In vitro resistance of artificial connective tissues to human bile and pancreatic juice.

The resistance of connective tissue generated from elastin, placenta extracts and human collagen was tested by in vitro incubation with bile and pancreatic juice to investigate the potential use in human digestive surgery. The resistance, determined by macroscopical and microscopical examinations, has been directly compared to those of bovine collagen matrices (Spongel, Pangen, Helistat, Translagen). Only the compact and cross-linked human collagen patch resisted both bile and pancreatic juice. All other biomaterials tested dissolved either in bile or in pancreatic juice. The in vivo behaviour of this new human collagen matrix and its involvement in gastrointestinal wound healing must now be investigated.

Covered stents are better than uncovered stents for transjugular intrahepatic portosystemic shunts in cirrhotic patients with refractory ascites: a retrospective cohort study.

BACKGROUND AND STUDY AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted interventional technique to treat refractory ascites in cirrhotic patients with severe portal hypertension. The expanded-polytetrafluoroethylene (e-PTFE) covered stent-graft (cs-TIPS) gives a better shunt patency rate than uncovered stents (ncs-TIPS). Our aim was to retrospectively evaluate whether cs-TIPS indeed improves refractory ascites and overall survival in a more effective way than ncs-TIPS in patients with cirrhosis. PATIENTS AND METHODS: From 1992 to 2006, 222 cirrhotic patients with refractory ascites underwent a TIPS-procedure. In 126 patients a ncs-TIPS was inserted, in the remaining 96 patients a csTIPS was inserted. Liver transplantation and/or death were the end points of the follow-up. RESULTS: The baseline characteristics of both groups were similar: age (55 +/- 11 years, ncs-TIPS/56 +/- 10 years, cs-TIPS), alcoholic cirrhosis (73% ncs-TIPS/80% cs-TIPS), Child-Pugh (9 +/- 2.0 ncs-TIPS/9.2 +/- 1.3 cs-TIPS) and MELD (15 +/- 6 ncs-TIPS/15 +/- 4.9 cs-TIPS), except that the bilirubin level was higher in the cs-TIPS group (2.5 +/- 2.7 mg/dL in cs-TIPS vs. 1.5 +/- 3.6 mg/dL in ncs-TIPS). One year shunt dysfunction occurred in 49% (n=63) of the ncs-TIPS vs. 19% (n = 18) of the cs-TIPS (P < 0.0001) and post TIPS encephalopathy in 56% (n=70) of the ncs-TIPS vs. 22% (n = 22) in the cs-TIPS group. Ascites control and overall survival were better in the cs-TIPS (P = 0.0071). The gain in survival in the cs-TIPS patients occurred especially in patients with a baseline MELD score <16 (P < 0.0001). Post TIPS encephalopathy and ncs-TIPS were independently related with poor survival (P < 0.0001, P = 0.0150; respectively). CONCLUSIONS: In cirrhotic patients with refractory ascites cs-TIPS offers better symptomatic control of the ascites at one year follow-up and a better overall survival, especially in patients with a MELD score of <16 at baseline.

Biomaterials for primary closure of a choledochotomy in dogs.

Since primary closure of the common bile duct is often not undertaken because of the risks of biliary leakage and peritonitis, we have evaluated feasibility and reliability of closure using biomaterials. In three groups of dogs, an unsutured choledochotomy was closed with circular glued patches: a scleroprotein patch in 4 dogs and an oxidized, compressed human collagen patch reinforced (n = 6) or not (n = 6) with three stitches. The scleroprotein patch (n = 4) was resorbed too soon, and in 2 dogs the unstitched collagen patches became unglued; biliary leakage was the result in both instances. The bile duct healed successfully within 1 month in the other 10 animals fitted with collagen patches, despite one common bile duct stricture. Safe primary closure of a choledochotomy may be envisioned in humans if the duct suture is protected by this new collagen biomaterial.

Endoscopic histoacryl obliteration vs. propranolol in the prevention of esophagogastric variceal rebleeding: a randomized trial.

BACKGROUND AND STUDY AIMS: The obliteration of esophageal and/or gastric varices using Histoacryl is highly effective in controlling active bleeding. However, it is not known whether repeated injections are useful for the long-term eradication of esophagogastric varices. The aim of the study was to compare endoscopic Histoacryl obliteration with propranolol in the secondary prevention of esophagogastric variceal bleeding. PATIENTS AND METHODS: Between August 1995 and February 1999, 41 patients with a first bleeding from esophageal (n = 31) or gastric (n = 10) varices were included in the study. After primary hemostasis with obliteration using Histoacryl, patients were randomly allocated either to undergo complete Histoacryl obliteration of the remaining varices (group A, n = 21) or to long-term propranolol administration (group B, n = 20), for the prevention of rebleeding. RESULTS: The two groups were well matched for age, sex, etiology of cirrhosis, Child-Pugh score, renal function, and infection at the time of admission. The median follow-up was 31.9 months (4.8 - 74.7) for group A and 23.2 months (3.0 - 70.0) for group B. Initial hemostasis was achieved in 40/41 patients (97 %). No significant difference was observed between groups A and B with regard to the incidence of early rebleeding (during the first 6 weeks; 5/21 and 3/20), bleeding-related deaths by 6 weeks (3/21 and 6/20), long-term rebleeding (11/21 and 5/20), or overall number of deaths (9/21 and 9/20). The incidence of complications was higher in group A (10/21) than group B (2/20) (P < 0.03). CONCLUSIONS: Repeated injections of Histoacryl with the aim of eradicating esophagogastric varices are associated with more complications compared with beta-blocker administration, with similar results in terms of rebleeding rate and survival in the long term.