[Subtotal gastric devascularization for hemorrhage caused by the rupture of gastric varices in cirrhotic patients]. / Dévascularisation gastrique subtotale pour hémorragie par rupture de varices gastriques chez le cirrhotique. A propos de 5 observations.

Hemorrhages caused by gastric varices are a real therapeutic problem in cirrhotic patients. We resort to gastric devascularization in such cases. In 5 of our patients, this devascularization was subtotal, preserving only the pyloric pedicle. Two patients died of liver failure, one immediately after the operation and the other during the second month. The other patients are still living and have not bled again after 9, 12 and 17 months, respectively. Three of the 5 operated patients presented with ischemia of the gastric mucosa postoperatively. In our opinion, the principle of gastric devascularization to an extent still to be defined seems to be an interesting way of treatment these hemorrhages, which are caused by the rupture of gastric varices due to overall portal hypertension.

[Prevention of recurrent hemorrhage caused by the rupture of esophageal varices in cirrhotic patients. A controlled study of propranolol and clip ligation of the esophagus]. / Prévention de la récidive hémorragique par rupture de varices oesophagiennes chez le cirrhotique. Etude contrôlée comparant le propranolol et la ligature de l'oesophage sur clip.

Among the various treatments of ruptured oesophageal varices two seem to be effective: oral propranolol therapy and ligation of the oesophagus on clip. In this controlled study these two methods were compared in a series of 55 patients hospitalized for ruptured oesophageal varices. After haemodynamic stability was obtained, the patients were allocated at random to either propranolol therapy (n = 28) or surgery (n = 27). Twenty-one per cent of these patients belonged to group C of Child's classification and 54 per cent to group A. The parameters studied were similar in both groups. Five patients were excluded from the study: 2 in the medical group when it appeared that propranolol was contra-indicated and 3 in the surgical group who died before the operation; however, these 5 patients were taken into account in a second statistical evaluation. Nineteen out the 26 patients under propranolol (73 per cent) had rebleeding (within the first 10 days in 3 cases). In the surgical group recurrent bleeding was observed in 4 out of the 24 patients (17 per cent), and 4 other patients died post-operatively. The difference in favour of the surgical group was highly significant (P less than 0.001), and it remained significant (P less than 0.05) when the 5 patients who could not be treated were included into the calculations. Cox's multivariate analysis showed that patients in Child's C group had a poorer prognosis.

[Surgical treatment of sliding hiatal hernia using a modified Collis' technic]. / Traitement chirurgical des hernies hiatales par glissement selon la technique de Collis modifiée.

The technique suggested in 1954 by Collis for the surgical treatment of sliding hiatal hernia is based upon relevant anatomical and physiological analysis. Its originality lies essentially in the pre-esophageal closure of the upper part of the hiatus. With a few changes, in particular a midline super-umbilical approach, the Collis operation is a technically very easy and hence rapid procedure, which can widen the range of surgical indications to include patients generally not considered to be appropriate.

[Injuries of the spleen. Value of an absorbable perisplenic mesh. 15 cases]. / Traumatismes de la rate. Intérêt du treillis périsplénique résorbable. Quinze observations.

Over a 2-year period, 15 patients with spleen injuries underwent a spleen repair using an absorbable perisplenic mesh. This procedure was the sole treatment in 11 cases, and it proved both simple and reliable. No major complication was observed. Eight patients could be followed up until the computerized tomographic images became normal. The absorbable perisplenic mesh is an important improvement, and in some cases it may replace other techniques for arresting splenic bleeding.

Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube. Experience in 82 patients.

