World journal of gastroenterology : WJG
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World J. Gastroenterol. · Jan 2016
ReviewModulation of splanchnic circulation: Role in perioperative management of liver transplant patients.
Splanchnic circulation is the primary mechanism that regulates volumes of circulating blood and systemic blood pressure in patients with cirrhosis accompanied by portal hypertension. Recently, interest has been expressed in modulating splanchnic circulation in patients with liver cirrhosis, because this capability might produce beneficial effects in cirrhotic patients undergoing a liver transplant. Pharmacologic modulation of splanchnic circulation by use of vasoconstrictors might minimize venous congestion, replenish central blood flow, and thus optimize management of blood volume during a liver transplant operation. ⋯ These effects are especially important in patients who receive a too small for size graft. Terlipressin selectively stimulates V1 receptors, and thus causes arteriolar vasoconstriction in the splanchnic region, with a consequent shift of blood from splanchnic to systemic circulation. As a result, terlipressin enhances renal perfusion by increasing both effective blood volume and mean arterial pressure.
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World J. Gastroenterol. · Jan 2016
ReviewHemostasis in liver transplantation: Pathophysiology, monitoring, and treatment.
Recent findings in the pathophysiology and monitoring of hemostasis in patients with end stage liver disease have major impact on coagulation management during liver transplantation. There is increasing evidence, that the changes in both coagulation factors and platelet count regularly observed in patients with liver cirrhosis cannot be interpreted as a reliable indicator of diffuse bleeding risk. Instead, a differentiated view on hemostasis has led to the concept of a rebalanced coagulation system: While it is important to recognize that procoagulant factors are reduced in liver cirrhosis, it is also evident that synthesis of anticoagulant factors and fibrinolytic proteins produced in the liver is also diminished. ⋯ Besides conventional laboratory methods, bed-side monitoring of hemostasis (e.g., thrombelastography, thrombelastometry) is often used during liver transplantation to rapidly diagnose decreases in fibrinogen and platelet count as well as hyperfibrinolysis and to guide treatment with blood products, factor concentrates, and antifibrinolytics. There is also evidence which suggests when algorithms based on bed-side hemostasis monitoring are used a reduction of blood loss, blood product use, and eventual mortality are possible. Notably, the bed-side monitoring of anticoagulant pathways and the thrombotic risk is not possible at time and thus a cautious and restrictive use of blood products is recommended.
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World J. Gastroenterol. · Jan 2016
ReviewCytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer.
Gastric cancer associated peritoneal carcinomatosis (GCPC) has a poor prognosis with a median survival of less than one year. Systemic chemotherapy including targeted agents has not been found to significantly increase the survival in GCPC. ⋯ HIPEC has been used for three indications in GC- as an adjuvant therapy after a curative surgery, HIPEC has been shown to improve survival and reduce peritoneal recurrences in many randomised trials in Asian countries; as a definitive treatment in established PC, HIPEC along with CRS is the only therapeutic modality that has resulted in long-term survival in select groups of patients; as a palliative treatment in advanced PC with intractable ascites, HIPEC has been shown to control ascites and reduce the need for frequent paracentesis. While the results of randomised trials of adjuvant HIPEC from western centres are awaited, the role of HIPEC in the treatment of GCPC is still evolving and needs larger studies before it is accepted as a standard of care.
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World J. Gastroenterol. · Jan 2016
ReviewTechnical feasibility of laparoscopic extended surgery beyond total mesorectal excision for primary or recurrent rectal cancer.
Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer. Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. ⋯ To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.
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World J. Gastroenterol. · Jan 2016
ReviewBuried bumper syndrome: A complication of percutaneous endoscopic gastrostomy.
Percutaneous endoscopic gastrostomy (PEG) is a widely used method of nutrition delivery for patients with long-term insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome (BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. ⋯ A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique (needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach (lamina muscularis propria) should be treated by a surgeon.