Richard A. Crass

Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up

In a continuation of a trial for which preliminary results were reported in the Journal two years ago, a total of 64 patients with Child Class C cirrhosis and variceal hemorrhage requiring six or more units of blood were randomly assigned to receive either a portacaval shunt (32 patients) or endoscopic sclerotherapy (32 patients). The duration of initial hospitalization and the total amount of blood transfused during hospitalization were significantly less in the patients receiving sclerotherapy (P less than 0.001). There was no difference in short-term survival (50 percent of the sclerotherapy group were discharged alive, as compared with 44 percent of the shunt-surgery group). Both groups were followed for a mean of 530 days after randomization. Rebleeding from varices, the duration of rehospitalization for hemorrhage, and transfusions received after discharge were all significantly greater in the sclerotherapy group (P less than 0.001). Forty percent of the sclerotherapy-treated patients discharged alive (7 of 16 patients) ultimately required surgical treatment for bleeding varices, despite a mean of 6.1 treatment sessions. Health care costs and long-term survival did not differ significantly between the groups (P greater than 0.05). We conclude that although endoscopic sclerotherapy is as good as surgical shunting for the acute management of variceal hemorrhage in poor-risk patients with massive bleeding, sclerotherapy-treated patients in whom varices are not obliterated and bleeding continues should be considered for elective shunt surgery.

Management of foreign body ingestion.

Management of ingested foreign bodies (FB) is a common clinical problem. A 10-year experience of 101 foreign body ingestions is reported. The experience suggests that endoscopic removal of foreign bodies is curative for objects located in the crico-pharynx or upper esophagus. Foreign bodies which pa

Endoscopic Sclerotherapy versus Portacaval Shunt in Patients with Severe Cirrhosis and Variceal Hemorrhage

Fifty-two patients with severe cirrhosis (Child Class C) and variceal hemorrhage requiring six or more units of blood were randomly assigned to either sclerotherapy or portacaval shunt. Of 38 pretreatment characteristics, only the frequency of active alcoholism differed significantly between the groups. During the initial hospitalization, the patients in the shunt group required significantly more blood (21.5 +/- 3.1 units) than did those in the sclerotherapy group (12.3 +/- 1.3 units), although the latter had significantly more rebleeding during hospitalization after the procedure (14 of 28 vs. 5 of 24 patients). There was no difference in short-term survival, with 13 patients in the sclerotherapy group discharged alive, as compared with 10 patients in the shunt group. Patients were followed for a mean of 263 days after the initial discharge (range, 8 to 1117). The sclerotherapy group required significantly more days of hospitalization for rebleeding, but we failed to demonstrate any significant difference in long-term survival between the sclerotherapy and shunt groups. Total health-care costs per patient were significantly higher for the shunt group (+23,957 +/- +3,111) than for the sclerotherapy group (+15,364 +/- +2,220). We conclude that sclerotherapy is less costly than portacaval shunt and as effective for the treatment of esophageal varices associated with severe cirrhosis.

Acute and chronic pancreatic pseudocysts are different

Our experience supports the concept that acute and chronic pancreatic pseudocysts differ and require different plans of management. Patients who present with a chronic pseudocyst should be scheduled for operation promptly; internal drainage is almost always possible, spontaneous resolution is extremely rare, and delay only runs the risk of complications. Patients who are found to have an acute pseudocyst that develops during an attack of acute pancreatitis should be managed expectantly for 4 to 6 weeks; in them, spontaneous resolution may occur and surgical therapy is more satisfactory if the pseudocyst wall is allowed to mature enough that internal drainage is possible.

Colorectal foreign bodies and perforation.

Although most rectal foreign bodies can be removed safely in the emergency room, some require removal in the operating room. Good results can be achieved if basic principles in the management of colorectal injuries in general are applied to colorectal perforations by foreign bodies. Although rectal foreign bodies and colorectal perforations from non-medical rectal instrumentation have been a medical curiosity for many years, especially in metropolitan general hospitals, there can be little doubt that the frequency of such problems is increasing. We expect that community hospitals, will see more of these problems in years to come, if they are not already.

Therapeutic regimens in acute experimental hemorrhagic pancreatitis. Effects of hydration, oxygenation, peritoneal lavage, and a potent protease inhibitor.

