Endoscopic injection treatment of gastrointestinal bleeding in hemophiliacs.

The aims of this prospective study were to determine the patterns of gastrointestinal (GI) bleeding in hemophiliacs and to assess the hemostatic effect of injection therapy with alcohol. During a 5-year period (1990-1994) 89 hemophiliacs were admitted to our department with acute GI bleeding. Among these patients duodenal ulcer was found endoscopically to be the most common (42.7%) cause of hemorrhage; gastric ulcer was the source of the bleeding in only three patients (3.4%). A group of 46 patients met the criteria of active or recent bleeding and underwent injection therapy with alcohol. The injected bleeding lesions were duodenal ulcer in 32 patients, duodenal erosion in 2, gastric ulcer in 3, and other gastric lesions (Mallory-Weiss tear, Dieulafoy lesion, stomal ulcer, erosions) in 9 patients. Initial hemostasis was achieved in 100% and permanent hemostasis in 82.6%. Rebleeding was observed in eight patients (17.4%), with five of them successfully treated by reinjections. Three patients (6.5%) required emergency surgery. The mortality rate in the group of injected patients was 2.2%. One patient died of stroke on day 10 after partial gastrectomy. All injected patients were given replacement therapy with factor VIII or IX for 2 days (29 patients) or 7 to 14 days (17 patients). Analysis of the hemostatic effect achieved in these two subgroups indicate that short-term replacement therapy (2 days) may be sufficient to ensure adequate hemostasis in hemophiliacs. The results of the present study indicate that injection therapy with alcohol is an effective, safe, proved method to control GI bleeding in hemophiliacs.

Extrahepatic portal hypertension: long-term results of surgical treatment.

Long-term results of surgical treatment were analysed in 42 patients with extrahepatic portal hypertension treated in the Department of Surgery, Institute of Haematology in Warsaw in the period 1971-1987. In all, 71 operations were carried out, and 20 patients were treated by endoscopic sclerotherapy of oesophageal varices. Recurrence of haemorrhage was found in 6 out of 11 patients 54% after venous shunting, in 13 out of 17 patients (76%) after treatment by ligation of oesophageal varices and in 32 out of 35 patients (91%) after splenectomy. Following repeated sclerotherapy of oesophageal varices, recurrence of haemorrhage occurred in 3 out of 20 patients (15%). During 17 years four deaths occurred (10%) none of which was due to haemorrhage from oesophageal varices. The authors conclude that the method of repeated sclerotherapy is presently the most effective way of preventing haemorrhage from oesophageal varices and consider this form of management as the treatment of choice in patients with extrahepatic portal hypertension.

[Comparison of the results of sclerotherapy of esophageal varices using a rigid esophagoscope and fiber-optics esophagoscope]. / Porównanie wyników leczenia obliteracyjnego zylaków przelyku z zastosowaniem ezofagoskopu sztywnego i ezofagofiberoskopu.

The authors compared the results of 20 emergency and 100 elective varicosclerotisations with rigid esophagoscope and the same number of obliterations with the use of esophagofiberoscope. Haemorrhage was stopped in 90% of patients injected through the rigid esophagoscope and in 80% of patients in whom esophagofiberoscope was used. Hospital mortality rate in patients with bleeding esophageal warices was 25% in both groups. Complications were seen in 4.2% of procedures carried out with the rigid esophagoscope, and 5.8% of obliterations with esophagofiberoscope. The authors recommend rigid esophagoscope for emergency sclerotherapy and for the initial 2-3 series of injections in patients with large varices. Esophagofiberoscope is prefered in case of repeated, elective varicosclerotisations, first injections and recurrence of esophageal varices following obliterative therapy.

Emergency and elective sclerotherapy of oesophageal varices.

Endoscopic injection sclerotherapy of oesophageal varices was performed in 71 patients: 50 with intrahepatic and 21 with extrahepatic block. In summary 330 procedures were done: 220 under general anaesthesia using the Negus rigid oesophagoscope and 110 with diazepam as premedication using a flexible, fibreoptic endoscope. Definitive control of variceal haemorrhage was achieved in 30 of 34 emergency admissions (88%). The hospital mortality in acute variceal bleeding was 26.5%. Elective, repeated sclerotherapy was performed in 60 patients. In 43 patients complete obliteration of varices or their marked reduction were observed. Rebleeding occurred in 23% and major complications in 17% of patients. The overall one year survival rate was 82%. We consider sclerotherapy as a method of choice in bleeding oesophageal varices uncontrollable by vasopressin and balloon tamponade. It also represents a valuable method of preventing rebleeding particularly in patients with a high operative risk.

Evaluation of early postsplenectomy complications.

This study was done to define the incidence of early postsplenectomy complications and is based upon 688 splenectomies--mainly in malignant and nonmalignant hematologic conditions--performed during the period 1952 to 1986. In 354 patients, early postoperative complications were observed, among whom wound and pulmonary infections were most common. A fatal outcome was noted in 32 patients for a mortality rate of 4.7 per cent. The incidence of early complications after splenectomy is higher than after most other surgical procedures within the abdominal cavity and depends upon the underlying diseases which lead to splenectomy. Deficient immunologic defense mechanisms may be a significant factor in the development of early complications in patients after splenectomy.

Moynihan Lecture, 1980. Major surgery in haemophilia.

The experience of the Department of Surgery of the Institute of Haematology, Warsaw, in surgery in haemophilic patients is discussed. From 1961 to 1980 131 surgical procedures were carried out on 110 patients with a mortality of 4.5%. The principles of replacement therapy, advantages of factor VIII concentrates, and factors influencing the haemorrhagic complications are described. The management of patients with inhibitors of factor VIII and the effect of the 'Feiba' preparation is discussed. Finally the importance of new work on an antihaemophilic globulin-liposome compound for oral administration to haemophilic patients is emphasised.

Influence of stroma-free hemoglobin solution on renal function in dogs.

In the presented series of experiments, stroma-free hemoglobin solution (SFHS) was used as a perfusate for extracorporeal perfusion of kidneys and for exchange transfusion. It was shown that SFHS was adequatly oxygenated both as perfusate during the extracorporal perfusion and in the lungs after the blood exchange. Furthermore, there was provided evidence that oxygen was being transported and released in the tissues. Histologic examination of the kidneys demonstrated hemoglobin casts in the glomerules. Most of them were seen after extracorporal perfusion of isolated kidneys, less frequently after perfusion in situ and few casts were present after exchange transfusion. The cause of these depositions may be small remnants of stroma in the preparation. Furthermore it is possible, that at the beginning of the extracorporal perfusion of the kidneys the urine pH was below 6 and then a hemoglobin casts formation could occur. There were essential no changes in urine pH in the course of blood exchange. In this group were only few casts present in the kidneys.

Investigations on tensile strength of intestinal anastomosis in pharmacologically induced blood clotting disturbances.

The authors present the results of investigations on tensile strength of intestinal anastomosis in pharmacologically induced blood clotting disturbances in the postoperative period (1-16 days). Experiments were carried out on 50 male rabbits in two groups- a treated group and another for control only. Animals in the experimental group were treated with Sincumar 24 hours before and in the postoperative period. The dosis of Sincumar was calculated to reduce the prothrombin index below 40 percent. The tensile strength of intestinal anastomosis was tested the 2nd, 3rd, 5th and 15th day after operation and in the same time histological examinations of anastomosis specimen were performed. In conclusion the authors found that the reduction of the prothrombin index below 40 percent does not influence the process of healing of anastomosis of the small intestine, prevents the formation of adhesions and inflammatory peritoneal reaction following operation.