Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1

BACKGROUND According to practice guidelines,endoscopic band ligation(EBL)and endoscopic tissue adhesive injection(TAI)are recommended for treating bleeding from esophagogastric varices.However,EBL and TAI are known to cause serious complications,such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI.However,the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage(GOV1)has not been determined.Therefore,the aim of this study was to discover an individualized treatment for mild to moderate GOV1.AIM To compare the efficacy,safety and costs of EBL and TAI for the treatment of mild and moderate GOV1.METHODS A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted.Patients were allocated to an EBL group or an endoscopic TAI group.The differences in the incidence of varicose relief,operative time,operation success rate,mortality rate within 6 wk,rebleeding rate,6-wk operation-related ulcer healing rate,complication rate and average operation cost were compared between the two groups of patients.RESULTS The total effective rate of the two treatments was similar,but the efficacy of EBL(66.7%)was markedly better than that of TAI(39.2%)(P<0.05).The operation success rate in both groups was 100%,and the 6-wk mortality rate in both groups was 0%.The average operative time(26 min)in the EBL group was significantly shorter than that in the TAI group(46 min)(P<0.01).The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group(11.8%vs 45.1%)(P<0.01).At 6 wk after the operation,the healing rate of operation-related ulcers in the EBL group was 80.4%,which was significantly greater than that in the TAI group(35.3%)(P<0.01).The incidence of postoperative complications in the two groups was similar.The average cost and other related economic factors were greater for the EBL than for the TAI(P<0.01).CONCLUSION For mild to moderate GOV1,patients with EBL had a greater one-time varix eradication rate,a greater 6-wk operation-related ulcer healing rate,a lower delayed rebleeding rate and a lower cost than patients with TAI.

Ligation-assisted endoscopic submucosal resection following unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria

BACKGROUND The majority of esophageal subepithelial lesions originating from the muscularis propria(SEL-MPs)are benign in nature,although a subset may exhibit malignant characteristics.Conventional endoscopic resection techniques are time-consuming and lack efficacy for small SEL-MPs.AIM To evaluate the efficacy and safety of ligation-assisted endoscopic submucosal resection(ESMR-L)following unroofing technique for small esophageal SEL-MPs.METHODS From January 2021 to September 2023,17 patients diagnosed with esophageal SEL-MPs underwent ESMR-L following unroofing technique at the endoscopy center of Shenzhen People’s Hospital.Details of clinicopathological characteristics and clinical outcomes were collected and analyzed.RESULTS The mean age of the patients was 50.12±12.65 years.The mean size of the tumors was 7.47±2.83 mm and all cases achieved en bloc resection successfully.The average operation time was 12.2 minutes without any complications.Histopathology identified 2 Lesions(11.8%)as gastrointestinal stromal tumors at very low risk,12 Lesions(70.6%)as leiomyoma and 3 Lesions(17.6%)as smooth muscle proliferation.No recurrence was found during the mean follow-up duration of 14.18±9.62 months.CONCLUSION ESMR-L following roofing technique is an effective and safe technique for management of esophageal SEL-MPs smaller than 20 mm,but it cannot ensure en bloc resection and may require further treatment.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices:Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Subsequent pregnancy outcomes and fertility rates in the case series that underwent bilateral hypogastric artery ligation(BHGAL)due to severe postpartum hemorrhage

Objective:To evaluate the effect of bilateral hypogastric artery ligation(BHGAL)on women's pregnancy outcomes and fertility rates in cases with severe postpartum hemorrhage.Methods:Patients hospitalized in a tertiary care center between 2007 and 2018 were included in the study.The records of cases were obtained from the hospital database,retrospectively.Maternal demographic data,morbidities or complications associated with BHGAL surgery,any additional haemostatic interventional or surgical procedures,preoperative admission and lowest postoperative haematocrit-hemoglobin values,blood products given,type of anaesthesia,intensive care unit(ICU)and length of hospital stay were recorded.In cases without surgical sterilization,future fertility and subsequent pregnancy outcomes were assessed for at least two years after operation.Information was obtained through face-to-face or telephone interviews with patients whose long-term fertility and subsequent pregnancy outcomes were assessed.Results:Sixty-eight patients with BHGAL surgery history were included in the study.26 Of 37 cases(70%)that did not undergo surgical sterilization had a desire for pregnancy after the surgery.Six of these cases(23%)were diagnosed with secondary infertility.The fertility rate of these cases was 77%,and subsequent pregnancy was detected in 20 women.A total of 25 pregnancies,including first and second pregnancies,developed,and 15 of these pregnancies resulted in term delivery,six preterm births,one stillbirth,and three abortions.Conclusions:The postoperative pregnancy rate was found to be higher than the rate of women with infertility problems,and this surgery does not seem to adversely affect pregnancy outcomes.This is a tertiary center experience and cohort studies with large patient series are needed.

Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery,ensuring the complete removal of the primary tumor and draining lymph nodes is crucial.Lymphatic drainage in the colon follows the vascular supply,typically progressing from pericolic to paraaortic lymph nodes.While NCCN guidelines recommend the removal of 10-12 lymph nodes for ade-quate oncological resection,achieving complete oncological resection involves more than just meeting these numerical targets.Various techniques have been developed and studied over time to attain optimal oncological outcomes.A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels.Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen,while D3 lymphade-nectomy targets all draining regional lymph nodes.Although these principles emphasize different aspects,they ultimately converge to achieve the same goal of complete oncological resection.This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Endoscopic“calabash”ligation and resection for small gastric mesenchymal tumors

BACKGROUND Gastric mesenchymal tumors(GMT)are identified as soft tissue neoplasms that arise from mesenchymal stem cells within the gastrointestinal tract.GMT pri-marily encompass gastric stromal tumors(GST),gastric leiomyomas,and gastric schwannomas.Although most GMT are benign,there are still potential malignant changes,especially GST.Thus,early surgical intervention is the primary treat-ment for GMT.We have designed a simple endoscopic“calabash”ligation and resection(ECLR)procedure to treat GMT.Its efficacy and safety need to be com-pared with those of traditional endoscopic techniques,such as endoscopic sub-mucosal excavation(ESE).AIM To assess the safety and effectiveness of ECLR in managing small GMT(sGMT)with a maximum diameter≤20 mm by comparing to ESE.METHODS This retrospective analysis involved patients who were hospitalized in our institution between November 2021 and March 2023,underwent endoscopic resection,and received a pathological diagnosis of GMT.Cases with a tumor diameter≤20 mm were chosen and categorized into two cohorts:Study and control groups.The study group was composed of patients treated with ECLR,whereas the control group was composed of those treated with ESE.Data on general clinical characteristics(gender,age,tumor diameter,tumor growth direction,tumor pathological type,and risk grade),surgery-related information(complete tumor resection rate,operation duration,hospitalization duration,hospitalization cost,and surgical complications),and postoperative follow-up were collected for both groups.The aforementioned data were subsequently analyzed and compared.RESULTS Five hundred and eighty-nine individuals were included,with 297 cases in the control group and 292 in the study group.After propensity score matching,the final analysis incorporated 260 subjects in each cohort.The findings indicated that the study group exhibited shorter operation duration and lowered medical expenses relative to the control group.Furthermore,the study group reported less postoperative abdominal pain and had a lower incidence of intraoperative perforation and postoperative electrocoagulation syndrome than the control group.There were no substantial variations observed in other parameters among the two cohorts.CONCLUSION ECLR is a viable and effective approach for managing sGMT.

Bile Acid Overload Induced by Bile Duct and Portal Vein Ligation Improves Survival after Staged Hepatectomy in Rats