The records of 82 patients treated with the Sengstaken-Blakemore tube for massive bleeding from esophageal varices have been reviewed. Initial control of hemorrhage was obtained in 78 patients (95 percent). Six patients suffered major nonfatal complications, including bronchial aspiration (five patients) and esophageal rupture (one patient). Twenty-one patients rebled after balloon deflation and underwent emergency portal disconnection of the esophagus with a clip. The other patients underwent elective operation. Long-term survival rates were 49 percent at 1 year, 35 percent at 5 years, and 14 percent at 10 years. Ninety-four percent of the patients were free of recurrent variceal bleeding, as proved by endoscopy, at 1 year, 90 percent at 5 years, and 77 percent at 10 years. This study shows that temporary use of the Sengstaken-Blakemore tube for the initial control of acutely bleeding esophageal varices is effective and relatively safe. In our experience, methods for the prevention of complications were early endotracheal intubation in patients under anesthesia, avoidance of traction on the tube, and a period of tamponade not exceeding 24 hours.

[Treatment of hemorrhage caused by rupture of esophageal varices in the cirrhotic patient: remote results of a practical controlled study comparing the esophageal clip to conventional medical treatment]. / Traitement des hémorragies par rupture de varices oesophagiennes chez le cirrhotique: résultats à distance d'une étude contrôlée pragmatique comparant le clip oesophagien au traitement médical conventionnel.

From 1974 to 1979, a prospective controlled study was conducted in 100 patients with cirrhosis and bleeding esophageal varices. The patients were randomly allocated to either portal disconnection of the esophagus with a clip or medical treatment. Randomization and treatment were performed in emergency situation for 50 patients and electively in 50 patients. All survivors had at least 5 years of observation after randomization. Concerning rebleeding, in the group randomized in emergency, 33 p. cent of patients had recurrent bleeding in the surgical group (mean delay: 64.1 +/- 12.4 months) and 84 p. cent among the medically treated patients (mean delay: 10.6 +/- 4.7 months). This difference is statistically significant (p less than 0.001). For the group randomized electively, 25 p. cent of the surgical patients had recurrent bleeding (mean delay: 76.3 +/- 6.4 months) and 92 p. cent of the medically treated patients had recurrent haemorrhage (mean delay: 20 +/- 5.9 months). The difference is statistically significant p less than 0.001). Concerning survival, among the patients randomized in emergency, 20 died in the surgical group (mean survival: 38.9 +/- 9.3 months) and 22 in the medical group (mean survival: 10.8 +/- 4.6 months). Among the patients randomized electively, there were 19 deaths in the surgical group (mean survival: 46.6 +/- 6.8 months) and 21 in the medical group (mean survival: 32.2 +/- 7.6 months). The difference of survival between the medical and the surgical group is not statistically significant.

[Subtotal gastric devascularization for hemorrhage caused by rupture of gastric varices]. / Dévascularisation gastrique subtotale pour hémorragie par rupture de varices gastriques.

Haemorrhage due to gastric varices raise a problem of surgical tactics. We performed subtotal gastric devascularization, respecting only the pyloric vessels, in 4 cirrhotic patients whose varices of the gastric fundus had ruptured. This technique, which is an extension of proximal oesophageal devascularization for oesophageal varices, may be necessary to control bleeding and seems to be effective in preventing recurrent hemorrhages.

Long term results after portal disconnection of the esophagus using an anastomotic button for bleeding esophageal varices in cirrhosis.

From 1968 to 1984, 250 patients with cirrhosis and bleeding esophageal varices underwent portal disconnection of the esophagus using either Murphy's button (before 1974) or an esophageal device developed by one of the authors (after 1974). One hundred and thirty-four patients underwent operation on an elective basis and 116 underwent emergency procedures. With the use of Child's classification, 62 patients were class A, 125 were class B and 63, class C. The over-all operative mortality rate was 24.4 per cent but this varied with the hepatic functional status and whether or not the operation was done on an elective or emergency basis. The long term survival rates were 53 per cent at one year, 36 per cent at three years, 24 per cent at five years and 8 per cent at ten years. Ninety-six per cent of the patients were without proved recurrent esophageal bleeding at one year, 88 per cent at three years, 79 per cent at five years and 66 per cent at ten years. Portal disconnection of the esophagus using an anastomotic button is a simple and effective procedure which can benefit many patients with cirrhosis who undergo an operation for bleeding varices on an elective or emergency basis. It constitutes an efficacious prophylactic means for preventing recurrent bleeding from esophageal varices.