[Strategy for secure hemostasis in hemophilia patients undergoing surgery for malignant neoplasms]. / Strategia zapewnienia bezpiecznej hemostazy u chorych na hemofilie operowanych z powodu nowotworów zlosliwych.

UNLABELLED: Surgery for malignant neoplasms in hemophilia patients is no different from standard procedures in the general population on condition that the normal hemostatic activity of deficient factors: VIII in hemophilia A and IX in hemophilia B in perioperative period is ensured. The aim of the study was to determine the type and frequency of malignant neoplasms in hemophilia patients as well as to provide a strategy for establishing safe hemostatic activity in surgically treated hemophilia patients. MATERIAL AND METHODS: In the period 2003-2008, surgical procedures were performed on 19 hemophilia A and B patients with diagnosed malignant neoplasms of various location. The following cases were diagnosed: 9 colorectal neoplasms, 2 pancreatic carcinomas, 2 larynx carcinomas, 1 stomach carcinoma, 1 liver, 1 nasopharyngeal, 1 testicle, 1 prostate and 1 skin. Seventeen patients were hemophilia A (6 severe, 4 severe with inhibitor, including 2 high titre and 2 low titre, 1 moderate and 6 mild) and 2 were hemophilia B (1 severe, 1 moderate). Patients mean age was 55.8 years (22-82). In factor-replacement therapy for patients with no inhibitor the strategy was to maintain the activity of the deficient clotting factor VIII before the operation at 80-100% of normal value, within the 80-100% range on the 1-3 day following surgery, at 60-80% on days 4-6, at 30-60% on days 7-10 day and at 20-40% on all subsequent days until the surgical wound healed. In hemophilia B patients the levels were about 20% lower. Deficient factor was injected every 8 or 12 hours or administered in continuous intravenous infusion. In hemophilia A patients with high titre inhibitors to factor VIII (above 5 Bethesda units/ml) activated prothrombin complex concentrates (aPCC)-FEIBA (Baxter AG) were used at 50-100 U/kg b.m., every 8-12 hours. RESULTS: The nineteen patients with diagnosed malignant neoplasms (in the period 2003-2008) constituted 0.77% of the overall 2475 hemophilia patients entered into the National Registry Congenital of Hemorrhagic Diathesis. An overall number of 26 surgical procedures were performed in this group of 19 hemophilia patients including 20 procedures for malignant neoplasms and 6 for postoperative complications. All patients survived surgery. Two patients with pancreatic carcinoma died in the postoperative period due to multi-organ failure. Complications occured in 7 (37%) patients including 6 (32%) with bleeding complications: haemopneumothorax (n=1), intraperitoneal bleeding (n=2), abdominal parietal hematoma (n=1), hematuria (n=1), bleeding from esophago-pharyngo-cutaneous fistula following total laryngectomy (n=1). Other complications included: ileus (n=1), leakage of pancreato-jejunal anastomosis (n=1), dehiscence of abdominal wound (n=1) and bleeding from duodenal ulcer (n=1). These complications were successfully treated with surgery or endoscopy. CONCLUSIONS: Surgery of malignant neoplasms in hemophilia patients is burdened with a high risk of complications which include bleedings despite adequate replacement therapy and administration of factor eight by-passing concentrates in patients with high titre inhibitor. Therefore surgical procedures involving these patients should be performed in specialized centers with experienced team (surgeon, anaesthesiologist, haematologist) and supported by a laboratory for coagulation disorders.

[Small volume resuscitation for acute intraoperative haemorrhage: comparison of 7.5% saline and 6% hydroxyethyl starch]. / Porównanie wplywu przetoczen malych objetosci 7,5% roztworu NaCL lub 6% roztworu hydroksy-etylowanej skrobi na zaburzenia hemodynamiczne, morfologiczne i elektrolitowe u chorych ze sródoperacyjna, ostra utrata krwi krazacej.