Objective Compared to portal vein ligation(PVL),simultaneous bile duct and portal vein ligation(BPL)can significantly enhance hypertrophy of the intact liver.This study aimed to investigate whether BPL could improve survival after extended hepatectomy independently of an increased remnant liver.Methods We adopted rat models of 90%BPL or 90%PVL.To investigate the role of bile acids(BAs)the BA pools in the PVL and BPL groups were altered by the diet.Staged resection preserving 10%of the estimated liver weight was performed 3 days after BPL;PVL;or sham operation.Histology,canalicular network(CN)continuity;and hepatocyte polarity were evaluated.Results At 3 days after BPL;PVL;or sham operation when the volumetric difference of the intended liver remained insignificant,the survival rates after extended hepatectomy were 86.7%,47%,and 23.3%,respectively(P<0.01).BPL induced faster restoration of canalicular integrity along with an intensive but transient BA overload.Staged hepatectomy after BPL shortened the duration of the bile CN disturbance and limited BA retention.Decreasing the BA pools in the rats that underwent BPL could compromise these effects,whereas increasing the BA pools of rats that underwent PVL could induce similar effects.The changes in CN restoration were associated with activation of LKB1.Conclusion In addition to increasing the future remnant liver,BPL shortened the duration of the spatial disturbance of the CN and could significantly improve the tolerance of the hypertrophied liver to staged resection.BPL may be a safe and efficient future option for patients with an insufficient remnant liver.

CD4^(+)CD25^(+) regulatory T cells decreased future liver remnant after associating liver partition and portal vein ligation for staged hepatectomy

BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)is an innovative surgical approach for the treatment of massive hepatocellular carcinoma(HCC),the key to successful planned stage 2 ALPPS is future liver remnant(FLR)volume growth,but the exact mechanism has not been elucidated.The correlation between regulatory T cells(Tregs)and postoperative FLR regeneration has not been reported.AIM To investigate the effect of CD4^(+)CD25^(+)Tregs on FLR regeneration after ALPPS.METHODS Clinical data and specimens were collected from 37 patients who developed massive HCC treated with ALPPS.Flow cytometry was performed to detect changes in the proportion of CD4^(+)CD25^(+)Tregs to CD4^(+)T cells in peripheral blood before and after ALPPS.To analyze the relationship between peripheral blood CD4^(+)CD25^(+)Treg proportion and clinicopathological information and liver volume.RESULTS The postoperative CD4^(+)CD25^(+)Treg proportion in stage 1 ALPPS was negatively correlated with the amount of proliferation volume,proliferation rate,and kinetic growth rate(KGR)of the FLR after stage 1 ALPPS.Patients with low Treg proportion had significantly higher KGR than those with high Treg proportion(P=0.006);patients with high Treg proportion had more severe postoperative pathological liver fibrosis than those with low Treg proportion(P=0.043).The area under the receiver operating characteristic curve between the percentage of Tregs and proliferation volume,proliferation rate,and KGR were all greater than 0.70.CONCLUSION CD4^(+)CD25^(+)Tregs in the peripheral blood of patients with massive HCC at stage 1 ALPPS were negatively correlated with indicators of FLR regeneration after stage 1 ALPPS and may influence the degree of fibrosis in patients’livers.Treg percentage was highly accurate in predicting the FLR regeneration after stage 1 ALPPS.

Endoscopic mucosal resection with double band ligation versus endoscopic submucosal dissection for small rectal neuroendocrine tumors

BACKGROUND Endoscopic resection remains an effective method for the treatment of small rectal neuroendocrine tumors(NETs)(≤10 mm).Moreover,endoscopic mucosal resection(EMR)with double band ligation(EMR-dB),a simplified modification of EMR with band ligation,is an alternative strategy to remove small rectal NETs.AIM To evaluate the feasibility and safety of EMR-dB for the treatment of small rectal NETs(≤10 mm).METHODS A total of 50 patients with small rectal NETs,without regional lymph node enlargement or distant metastasis confirmed by endoscopic ultrasound,computerized tomography scan,or magnetic resonance imaging,were enrolled in the study from March 2021 to June 2022.These patients were randomly assigned into the EMR-dB(n=25)group or endoscopic submucosal dissection(ESD)group(n=25).The characteristics of the patients and tumors,procedure time,devices cost,complete resection rate,complications,and recurrence outcomes were analyzed.RESULTS There were 25 patients(13 males,12 females;age range 28-68 years old)in the EMR-dB group,and the ESD group contained 25 patients(15 males,10 females;age range 25-70 years old).Both groups had similar lesion sizes(EMR-dB 4.53±1.02 mm,ESD 5.140±1.74 mm;P=0.141)and resected lesion sizes(1.32±0.52 cm vs 1.58±0.84 cm;P=0.269).Furthermore,the histological complete resection and en bloc resection rates were achieved in all patients(100%for each).In addition,there was no significant difference in the complication rate between the two groups.However,the procedure time was significantly shorter and the devices cost was significantly lower in the EMRdB group.Besides,there was no recurrence in both groups during the follow-up period.CONCLUSION The procedure time of EMR-dB was shorter compared with ESD,and both approaches showed a similar curative effect.Taken together,EMR-dB was a feasible and safe option for the treatment of small rectal NETs.

