Totally extraperitoneal inguinal hernia repair in patients with hemophilia and von Willebrand disease. Prospective controlled study.

INTRODUCTION: Laparoscopic surgery is associated with several advantages. Surgical procedures in hemophilia or von Willebrand patients without replacement therapy (RT) to correct clotting factor deficiency may result in serious, life-threatening hemorrhagic episodes. Clotting factor concentrates improve hemostatic control but bleeding risk in major invasive procedures remains high. AIM: Evaluation of totally extraperitoneal inguinal hernia repair (TEP-IHR) in patients with congenital hemorrhagic disorders (H) and comparison with results for non-hemophiliacs (NH) with regard to bleeding, postoperative pain, hernia recurrence, surgery time, demand for painkillers, hospital stay and recovery time. MATERIAL AND METHODS: The prospective controlled trial included 67 consecutive male patients scheduled for TEP-IHR between January 2010 and December 2018. Surgery was performed in groups H (n = 22) and NH (n = 45). Full study inclusion criteria were met by 65 patients (22 and 43 in H and NH groups respectively). Follow-up was carried out on the 1st, 2nd, and 7th day and in the 1st and 3rd month postoperatively. RESULTS: TEP-IHR was successful for all patients. No life-threatening bleeding occurred and no patient required red blood cell transfusions or reoperation. No hernia recurrence was reported. No statistically significant differences were observed between the groups with regard to surgery duration, postoperative hematoma frequency and demand for painkillers. In the H group, pain intensity was significantly higher during the first postoperative month and hospitalization and recovery were significantly longer. CONCLUSIONS: TEP-IHR in hemophiliacs with RT is feasible and as effective for preventing hernia recurrence as in NH-patients. In hemophiliacs risk of bleeding complications and demand for painkillers are comparable to non-hemophiliacs although pain is more intense.

Totally extraperitoneal inguinal hernia repair with or without fixation leads to similar results. Outcome of randomized prospective trial.

INTRODUCTION: The use of implants in inguinal hernia repair has reduced its recurrence rate. However, postoperative groin pain still remains an unresolved problem. There are suggestions that in totally extraperitoneal inguinal hernia repair (TEP-IHR) two of the likely factors responsible for pain are use of fixation and the type of fixation used. AIM: To evaluate the impact of mesh fixation on the incidence of postoperative pain, restriction of physical activities, hernia recurrence risk, return to normal activities and demand for analgesics in patients after unilateral TEP-IHR. MATERIAL AND METHODS: Unilateral TEP-IHR was performed in 139 male patients randomized to three groups: self-gripping mesh (SG), lightweight mesh (L) and lightweight mesh with fixation (LF). Full study-inclusion criteria were met by 110 patients; 43, 18 and 49 in groups SG, L and LF respectively. Follow-up occurred on the 1st, 2nd, and 7th day and 3, 6, 12 months postoperatively. The numeric rating scale (NRS) was used to assess pain and the EuraHS-QoL (European Registry for Abdominal Wall Hernias Quality of Life Score) questionnaire to compare quality of life (QoL) prior to surgery and one year later. RESULTS: No statistically significant differences were observed between study groups with regard to the incidence rate and intensity of acute post-operative pain, chronic pain, analgesic demand, return to normal activity, hernia recurrence rate and post-operative QoL. CONCLUSIONS: Lack of fixation in TEP-IHR does not increase the risk of hernia recurrence, and its presence does not significantly worsen the treatment results; especially it does not increase the incidence of chronic pain.

Sclerotherapy of esophageal varices in hemophilia patients with liver cirrhosis - a prospective, controlled clinical study.

