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UNLABELLED: Vasoactive agents plus endoscopic treatment was recommended in esophageal variceal bleeding (EVB). However, the use according to severity on admission has been poorly evaluated OBJECTIVES: To evaluate the efficacy of endoscopic versus endoscopic plus octreotide treatment in patients with EVB according to severity on admission. METHODS: Between June 2001 and December 2011, 247 patients with EVB were treated using endoscopic or combined endoscopic plus octreotide treatment. Patients were analyzed according to the following cohorts: all patients, those with and without active bleeding, and by Child classes. Initial hemostatic failure, in-hospital rebleeding and in-hospital mortality were compared with both treatments. RESULTS: All patients with combined treatment had less initial hemostatic failure (P = 0.0157) and rebleeding (P = 0.0011) when compared to endoscopic treatment. Active bleeding patients and Child C patients had a significant reduction of initial hemostatic failure when receiving combined treatment vs endoscopic treatment (P = 0.0479 and P = 0.0222, respectively). Child C patients and patients without active bleeding significantly decreased rebleeding with combined treatment (P = 0.0139 and P = 0.0056, respectively). Global mortality was 17%, and did not differ between treatments. None patient in Child A died. CONCLUSIONS: Combined endoscopic plus octreotide treatment in patients with EVB resulted in a reduction of initial hemostatic failure and rebleeding. Moreover, the most relevant effect of combined treatment in decreasing initial hemostatic failure was seen in Child C and active bleeding patients, and for in-hospital rebleeding the same effect was seen in Child C and in patients without active bleeding. Mortality did not differ with both mentioned treatments.

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RESUMO

UNLABELLED: Vasoactive agents plus endoscopic treatment was recommended in esophageal variceal bleeding (EVB). However, the use according to severity on admission has been poorly evaluated OBJECTIVES: To evaluate the efficacy of endoscopic versus endoscopic plus octreotide treatment in patients with EVB according to severity on admission. METHODS: Between June 2001 and December 2011, 247 patients with EVB were treated using endoscopic or combined endoscopic plus octreotide treatment. Patients were analyzed according to the following cohorts: all patients, those with and without active bleeding, and by Child classes. Initial hemostatic failure, in-hospital rebleeding and in-hospital mortality were compared with both treatments. RESULTS: All patients with combined treatment had less initial hemostatic failure (P = 0.0157) and rebleeding (P = 0.0011) when compared to endoscopic treatment. Active bleeding patients and Child C patients had a significant reduction of initial hemostatic failure when receiving combined treatment vs endoscopic treatment (P = 0.0479 and P = 0.0222, respectively). Child C patients and patients without active bleeding significantly decreased rebleeding with combined treatment (P = 0.0139 and P = 0.0056, respectively). Global mortality was 17

, and did not differ between treatments. None patient in Child A died. CONCLUSIONS: Combined endoscopic plus octreotide treatment in patients with EVB resulted in a reduction of initial hemostatic failure and rebleeding. Moreover, the most relevant effect of combined treatment in decreasing initial hemostatic failure was seen in Child C and active bleeding patients, and for in-hospital rebleeding the same effect was seen in Child C and in patients without active bleeding. Mortality did not differ with both mentioned treatments.

Assuntos

RESUMO

UNLABELLED: Vasoactive agents plus endoscopic treatment was recommended in esophageal variceal bleeding (EVB). However, the use according to severity on admission has been poorly evaluated OBJECTIVES: To evaluate the efficacy of endoscopic versus endoscopic plus octreotide treatment in patients with EVB according to severity on admission. METHODS: Between June 2001 and December 2011, 247 patients with EVB were treated using endoscopic or combined endoscopic plus octreotide treatment. Patients were analyzed according to the following cohorts: all patients, those with and without active bleeding, and by Child classes. Initial hemostatic failure, in-hospital rebleeding and in-hospital mortality were compared with both treatments. RESULTS: All patients with combined treatment had less initial hemostatic failure (P = 0.0157) and rebleeding (P = 0.0011) when compared to endoscopic treatment. Active bleeding patients and Child C patients had a significant reduction of initial hemostatic failure when receiving combined treatment vs endoscopic treatment (P = 0.0479 and P = 0.0222, respectively). Child C patients and patients without active bleeding significantly decreased rebleeding with combined treatment (P = 0.0139 and P = 0.0056, respectively). Global mortality was 17

, and did not differ between treatments. None patient in Child A died. CONCLUSIONS: Combined endoscopic plus octreotide treatment in patients with EVB resulted in a reduction of initial hemostatic failure and rebleeding. Moreover, the most relevant effect of combined treatment in decreasing initial hemostatic failure was seen in Child C and active bleeding patients, and for in-hospital rebleeding the same effect was seen in Child C and in patients without active bleeding. Mortality did not differ with both mentioned treatments.