Genitourinary function and defecation after colorectal cancer surgery with low-and high-ligation of the inferior mesenteric artery:A meta-analysis

BACKGROUND The effect of low ligation(LL)vs high ligation(HL)of the inferior mesenteric artery(IMA)on functional outcomes during sigmoid colon and rectal cancer surgery,including urinary,sexual,and bowel function,is still controversial.AIM To assess the effect of LL of the IMA on genitourinary function and defecation after colorectal cancer(CRC)surgery.METHODS EMBASE,PubMed,Web of Science,and the Cochrane Library were systematically searched to retrieve studies describing sigmoid colon and rectal cancer surgery in order to compare outcomes following LL and HL.A total of 14 articles,including 4750 patients,were analyzed using Review Manager 5.3 software.Dichotomous results are expressed as odds ratios(ORs)with 95%confidence intervals(CIs)and continuous outcomes are expressed as weighted mean differences(WMDs)with 95%CIs.RESULTS LL resulted in a significantly lower incidence of nocturnal bowel movement(OR=0.73,95%CI:0.55 to 0.97,P=0.03)and anastomotic stenosis(OR=0.31,95%CI:0.16 to 0.62,P=0.0009)compared with HL.The risk of postoperative urinary dysfunction,however,did not differ significantly between the two techniques.The meta-analysis also showed no significant differences between LL and HL in terms of anastomotic leakage,postoperative complications,total lymph nodes harvested,blood loss,operation time,tumor recurrence,mortality,5-year overall survival rate,or 5-year disease-free survival rate.CONCLUSION Since LL may result in better bowel function and a reduced rate of anastomotic stenosis following CRC surgeries,we suggest that LL be preferred over HL.

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of colorectal cancer liver metastases

Colorectal cancer(CRC)is a common malignancy of the digestive system.Colorectal liver cancer metastasis(CRLM)occurs in approximately 50%of the patients and is the main cause of CRC mortality.Surgical resection is currently the most effective treatment for CRLM.However,given that the remnant liver volume after resection should be adequate,only a few patients are suitable for radical resection.Since Dr.Hans Schlitt first performed the associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)for CRLM in 2012,ALPPS has received considerable attention and has continually evolved in recent years.This review explains the technical origin of the ALPPS procedure for CRLM and evaluates its efficacy,pointing to its favorable postoperative outcomes.We also discuss the patient screening strategies and optimization of ALPPS to ensure long-term survival of patients with CRLM in whom surgery cannot be performed.Finally,further directions in both basic and clinical research regarding ALPPS have been proposed.Although ALPPS surgery is a difficult and high-risk technique,it is still worth exploration by experienced surgeons.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage

