Uncontrolled gastrointestinal bleeding in two cases was treated successfully by EPSD after endoscopic intervention

failed. The extended duodenotomy performed during inspection Ku-0059436 ic50 for bleeding sites created the necessity of complex reconstruction of D2-3 parts of the duodenum. In these two cases, D2-4 parts of duodenum were excised due to the compromised blood supply to the duodenal suture lines. The surgical cessation of bleeding is currently very rarely in use; only in patients with persistent or recurrent bleeding resistant to endoscopic or endovascular haemostatic techniques [31]. Thus in some special conditions an extended enterotomy to the duodenal lumen for localisation of the atypical bleeding sites is indicated. After haemostatic control is reassumed, the closure of the duodenum is sometimes precarious, especially when the suture line is localised near D2/3 or directly on its horizontal part (D3). Additionally, the intra-luminal pressure in infrapapillary region of duodenum reaches approximately 10 kPa and may be an important factor conditioning healing process [32]. Thus the intestinal loop decompression

lowers the intra-luminal pressure and prevents the leak from suture-line [33]. The described surgical procedures resulted in good outcomes in four patients and although one patient suffered a terminal myocardial infarction at day 28, no adverse gastrointestinal events

were recorded postoperatively. EPSD appears complex however the fact that it may be successfully applied in the emergency setting as a one-step and definitive Selleckchem Torin 1 surgical procedure makes it a very promising alternative to other 6-phosphogluconolactonase less comprehensive procedures. In all cases presented in this paper, the blood loss associated with EPSD itself was generally limited. Only in one patient with gastrointestinal haemorrhage were packed red cells required. This particular patient had a history of coronary disease and required a maintained haemoglobin level of above 10 g/dL for reducing strain on the heart through lowering tachycardia, improving anaemia and correcting of base-acid balance. Our group believe that careful surgical technique and the avoidance of any required blood resuscitation reduced both the risk of postoperative morbidity and improved outcome. The benefits of restricting blood transfusions have been described more recently in various clinical conditions [34]. Nasojejunal feeding tubes were introduced in all patients for early postoperative enteral nutrition. This nutritional support reduces septic events by maintaining integrity, limiting transmigration of bacteria, accelerates return of the bowel peristalsis and influences on inflammatory response during earliest days after surgery. Additionally, nutritional support shortens the length of stay both in the hospital and in ITU [35].