion and subsequent retention. These difficulties are reduced with careful procedural technique (2). In summary, this case demonstrates a novel use of glue embolization for successful treatment of an AV malformation in the distal SMA presenting with massive lower intestinal bleeding and hypovolemic shock. Future studies are necessary to examine long-term safety and efficacy of glue embolization in the mesenteric arterial system, including the incidences of recurrent bleeding and bowel ischemia.

Erosive gastritis: its diagnosis, management, and surgical treatment.

Abstract Three hundred and thirty-one patients with severe haemorrhage resulting from erosive gastritis, representing 10 per cent of 3938 patients admitted with severe gastroduodenal bleeding during the past 30 years, are presented. The problems of diagnosis and management are discussed; particularly, the role of immediáte gastroscopy and the indications for surgical treatment and the surgical procedure best designed to control the haemorrhage. Forty-seven patients required 51 emergency surgical procedures, and it was found that the Billroth-I gastrectomy was far superior to any other operation. Polya gastrectomy, vagotomy, and gastric vasoligation were used, with a high incidence of recurrent bleeding and often necessitating a further emergency surgical operation—usually total gastrectomy. It is suggested that a possible explanation of this is the prevention of biliary reflux into the stomach, which is what the Billroth-I gastrectomy seems to achieve. In 1 case presented, a patient with a Polya gastrectomy and erosions who had severe haemorrhage, bleeding was controlled by conversion to a Billroth-I anastomosis.

Results of a Retrospective Multicenter Trial of the Viatorr Expanded Polytetrafluoroethylene– covered Stent-Graft for Transjugular Intrahepatic Portosystemic Shunt Creation

To report the results of a multicenter experience with the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt (TIPS) creation in which patency and clinical outcome were evaluated. One hundred consecutive patients with portal hypertension, with a mean age of 52 years (range, 22-86 years), underwent implantation of the Viatorr TIPS stent-graft at one of three hospital centers. The indications for TIPS creation were variceal bleeding (n = 81) and refractory ascites (n = 19). Twenty patients had Child-Pugh class A disease, 46 had class B disease, and 34 had class C disease. Eighty-seven patients underwent de novo TIPS placements, with 13 treated for recurrent TIPS stenosis. Sixty-two patients were available for follow-up portal venography and portosystemic pressure gradient (PSG) measurement commencing 6 months after Viatorr stent-graft placement. The technical success rate was 100%. TIPS creation resulted in an immediate decrease in mean PSG (+/-SD) from 21 mm Hg +/- 6 to 7 mm Hg +/- 3. Acute repeat intervention (within 30 days) was required for portal vein thrombosis (n = 1), continued bleeding (n = 3), and encephalopathy (n = 1). The all-cause 30-day mortality rate was 12%. Two patients developed acute severe refractory encephalopathy, which led to death in one case. New or worsening encephalopathy was identified in 14% of patients. The incidence of recurrent bleeding was 8%. The cumulative survival rate at 1 year was 65%. Sixty-two patients available for venographic follow-up had a mean PSG of 9 mm Hg +/- 5 at a mean interval of 343 days (range, 56-967 days). There were four stent-graft occlusions (6%) and seven hemodynamically significant stenoses (11%), four within the stent-graft and three in the non-stent-implanted hepatic vein. The primary patency rate at 1 year by Kaplan-Meier analysis was 84%. This retrospective multicenter experience with the Viatorr stent-graft confirms the preliminary findings of other investigators of good technical results and improved patency compared with bare stents. Early mortality and symptomatic recurrence rates are low by historical standards. The theoretical increase in TIPS-related encephalopathy was not demonstrated. Longer-term follow-up will be required to determine whether the additional cost of the Viatorr stent-graft will be offset by reduced surveillance and repeat intervention.

Comparison of Transcatheter Arterial Embolization and Surgery for Treatment of Bleeding Peptic Ulcer after Endoscopic Treatment Failure

To compare the outcomes of embolotherapy and surgery as salvage therapy after therapeutic endoscopy failure in the treatment of upper gastrointestinal peptic ulcer bleeding. Retrospective analysis of 70 cases of refractory peptic upper gastrointestinal hemorrhage was performed. Thirty-one cases were managed with embolotherapy and 39 were managed surgically. Demographic variables, underlying conditions, clinical findings, endoscopic treatment, transfusion requirements before and after alternative therapeutic approach, length of hospital stay, and outcomes including recurrent bleeding, need for surgery after initial alternative treatment, and in-hospital death were recorded. Patients who received embolotherapy were older (75.2 years +/- 10.9 vs 63.3 years +/- 14.5; P <.001) and had greater incidences of heart disease (67.7% vs 20.5%; P <.001) and previous anticoagulation treatment (25.8% vs 5.1%; P =.018). There were no differences in the rest of the pretreatment variables. No differences were found between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%), need for additional surgery (16.1% vs 30.8%), or death (25.8% vs 20.5). The lack of differences between these two treatment alternatives, despite the more advanced age and greater prevalence of heart disease in the embolotherapy group, provides support for future prospective randomized studies aimed to evaluate the role of embolotherapy in the management of refractory peptic ulcer bleeding.