BACKGROUND Liver cirrhosis is the main cause of portal hypertension.The leading cause of death in patients with liver cirrhosis is its most common complication,esophageal variceal bleeding(EVB).Endoscopic variceal ligation(EVL)is recommended by many guidelines to treat EVB and prevent rebleeding;however,esophageal ulcers occur after treatment.Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates.Thus,the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.AIM To evaluate the efficacy of aluminum phosphate gel(APG)plus a proton pump inhibitor(PPI)in the prevention of early rebleeding after EVL in patients with EVB.METHODS The medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital,Guangdong Province,China from January 2015 to December 2020 were collected.According to the study inclusion and exclusion criteria,401 cases were included in a PPI-monotherapy group(PPI group),and 377 cases were included in a PPI and APG combination therapy(PPI+APG)group.We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups.The two-sample t-test,Wilcoxon rank-sum test,and chisquared test were adopted for statistical analyses.RESULTS No significant differences in age,sex,model for end-stage liver disease score,coagulation function,serum albumin level,or hemoglobin level were found between the two groups.The incidence of early rebleeding in the PPI+APG group(9/337;2.39%)was significantly lower than that in the PPI group(30/401;7.48%)(P=0.001).Causes of early rebleeding in the PPI group were esophageal ulcer(3.99%,16/401)and esophageal varices(3.49%,14/401),while those in the PPI+APG group were also esophageal ulcers(5/377;1.33%)and esophageal varices(4/377;1.06%);such causes were significantly less frequent in the PPI+APG group than in the PPI group(P=0.022 and 0.024,respectively).The early mortality rate within 6 wk in both groups was 0%,which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy.The incidence of adverse events other than early bleeding in the PPI+APG group(28/377;7.43%)was significantly lower than that in the PPI group(63/401;15.71%)(P<0.001).The incidence of chest pain in the PPI+APG group(9/377;2.39%)was significantly lower than that in the PPI group(56/401;13.97%)(P<0.001).The incidence of constipation in the PPI+APG group(16/377;4.24%)was significantly higher than that in the PPI group(3/401;0.75%)(P=0.002)but constipation was relieved after patients drank more water or took lactulose.In the PPI and PPI+APG groups,the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50%(2/401)and 0.53%(2/377),respectively,and those of hepatic encephalopathy were 0.50%(2/401)and 0.27%(1/377),respectively,presenting no significant difference(P>0.999).CONCLUSION PPI+APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

Simultaneous bile duct and portal venous branch ligation in two-stage hepatectomy

Hepatectomy is an effective surgical treatment for multiple bilobar liver metastases from colon cancer;however,one of the primary obstacles to completing surgical resection for these cases is an insufficient volume of the future remnant liver,which may cause postoperative liver failure.To induce atrophy of the unilateral lobe and hypertrophy of the future remnant liver,procedures to occlude the portal vein have been conventionally used prior to major hepatectomy.We report a case of a 50-year-old woman in whom two-stage hepatectomy was performed in combination with intraoperative ligation of the portal vein and the bile duct of the right hepatic lobe.This procedure was designed to promote the atrophic effect on the right hepatic lobe more effectively than the conventional technique,and to the best of our knowledge,it was used for the first time in the present case.Despite successful induction of liver volume shift as well as the following procedure,the patient died of subsequent liver failure after developing recurrent tumors.We discuss the first case in which simultaneous ligation of the portal vein and the biliary system was successfully applied as part of the first step of two-stage hepatectomy.

Comparison of murine cirrhosis models induced by hepatotoxin administration and common bile duct ligation

AIM： To build up the research models of hepatic fibrosis in mice.METHODS： Inbred wild-type FVB/N mice were either treated with alpha-naphthyl-isothiocyanate （ANIT）, allyl alcohol （AA）,carbon tetrachloride （CCl4）, 3,5-diethoxycarbonyl-l,4-dihydrocollidine （DDC）, and silica, or subjected to common bile duct ligation （CBDL） to induce hepatic injury. Liver biopsies were performed every 4 wk to evaluate hepatic fibrosis over a period of 6 mo. Cumulative cirrhosis and survival curves were constructed by life table method and compared with Wilcoxon test.RESULTS： Under the dosages used, there was neither mortality nor cirrhosis in AA and silica-treated groups. DDC and ANIT caused cirrhosis within 4-12 and 12-24 wk, respectively.Both showed significantly faster cirrhosis induction at high dosages without significant alteration of survival. The duration for cirrhosis induction by CCl4 ranged from 4 to 20 wk, mainly dependent upon the dosage. However, the increase in CCl4 dosage significantly worsened survival. Intraperitoneal CCl4 administration resulted in better survival in comparison with garage administration at high dosage, but not at medium and low dosages. After CBDL, all the mice developed liver cirrhosis within 4-8 wk and then died by the end of 26 wk.CONCLUSION： CBDL and administrations of ANIT, CCl4, and DDC ensured liver cirrhosis. CBDL required the least amount of time in cirrhosis induction, but caused shortened lives of mice. It was followed by DDC and ANIT administration with favorable survival. As for CCl4, the speed of cirrhosis induction and the mouse survival depended upon the dosages and the administration route.

Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation

AIM: To analyze the clinical risk factors for early variceal rebleeding after endoscopic variceal ligation (EVL).METHODS: 342 cirrhotic patients with esophageal varices who received elective EVL to prevent bleeding or rebleeding at our endoscopy center between January 2005 and July 2010.were included in this study.The early rebleeding cases after EVL were confirmed by clinical signs or endoscopy.A case-control study was performed comparing the patients presenting with early rebleeding with those without this complication.RESULTS: The incidence of early rebleeding after EVL was 7.60%,and the morbidity of rebleeding was 26.9%.Stepwise multivariate logistic regression analysis showed that four variables were independent risk factors for early rebleeding: moderate to excessive ascites [odds ratio (OR) 62.83,95% CI: 9.39-420.56,P < 0.001],the number of bands placed (OR 17.36,95% CI: 4.00-75.34,P < 0.001),the extent of varices (OR 15.41,95% CI: 2.84-83.52,P = 0.002) and prothrombin time (PT) > 18 s (OR 11.35,95% CI: 1.93-66.70,P = 0.007).CONCLUSION: The early rebleeding rate after EVL is mainly affected by the volume of ascites,number of rubber bands used to ligate,severity of varices and prolonged PT.Effective measures for prevention and treatment should be adopted before and after EVL.

Ligation of intersphincteric fistula tract:What is the evidence in a review?

Broadly,complex fistulas are those that are not low transsphincteric or intersphincteric. The objectives of surgical management are to achieve fistula healing,prevent recurrences and maintain continence. The risk of incontinence associated with treatment ranges from10% to 57%. The objective of this manuscript is to review the current literature to date on the ligation of the intersphincteric fistula tract procedure(LIFT procedure) as a treatment option in these types of fistula.A search was conducted in Medline,PUBMED,EMBASE and ISI Web of Knowledge,and studies published from January 2009 to May 2013 were included. The primary outcomes were fistula healing rates,mean healing time and patient satisfaction with this surgical technique.Eighteen studies were included in this review. The total number of patients included was 592(65% male).The median age reported was 42.8 years. The most common type of fistula included was transsphincteric(73.3% of cases). The mean healing rate reported was74.6%. The risk factors for failure discovered were obesity,smoking,multiple previous surgeries and the length of the fistula tract. The mean healing time was5.5 wk,and the mean follow-up period was 42.3 wk.The patient satisfaction rates ranged from 72% to 100%. No de novo incontinence developed secondary to the LIFT procedure. There is not enough evidence that variants in the surgical technique achieve better outcomes(Bio-LIFT,LIFT-Plug,LIFT-Plus). This review indicates that the LIFT procedure is primarily effective for transsphincteric fistulas with an overall fistula closure of 74.6% and has a low impact on fecal continence. This procedure produces better outcomes at the first surgical attempt.

Rubber band ligation of hemorrhoids: A guide for complications

Rubber band ligation is one of the most important, costeffective and commonly used treatments for internal hemorrhoids. Different technical approaches were developed mainly to improve efficacy and safety. The technique can be employed using an endoscope with forward-view or retroflexion or without an endoscope, using a suction elastic band ligator or a forceps ligator. Single or multiple ligations can be performed in a single session. Local anaesthetic after ligation can also be used to reduce the post-procedure pain. Mild bleeding, pain, vasovagal symptoms, slippage of bands, priapism, difficulty in urination, anal fissure, and chronic longitudinal ulcers are normally considered minor complications, more frequently encountered. Massive bleeding, thrombosed hemorrhoids, severe pain, urinary retention needing catheterization, pelvic sepsis and death are uncommon major complications. Mild pain after rubber band ligation is the most common complication with a high frequency in some studies. Secondary bleeding normally occurs 10 to 14 d after banding and patients taking anti-platelet and/or anti-coagulant medication have a higher risk, with some reports of massive life-threatening haemorrhage. Several infectious complications have also been reported including pelvic sepsis, Fournier's gangrene, liver abscesses, tetanus and bacterial endocarditis. To date, seven deaths due to these infectious complications were described. Early recognition and immediate treatment of complications are fundamental for a favourable prognosis.

Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding

AIM: To compare the hemostatic efficacy and safety of two mechanical endoscopic methods: endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in patients with actively bleeding Mallory-Weiss syndrome (MWS). METHODS: A prospective randomized study to compare the efficacy and safety of EHP with EBL was performed from January 2002 to August 2005. Forty-one patients with active bleeding from MWS were treated with EHP (n = 21) or EBL (n = 20). RESULTS: There were no significant differences between groups with respect to clinical and endoscopic characteristics. The mean number of hemoclips applied was 3.2 ± 1.5 and the mean number of bands applied was 1.2 ± 0.4. Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient from the EHP group and two from the EBL group. Patients with recurrent bleeding were treated by the same modality as at randomization and secondary hemostasis was achieved in all. There were no significant differences between the two groups in total transfusion amount or duration of hospital stay. No complications or bleeding-related death resulted. CONCLUSION: EHP and EBL are equally effective and safe for the management of active bleeding in patients with Mallory-Weiss syndrome, even in those with shock or comorbid diseases.

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was conducted.After endoscopic diagnosis of esophageal variceal rupture,patients were randomized into groups for SCL or BL treatment.Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point,with a maximum volume of 20 mL.For BL patients,banding at the rupture point was attempted,followed by ligation of all variceal tissue of the distal esophagus.Primary outcomes for both groups were initial failure of bleeding control(5 d) ,early re-bleeding(5 d to 6 wk),and complications,including mortality.From May 2005 to May 2007,100 patients with variceal bleeding were enrolled in thestudy:50 SCL and 50 BL patients.No differences between groups were observed across gender,age,ChildPugh status,presence of shock at admission,mean hemoglobin levels,and variceal size. RESULTS:No differences were found between groups for bleeding control,early re-bleeding rates,complications,or mortality.After 6 wk,36(80%) SCL and 33(77 %) EBL patients were alive and free of bleeding.A statistically significant association between Child-Pugh status and mortality was found,with 16%mortality in Child A and B patients and 84%mortality in Child C patients(P<0.001) . CONCLUSION:Despite the limited number of patients included,our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.

Elastic band ligation of hemorrhoids:Flexible gastroscope or rigid proctoscope?

AIM： To compare dgid proctoscope and flexible endoscope for elastic band ligation of internal hemorrhoids. METHODS： Patients between 18 and 80 years old, with chronic complaints （blood loss, pain, itching or prolapse） of internal hemorrhoids of grade 1-91, were randomized to elastic band ligation by rigid proctoscope or flexible endoscope （preloaded with 7 bands）. Patients were retreated every 6 wk until the cessation of complaints. Evaluation by three-dimensional anal endosonography was performed. RESULTS： Forty-one patients were included （median age 52.0, range 27-79 years, 20 men）. Nineteen patients were treated with a rigid proctoscope and twenty two with a flexible endoscope. Twenty-nine patients had grade I hemorrhoids, 9 patients had grade 11 hemorrhoids and 3 patients had grade 91 hemorrhoids. All patients needed a minimum of 1 treatment and a maximum of 3 treatments. A median of 4.0 bands was used in the rigid proctoscope group and a median of 6.0 bands was used in the flexible endoscope group （P 〈 0.05）. Pain after ligation tended to be more frequent in patients treated with the flexible endoscope （first treatment： 3 vs 20 patients, P 〈 0.05）. Three- dimensional endosonography showed no sphincter defects or alterations in submucosal thickness. CONCLUSION： Both techniques are easy to perform, well tolerated and have a good and fast effect. It is easier to perform more ligations with the flexible endoscope. Additional advantages of the flexible scope are the maneuverability and photographic documentation. However, treatment with the flexible endoscope might be more painful and is more expensive.