One hundred and one over-the-scope-clip applications forsevere gastrointestinal bleeding,leaks and fistulas

AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients(48.8%) presented with severe upper-gastrointestinal(GI) bleeding, 3(3.6%) patients with lower-GI bleeding, 7 patients(8.3%) underwent perforation closure, 18 patients(21.4%) had prevention of secondary perforation, 12 patients(14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection(ESD) and 3 patients(3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients(92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients(89.28%). The overall mortality in the study patients was 11/84(13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41(85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases(57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18(100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen(2%).CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.

Interpatient heterogeneity in hepatic microvascular blood flow during vascular inflow occlusion (Pringle manoeuvre)

Hepatic inflow occlusion(Pringle manoeuvre),is a widely used technique,consisting in temporary intermittent or continuous clamping of the hepatic pedicle.This technique was described in 1908 by Pringle to minimize blood loss during emergency surgery for liver trauma.Therefore,in hepatobiliary surgery,the Pringle manoeuvre assumes a primary role especially in complex liver resections where an intraoperative blood loss could be significant.Afterwards.

Comment on:simultaneous versus delayed resection for initially resectable synchronous colorectal cancer liver metastases

We read with great interest the recently published article of Boudjema and collaborators(1).The authors evaluated the safety and efficacy of delayed resection(DR)versus simultaneous resection(SR)for patients with initially resectable synchronous colorectal cancer liver metastases(CRC-SLM).The aforementioned study(METASYNC)was the first randomized controlled trial comparing two resection strategies for CRC-SLM.In the literature,large retrospective studies didn’t seem to favor one type of treatment,particularly when comparisons are based on a propensity match score(2).

Value-based healthcare:a novel approach to the evaluation of patient care

Patti et al.(1)have reported an analysis of the literature searching for an evaluation of robotic liver and pancreatic surgery according to a value-based health care(VBHC)approach.This model was developed by Porter(2)in order to consider the following two aspects:vthe outcomes that matter most to patients,which are defined as the sum of patients’health objectives;vthe costs required to achieve these results.