BACKGROUND: The immediate effect of acute haemorrhage is a significant reduction in tissue blood flow, frequently resulting in haemorrhagic shock. The main aim of resuscitation after bleeding is the immediate restoration of intravascular volume. Intravenous administration of volume expanders should be commenced immediately, regardless of whether they are colloids or electrolytes. The purpose of the study was to analyze haemodynamic changes during intraoperative acute bleeding and to compare the effects of intravenous infusion with 7.5% saline solution to 6% starch solution on the volume resuscitation process. METHODS: Sixty adult patients, of both sexes, in whom massive loss of blood followed by rapid cardiovascular collapse occurred during elective surgery, were enrolled in the study. In addition to standard fluid transfusion, all patients received either 4 mL kg(-1) of 7.5% NaCl solution or an equal volume of 6% of hydroxyethyl starch. Heart rate (HR) and mean arterial pressure (MAP) were noted. Cardiac output (CO) and systemic vascular resistance (SVR) were measured using a descending aortic blood flow ultrasound monitor. RESULTS: Massive intraoperative haemorrhage resulted in a rapid decrease in CO and SV with a simultaneous increase in HR and SVR in all patients. Injection of hypertonic salt or 6% HAES over 5 min increased the CO and SV. HR and SVR returned quickly to pre-existing levels and remained so until the end of the procedures. CONCLUSION: Small volume resuscitation with 7.5% saline or starch can be regarded as an efficient and effective method for restoring intravascular volume.

Partial splenectomy in the management of nonparasitic splenic cysts.

BACKGROUND: Recognition of the importance of the spleen in immunological function and the potential threat of severe postsplenectomy complications have led to the development of parenchyma-preserving surgical procedures. The aim of the present study was to assess the impact of open splenic partial resection on the management of splenic cysts. PATIENTS AND METHODS: From April 2003 to June 2007, 11 patients with splenic cysts were evaluated. All patients fulfilled the criteria for surgical resection. Ten of the patients (6 women and 4 men) 15-42 years of age (mean: 26.4 years) were subjected to open partial splenectomy. In one patient, a centrally located splenic cyst was considered unsuitable for partial splenectomy, and the patient therefore underwent total spleen excision. Patients with splenic cysts constituted 3.8% of all 290 patients subjected to splenectomy during the study period. Spleen parenchyma was cut with the aid of a LigaSure instrument. Bleeding from the transected splenic parenchyma was secured with argon plasma coagulation and absorbable tape sutures or oxidized cellulose. RESULTS: Nine of the ten patients underwent successful partial splenectomy. In one patient, insufficient arterial supply to the preserved splenic remnant after excision of the upper cyst-containing splenic pole led to total splenectomy. The mean operative time was 98 min (range: 85-160 min), and mean blood loss was 106 ml (55-200 ml). The mean cyst diameter was 9.1 cm (range: 7-17 cm) and weight was 738 g (range: 230-2,420 g). The postoperative course was uneventful in all cases. Pathological examination showed an epithelial cyst in 8 patients and a pseudocyst in 2. After a mean follow-up of 26.4 months, the size of the splenic remnant constituted, on average, 71% of preoperative spleen size. Moreover, normal splenic vein flow was observed. Platelet counts remained within the normal range, and no cyst recurrence was observed. There were no infections documented during the follow-up period. CONCLUSIONS: Open partial splenectomy is a safe and effective method in the management of nonparasitic splenic cysts. It ensures complete cyst removal, lack of cyst recurrence, and preservation of the spleen functions.

[Emergency sclerotherapy in esophageal varices bleeding: prospective study in unselected patients with portal hypertension]. / Dorazna skleroterapia w leczeniu krwotoków z iylaków przetyku: badanie prospektywne w niewyselekcjonowanej grupie chorych z nadcisnieniem wrotnym.

UNLABELLED: Bleeding from esophageal varices is a serious life-threatening complication of portal hypertension. The aim of the study was to evaluate the efficacy and safety of endoscopic sclerotherapy in the emergency management of esophageal variceal bleeding and analysis of recurrent bleedings, complications and mortality within 6-week observation period. MATERIAL AND METHODS: Prospective study involved 128 unselected patients with portal hypertension, including 116 with liver cirrhosis and 12 with portal vein thrombosis, with active bleeding from esophageal varices, in age 20 to 83, mean 50.9. Twenty one patients were classified as Child-Pugh grade A, 43 as grade B and 64 as grade C. After confirmation of diagnosis by endoscopy, emergency scierotherapy procedures were performed according to strictly defined protocol. RESULTS: Active esophageal variceal bleeding was ceased in 123 out of 128 (96.1%) patients. Two patients with persisting bleeding were subjected to gastro-esophageal devascularisation and splenectomy. Three patients died of bleeding and liver insufficiency. Recurrent bleedings in 19 (14.8%) patients were successfully treated with repeated sclerotherapy procedures. Complications were found in 17 (13.3%) patients. During a 6-week observation period, 14 patients died, including 12 in Child-Pugh grade C. CONCLUSIONS: Endoscopic sclerotherapy was proved to be an effective method of esophageal variceal bleeding management which allows to ceases hemorrhage in over 95% patients and reduced mortality rate to 11%. An important factor for achieving good results is experience of treating center.