Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

AIM To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane(NBCA + MS)] to treat nonvariceal upper gastrointestinal bleeding(NV-UGIB).METHODS In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy's lesions, and 1 had duodenal diverticular bleeding.RESULTS Of the 45 patients treated endoscopically without initialhemostasis or with early rebleeding, 33(76.7%) were treated with modified cyanoacrylate glue, 16(37.2%) underwent surgery, and 3(7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS(23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients(78.8%): 19 out of 24(79.2%) during the first endoscopy and in 7 out of 9(77.8%) among early rebleeders. Two patients(22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded.CONCLUSION Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

Combined Endoscopic Transanal Vacuum-Assisted Rectal Drainage:A Novel Therapy for Colorectal Anastomotic Leak after TME for Cancer

Introduction: Low colorectal and colo-anal anastomosis leakage after anterior resection of rectum occurs in up to 24% of cases. Leak is the main cause of morbidity and mortality in postoperative period and can result in a permanent stoma in up to 25% of cases. Loop ileostomy or colostomy does not reduce the percentage of fistulas, but reduces flow rate. Conservative management imply long times to heal. Endosponge®system (B. Braun Aesculap AG, Germany) was recently acquired in clinical practice. This system accelerates healing process through vacuum creation, removal of fluids and edema, infection control, local increase of blood flow and stimulation of granulation tissue formation. The device consists of a cylindrical polyurethane sponge, with 400 to 600 micron pores, standard dimension of 7 cm, which can be cut to fit the estimated size of the abscess cavity. The drain tube is connected to a Redyrob Trans Plus®bottle which exerts a constant suction during the therapy. Materials and Methods: From November 2012 and March 2014 four patients were treated with Endosponge®system, all of them underwent operation of anterior resection of rectum for cancer and developed anastomotic leakage during postoperative course. All patients had loop ileostomy, none presented signs of sepsis. The Endosponge®system was then placed endoscopically. In all cases, after the first placing, the authors utilized sterile foam dressing from negative pressure wound therapy kit, tailored to better fill the abscess cavity and connected with Redyrob Trans Plus?bottle. Device changes were performed every 5 - 7 days, according to the size of the cavity and the amount of secretions produced. The treatment was started during hospitalization first and then continued as outpatient. Results: There was no mortality. The amount of secretions was related to the initial size and the degree of contamination of the abscess cavity. Antibiotic therapy was discontinued after an average of 21 days, with a range between 14 and 32 days. Complete healing was achieved in a median of 82 days (30 to 148) in all patients with good functional results, no further surgery was required. Conclusions: The results of therapy with Endosponge®seem encouraging. Success of therapy is higher if initiated as soon possible after the intervention and is also related to the size of dehiscence and abscess cavity. In cases with large abscesses, it is not clear whether this new treatment leads to reduction in healing time, however, can prevent the packaging of a (often definitive) colostomy. Further studies will be able to select patients who will most benefit from the procedure.

The Long Magenstrasse in the Treatment of Super Obese Patients (Results over 5 Years after Surgery)

Background: The considerable increase in Obesity and especially the increase in super obese patients (Body Mass Index—BMI ≥ 50 Kg/m2) who require surgery lead doctors to search for surgery techniques which give good results in terms of a consistent and stable weight loss associated with low morbidity and good quality of life. The Long Magenstrasse (LM) intervention, born from combining two properly modified surgical procedures (Selective Vagotomy with pyloric divulsion and Mangestrasse & Mill by Johnston) seems to have these characteristics according to our experience after operating on 660 patients. Methods: From October 2003 to October 2008 we treated 186 patients with LM. One hundred and sixty-two patients were regularly present to the annual follow-up, but 24 patients didn’t turn up, therefore, they were contacted by phone. On average, surgery lasted approximately 80 minutes (range: 50 - 90 minutes). Thirty patients were super obese with an average BMI of 57.4 Kg/m2;156 patients were grade II and III obese with an average BMI of 40.7 Kg/m2. Results: The average BMI of the 30 super obese patients decreased from 57.4 Kg/m2 to 35.9 Kg/m2 one year after surgery, to 35.6, 5 years after surgery and it has remained stable until now. In the 156 patients suffering from II and III grade obesity, the average BMI decreased from 40.7 Kg/m2 to 27.8 Kg/m2 one year after surgery and it has remained stable until now. Out of all super obese diabetic patients, only one has partially maintained his/her therapy. Patients have reported a decreased appetite since the very first days of post-operative period with an early sense of satiety which is unchanged until today. Conclusions: A consistent and stable weight loss over 5 years after surgery even in Super Obese patients, a decrease in appetite with an early sense of satiety, a re-equilibrium of the metabolic syndrome in particular of Diabetes Mellitus, allow to classify LM among those surgical treatments with a mixed mechanism of action: both restrictive and functional, in particular, entero-hormonal and gastric neurosecretory.