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BACKGROUND: The knowledge of mortality predictors and evolutive variables linked with in-hospital death can help us to optimize corrective procedures. OBJECTIVES: To identify independent predictors of in-hospital mortality and survival, and independent evolutive links with death in patients with generalized secondary peritonitis (GSP). METHODS: Two hundred and forty-two patients admitted into the hospital due to GSP were followed until in-hospital death or hospital discharge. Mortality and survival predictors were identified from several variables evaluated at the time of admission and evolutive links to death from evolutive variables. RESULTS: In-hospital mortality was 16.5%. Independent mortality predictors were APACHE II > or =16 [OR=31,9 (IC 95% 10.5-96,5)] and chronic renal failure history, with specificity (1) An appropriate nutritional condition was the only survival predictor [OR = 0.2 (IC 95% 0.1-0.6)]. The highest contribution to APACHE II predictive power came from the deterioration of blood tests values and vital signs, followed by age, sensory condition, and medical history. Independent evolutive links to mortality were multiorganic dysfunction involving three or more organs [OR = 63.2 (IC 95% 18.4-217)], hemodynamic failure and septic shock, and necessity of vital support with mechanical ventilation and/or inotropic/vasoconstrictor drugs. CONCLUSIONS: In generalized secondary peritonitis the independent predictors of in-hospital mortality are APACHE II score > or =16 and chronic renal failure history, not very useful due to the low prevalence. The only independent survival predictor is an appropriate nutritional status. The evolutive links to mortality are multiorganic dysfunction involving three or more organs, hemodynamic failure and septic shock, and necessity of vital-support with mechanical ventilation and/or inotropic/vasoconstrictor agents.

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OBJECTIVE: To identify clinical warning signs and independent predictors of survival in mediastinitis related to esophagogastric diseases and injuries. METHODS: From March 1998 to February 2009, 36 patients with a mean age of 55.7 +/- 12.3 years old, with mediastinitis due to esophagogastric diseases and injuries were treated. Signs present before diagnosis of mediastinitis were identified. Several presentation and evolutive variables were confronted with mortality and survival. RESULTS: Mortality was 41.7%. Three etiological groups were discriminated: 1) 21 postoperatives of esophagogastric surgery with 57.1% mortality, 2) 14 instrumental and foreign bodies perforations of esophagus with 14.3% mortality, 3) 1 esophageal cancer perforation with no survival. Warning signs in group 1 were: bad postoperative evolution with sepsis and no other septic focus, septic pleural effusion, neumothorax, and supraventricular tachyarrhythmia. Warning signs in group 2 were: thorax pain usually retrosternal, pneumomediastinum, prevertebral cervical and subcutaneous emphysema, pleural effusion, sepsis, and odynophagia. Independent predictors of survival were: surgical procedure tactics that prioritizes debridement with mediastinal, pleural and neck drainage, esophagostomy and gastrostomy in opposition to less aggressive surgical tactics [OR 12.6 (95% CI: 1.7-66.5)], and surgery within the 24 hs of noticing the warning signs [OR 10.6 (95% CI: 1.7-96.7)]. These survival predictors were at the expense of group 1. Group 2 did not show any predictor of survival. CONCLUSIONS: In mediastinitis involving esophagogastric surgery, we recommend to apply the surgical tactics delineated previously and perform surgery within the 24 hs of noticing the warning signs. In mediastinitis involving instrumental and foreign bodies esophageal perforation, we can not recommend any particular surgical tactic.