In this study we evaluated the effects of hydration, oxygenation, peritoneal lavage, and the protease inhibitor gabexate mesilate in acute hemorrhagic pancreatitis induced by feeding mice a choline-deficient, ethionine-supplemented diet. Different groups of mice were kept at various concentrations of O2 (21%, 35%, and 45% O2), or were treated by either s.c. injections or i.p. injections of electrolyte solution at various doses (0, 4, 6, or 8 ml/day). Further groups were treated either with i.p. lavage, lavage with 1.5 mg/ml of gabexate, or i.p. injections of 100 mg/kg of gabexate without lavage. The potential benefits of the various regimens were assessed by measuring survival, various biochemical and histologic features, and alterations in hematocrit, pH, and blood gases. Increasing O2 concentrations reversed hypoxemia and acidosis, but had no effect on biochemical or morphologic alterations and did not improve survival. However, hydration by s.c. fluid markedly improved survival and normalized the hematocrit without having major effects on biochemical or morphologic alterations. Intraperitoneal fluid did not improve survival. Gabexate injections without lavage had a slight effect on survival and serum amylase concentration and very little effect on histology. Lavage without gabexate had a greater effect on survival, serum amylase, and histology. Addition of gabexate to the lavage fluid increased the beneficial effect of lavage. Increases in amylase and activated trypsin in ascites were markedly reduced by lavage and even more so by lavage with addition of gabexate. We conclude that sufficient hydration appears to be an important factor in supportive care for severe acute pancreatitis, whereas oxygenation without sufficient hydration has no major benefit. Peritoneal lavage with gabexate showed the greatest benefit of the various regimens for acute severe pancreatitis and is worthy of clinical trials.

Colostomy closure after colon injury: a low-morbidity procedure.

One justification for expanding the indications for primary repair of colonic injuries is the high morbidity classically associated with colostomy closure. Our impression that this morbidity is overstated prompted us to review our experience with closure of colostomies constructed for treatment of colon trauma for the 5-year period 1979-1984. During this period 75 colostomies created for treatment of colorectal injuries were closed. Complications were frequent after colostomy creation, but few could be attributed to the colostomy. Following colostomy closure, however, complications were infrequent (5%) and generally minor. If morbidity of colostomy closure is cited as a factor justifying expanded indications for primary repair of colon injuries, current morbidity rates should be borne in mind.

Pancreatic abscess: Impact of computerized tomography on early diagnosis and surgery☆

Pancreatic abscess continues to be a lethal complication of acute pancreatitis, with mortality rates of 40 percent in recent surgical series. A major factor contributing to this high mortality has been delay in diagnosis. When combined with diagnostic needle aspiration, computerized tomographic scanning has greatly enhanced the early detection of pancreatic abscesses. In a 4 year period at our institutions, 21 patients with proved pancreatic abscesses were evaluated early in their clinical course by computerized tomography. On follow-up ranging from 7 months to 3 1/2 years, there were only four deaths for a mortality rate of 19 percent. Many of the surviving patients had a long and protracted clinical course (mean length of hospitalization was 56 days) and reoperation for recurrent abscess or gastrointestinal complications was required in eight patients (38 percent). Computerized tomography proved to be of considerable value in localizing the site of de novo or recurrent pancreatic abscess and in detecting postoperative complications. An aggressive approach encompassing early computerized tomographic scanning with diagnostic needle aspiration appears to be a factor in the improved survival rate of these patients.

Management of variceal hemorrhage in the potential liver transplant candidate

The increased utilization of liver transplantation raises new issues regarding the management of bleeding esophageal varices in patients who are or may become transplant candidates. Since December 1982, 53 patients were referred from a university hospital to distant liver transplant centers for transplantation. Transplants were performed in 37 patients; at last follow-up, 6 died before transplantation, 7 were awaiting transplantation, and 3 were declined. Of the 53 patients referred for transplantation, 22 (42 percent) had a history of variceal hemorrhage. Sclerotherapy was required in nine patients and portosystemic shunt in four patients. Variceal hemorrhage contributed to the deaths of three of the six patients who died before transplantation could be performed. Endoscopic sclerotherapy has become the mainstay of invasive therapy in most patients with bleeding esophageal varices. If sclerotherapy is unsuccessful in the arrest or control of variceal hemorrhage, the decision must be made whether to proceed with urgent liver transplantation or portosystemic shunt. Factors which influence this choice include the ability to stabilize an acutely bleeding patient, the hepatic reserve and general clinical stature of a patient, and the availability of a liver transplant center.