The EORTC QLQ-C30 and QLQ-PAN26 appear to be an appropriate assessment system for CP, with the addition of items to cover guilt about alcohol consumption, and the burden of abstention. Patients' QoL is adversely affected by the fear of future health problems, difficulty sleeping, and fatigue.

Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of < 1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.

No abstract

Preoperative manometric assessment of oesophageal motility does not correlate with postoperative outcome, and oesophageal dysmotility should not be regarded as a contraindication to laparoscopic Nissen fundoplication.

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.

The venous anatomy of the lower oesophagus and upper stomach in man was studied using high resolution resin casts obtained from ten fresh cadavers. Four layers of veins were identified in the oesophagus of both normal and portal hypertension patients. Intra-epithelial channels drained into a superficial venous plexus which connected to larger deep intrinsic veins. Both the superficial plexus and the deep intrinsic veins communicated directly with their counterpart veins in the stomach. Perforating veins connected the deeper veins with the adventitial plexus, the fourth layer. In patients with portal hypertension all of these veins were significantly dilated. Typical large oesophageal varices arose from the main trunks of the deep intrinsic veins which communicated directly with gastric varices. This study clarifies the anatomy of oesophageal varices and may explain why sclerotherapy is usually effective. The venous communications are probably partly responsible for the recurrence of varices after sclerotherapy.

Packing for control of haemorrhage was used in 22 of 294 patients undergoing surgery for liver trauma over a 6-year period. The major indication for packing was transfusion-induced coagulopathy. Sixteen patients had blunt trauma and six penetrating trauma including five gunshot wounds; 19 patients had major right lobe injuries, three left lobe and five also had hepatic vein injuries. Packing provided definitive control of bleeding in 18 patients but four patients had recurrent bleeding due to hepatic artery injury (three) and hepatic vein injury (one); three required further surgery and bleeding was controlled in the fourth by selective hepatic artery embolization. Six patients died and in two of these recurrent bleeding, despite packs, was a contributing factor. Mean blood loss in the six patients who died was 18 (range 10-30) units, compared with 13.1 (range 8-30) units in survivors. Packs were removed from the 16 survivors at laparotomy at a mean of 3.1 days after insertion; six patients rebled during pack extraction and were successfully repacked. Major morbidity occurred in 12 of the 16 survivors. Seven patients developed intra-abdominal sepsis following packing, one of whom died. Therapeutic liver packing provides life-saving control of hepatic bleeding which is frequently aggravated by coagulopathy. This approach permits resuscitation in an intensive care unit and subsequent planned relaparotomy for retrieval of packs and further intervention as necessary.

SUMMARY BackgroundControlled pantoprazole data in peptic ulcer bleeding are few.