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UNLABELLED: Upper gastrointestinal variceal bleeding is one of the most serious complications in patients with chronic liver disease. The aim of this trial is to identify in hospital mortality predictors in this illness. MATERIAL AND METHODS: 106 hospitalizations due to this disease from October 2001 to April 2006 in cohort design. In hospital mortality was confronted with age, sex, liver disease etiology, Apache II score at admission, variceal severity, severity of the hepatic failure evaluated according to the Child Pugh's classes, a history of variceal bleeding, initial endoscopic treatment failure, haemostatic failure within the first 48 hours, and rebleeding after 48 hours from admission. In order to identify independent mortality predictors, all the variables correlated significantly with hospital mortality were selected. For the quantitative variable APACHE II score at admission, the best mortality discrimination value was chosen. RESULTS: independent in hospital mortality predictors were: initial endoscopic treatment failure (p = 0.005), haemostatic failure in the first 48 hours (p = 0.012), and Child Pugh C class (p = 0.024). Although male sex, Apache II score at admission and rebleeding after 48 hours were also significantly related to mortality by univaried model, they did not qualify as independent predictors. CONCLUSIONS: the independent predictors of intrahospitalary mortality in patients with variceal bleeding due to chronic liver disease, and first-line of endoscopic treatment were: 1) Initial haemostatic endoscopic treatment failure, 2) Haemostatic failure in the first 48 hs, and 3) Child Pugh C class hepatic failure at admission.

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La hemorragia digestiva alta variceal es una de las complicaciones más graves en la hepatopatía crónica. El objetivo de este trabajo es identificar variables que predicen mortalidad hospitalaria. Material y métodos: 106 internaciones por esta patología desde octubre de 2001 hasta abril de 2006 en diseño de cohortes. Se confrontó mortalidad hospitalaria con edad, sexo, etiología de la hepatopatía, score APACHE II al ingreso, imensión de las várices evaluada endoscópicamente, severidad de la insuficiencia hepática evaluada por clases de Child Pugh, antecedente de hemorragia variceal, fracaso de la terapia endoscópica inicial, fracaso hemostático en las primeras 48hs y resangrado posterior a 48hs. Para identificar predictores independientes de mortalidad se seleccionaron todas las variables que correlacionaron significativamente con muerte hospitalaria. Para la variable cuantitativa score APACHE II de ingreso se consideró el valor que mejor discriminó mortalidad. Resultados: los predictores independientes de muerte hospitalaria fueron: el fracaso de la terapia endoscópica inicial (p=0,005), el fracaso hemostático en las primeras 48hs (p=0,012) y la clase C de Child Pugh (p=0,024). Si bien en el sexo masculino el score APACHE II al ingreso y el resangrado con posterioridad a las 48hs también correlacionaron con mortalimortalidad, no calificaron como predictores independientes. Conclusión: en portadores de hepatopatía crónica con hemorragia digestiva alta variceal y primera línea de tratamiento endoscópico, resultaron predictores independientes de muerte hospitalaria: 1) el fracaso de la terapia endoscópica hemostática inicial, 2) el fracaso hemostático en las primeras 48hs, y 3) la clase C de Child Pugh al ingreso.

Upper gastrointestinal variceal bleeding is one of the most serious complications in patients with chronic liver disease. The aim of this trial is to identify in hospital mortality predictors in this illness. Material and methods: 106 hospitalizations due to this disease from October 2001 to April 2006 in cohort design. In hospital mortality was confronted with age, sex, liver disease etiology, Apache II score at admission, variceal severity, severity of the hepatic failure evaluated according to the Child Pugh’s classes, a history of variceal bleeding, initial endoscopic treatment failure, haemostatic failure within the first 48 hours, and rebleeding after 48 hours from admission. In order to identify independent mortality predictors, all the variables correlated significantly with hospital mortality were selected. For the quantitative variable APACHE II score at admission, the best mortality discrimination value was chosen. Results: independent in hospital mortality predictors were: initial endoscopic treatment failure (p = 0,005), haemostatic failure in the first 48 hours (p = 0,012), and Child Pugh C class (p = 0,024). Although male sex, Apache II score at admission and rebleeding after 48 hours were also significantly related to mortality by univaried model, they did not qualify as independent predictors. Conclusions: the independent predictors of intrahospitalary mortality in patients with variceal bleeding due to chronic liver disease, and firstline of endoscopic treatment were: 1) Initial haemostatic endoscopic treatment failure, 2) Haemostatic failure in the first 48hs, and 3) Child Pugh C class hepatic failure at admission.

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