Zum Stellenwert der Embolisationsbehandlung bei akuten Blutungen

137 arteries of 95 patients were treated by transcatheter embolization for massive haemorrhage using Ethibloc, Gelfoam, wire coils and Tissucol (Fibrinogen + Thrombin). The bleeding was secondary to trauma in 23 patients, to neoplasms in 16 patients and to vascular malformations or chronic inflammatory processes in 41 cases. 15 patients were treated for iatrogenic bleeding following surgery. Bleeding was referred to haemoptysis (n = 27), pelvic (n = 24), renal (n = 16) or gastrointestinal haemorrhage (n = 13) as well as several other diseases (n = 15). Most patients were poor surgical candidates. The overall bleeding control rate was 89.5% with a incidence of recurrent bleeding in 14 out of 95 patients (14.7%) treated by re-embolization or surgery. 6 patients died (6.3%) due to intractable haemorrhage, 4 patients (4.2%) died of complications related to embolization procedure (4 x bowel infarction!) and 33 patients (34.7%) died of procedure-unrelated causes such as myocardial infarction, trauma, malignancy or other underlying diseases. 58 patients (61.1%) are still alive (follow-up 16.2 +/- 4.8 months). Significant complications (5.3%) included bowel necrosis (4x) and ischaemia of the spinal cord with incomplete paralysis in one patient. One patient suffered thrombosis of the common iliac artery due to angiography. On the basis of our results, peripheral embolization using Ethibloc can be recommended as palliative treatment for devascularisation of bleeding tumours. Satisfactory results are obtained in haemoptysis, renal and pelvic haemorrhage, but gastrointestinal bleeding should not be occluded by means of Ethibloc because of its considerable risk of bowel infarction.

Bleeding from peristomal varices

Peristomal variceal bleeding is a serious complication in patients with chronic liver disease undergoing colon surgery with a stoma. Our aim was to examine the morbidity of bleeding for peristomal, perianastomotic, and esophageal varices in a group of patients with chronic liver disease who underwent colectomy at the Mayo Clinic between 1970 and 1988. Morbidity was evaluated in terms of the number of major bleeding episodes and the number of units of blood transfused. The treatment of bleeding was also evaluated. One hundred seventeen patients (74 males and 43 females) aged 11-78 years were studied. Sixty-two patients (53 percent) had a permanent stoma, while 55 patients (47 percent) had a colonic resection and anastomosis. Sixty-seven patients (62 percent) had chronic ulcerative colitis and primary sclerosing cholangitis. In the stoma group, bleeding appeared from stomal and/or esophageal varices in 19 patients (31 percent), while, in the non-stoma group, bleeding exclusively from the esophageal varices occurred in eight patients (15 percent). Perianastomotic variceal bleeding was never observed. The 5-year cumulative probabilities of one major bleed occurring from gastrointestinal varices appeared to be similar between the two groups. Patients who bled from peristomal varices with or without esophageal bleeding (n = 17) rebled more frequently (6.5 +/- 5.5 vs. 3 +/- 1.6; P less than 0.05) and were transfused more often (14.9 +/- 12.3 vs. 7.5 +/- 4.1; P less than 0.05) than patients who bled exclusively from esophageal varices (n = 10). No difference was found in the incidence of recurrent bleeding and the number of units of blood transfused between patients who bled exclusively from peristomal varices (n = 10) and those who bled from both peristomal and esophageal varices (n = 7). Medical and local measures were more effective in controlling esophageal bleeding than in controlling peristomal bleeding. Therefore, patients with chronic liver disease who must undergo colectomy should have a distal anastomosis rather than a terminal stoma.

Endoscopic variceal ligation: an alternative to sclerotherapy

Endoscopic variceal ligation (EVL) consists of mechanical ligation and thrombosis of varices using elastic "O" rings. This study assessed the efficacy and safety of EVL as definitive therapy for bleeding esophageal varices. During a 16-month period, 68 consecutive patients with bleeding varices had EVL. Fourteen patients died from 3 to 125 (median = 12.5) days after initial EVL. Fifteen (88%) of those actively bleeding at index treatment had bleeding controlled during index hospitalization. Survivors of index hospitalization had a 37% incidence of recurrent bleeding. Thirty-five patients had varices eradicated or reduced to small size with a median of five EVL treatments. No significant treatment-related nonbleeding complications resulted from 265 EVL sessions. EVL appears to control active variceal bleeding and eradicates varices with repeat treatments. EVL results in few nonbleeding complications, and may be employed as a safe alternative to sclerotherapy.

Hemorrhaging peptic ulcer--Therapy? When? Which?

The influence of frequency of surgical interventions and the time of operation on the overall mortality is still a matter of considerable controversy. A close correlation between the risk and incidence of recurrent bleeding and the primary bleeding status during emergency endoscopy let us to design a new concept of a more aggressive surgical strategy. The dominating criteria for choice of treatment based on instant endoscopical classification of bleeding type and activity. The overall mortality was 5.4%. 59 patients (53%) underwent surgery with only two hospital deaths (3.4%). Among the group with conservative treatment there were four additional deaths (7.5%), all patients being above 70 years of age. The results suggest that mortality rates in patients with bleeding gastroduodenal ulcers can be reduced by a more aggressive surgical approach.