INTRODUCTION: Bleeding from esophageal varices is a serious clinical condition in hemophilia patients due to congenital deficiency or lack of clotting factors VIII (in hemophilia A) and IX (in hemophilia B), decreased clotting factor II, VII, IX, X synthesis in the course of chronic liver disease and hipersplenic thrombocytopenia. The aim of this study was to assess the efficacy and safety of endoscopic sclerotherapy in acute esophageal variceal bleeding and in secondary prophylaxis of hemorrhage. The aim was also to investigate the optimal activity of deficiency factors VIII or IX and duration of replacement therapy required to ensure proper hemostasis after sclerotherapy procedures. MATERIAL AND METHODS: 22 hemophilia patients (A-19, B-4) with coexistent liver cirrhosis and active esophageal variceal bleeding treated with endoscopic sclerotherapy were subjected to prospective analysis. The patients who survived were qualified to repeated sclerotherapy procedures every 3 weeks within secondary prophylaxis of bleeding (investigated group). A 3-day substitution therapy enhanced the infusion of the deficient or lacking factor in doses allowing to reach 80-100% of normal value activity of factor VIII on the 1st day and 60-80% in the next two days. The desired activity of factor IX was 60- 80% and 40-60% respectively. The control group consisted of 20 non-hemophiliac patients with liver cirrhosis comparable in terms of age, sex, stage of advancement of liver cirrhosis, who underwent the same medical proceedings as the investigated group. RESULTS: Active esophageal bleeding was stopped in 21 of 22 (95%) hemophilia patients. Complications were observed in 3 patients; 2 patients died. The rate of hemostasis, complications and deaths in the control group were comparable and no statistical differences were found. In hemophilia patients subjected to secondary prophylaxis of hemorrhage, in 18 of 20 (80%), complete eradication of esophageal varices was achieved after 4 to 7 sclerotherapy procedures in 1 patient (average 5.4). Recurrent bleeding was observed in 15% of patients, complication in 20%; 1 patient died. Time lapse from bleeding to eradication was 12-21 weeks (average 15.2). In the control group the rate of variceal eradication, complication and deaths was comparable and no statistical differences were found. The usage of factor VIII concentrates was as follows: in hemophilia A, in a severe form - 80.9 U/kg b.w./day, in hemophilia A in a severe form with an inhibitor <5 BU - 95.2 U/kg b.w./day, in mild form - 64.2 U/kg b.w./day and in severe hemophilia B - 91.6 U/kg b.w./day. CONCLUSIONS: Sclerotherapy is an effective method in the management of esophageal variceal bleeding in hemophilia patients. It is also effective for total eradication of varices when applied as a secondary prophylaxis of hemorrhage. In our opinion, a 3-day replacement therapy at the applied doses is sufficient to ensure hemostasis and avoid bleeding complications.

Splenic abcesses as infectious complication following implantation of left ventricular asssist device - case report.

Left ventricular assist device (LVAD) is one of the modern management therapies in patients with advanced heart failure, and it serves as a bridge to heart transplantation or even as destination therapy. However, it is burdened with a high risk of thromboembolic, hemorrhagic, and infectious complications despite prophylactic management. Splenic abscesses, as septic complications following implantation of mechanical ventricular support, have not yet been described in the literature. We report of a patient with severe left ventricular insufficiency (NYHA II/III), pulmonary hypertension, and arrhythmia who underwent implantation of the Heart Ware® pump for left ventricular support with simultaneous tricuspidvalvoplasty, as a bridge therapy to heart transplantation. During two years after LVAD implantation, the patient had three MRSA skin infections, localized at the exit site of the drive-line connecting the artificial ventricle with external unit, that were complicated by sepsis and treated with broad-spectrum antibiotics. A few months later, abdominal CT revealed two abscesses in the spleen, and the patient was qualified for splenectomy. Open splenectomy was performed under full-dose anticoagulant therapy with continuous intravenous infusions of unfractionated heparin (UFH). The intra- and postoperative course was uneventful. UFH therapy was continued for 6 days, and oral anticoagulation was re-administered on day 4 after surgery. The patient was discharged on day 7 after surgery with primary healed wound. Open splenectomy, performed with full-dose anticoagulant therapy, proved to be an effective and definitive method of treatment without any complications.

Laparoscopic nephrectomy in a hemophilia B patient.

Surgery in patients with hemophilia is a serious challenge. It requires a comprehensive approach, as well as careful postoperative monitoring. We present here the first case of a transperitoneal laparoscopic radical nephrectomy (TLRN) for renal cell carcinoma, of the clear-cell type, performed in a hemophilia B patient. The level of factor IX clotting activity before surgery and on postoperative days 1-6 was maintained at 65-130% and at 30-40% on subsequent days until healing of the post-operative wound was achieved. The intraoperative and postoperative courses were uneventful. TLRN can therefore be considered safe and effective for renal cell carcinoma. In hemophilia patients, the TLRN procedure requires proper preparation, as well as adequate substitution therapy for the deficient coagulation factor provided by a multidisciplinary team in a comprehensive center.

Sclerotherapy Of Esophageal Varices In Severe Hemophilia A Patient And High Titer Inhibitor--Case Report.

In cirrhotic hemophilia patients bleeding from esophageal varices is a serious clinical condition due to congenital deficiency of clotting factors VIII or IX, decreased prothrombin synthesis and hypersplenic thrombocytopenia. In hemophiliac with high-titer inhibitor bypassing therapy is required with activated prothrombin complex concentrates (aPCC) or recombinant activated coagulation factor VII (rFVIIa). Doses and duration treatment with these agents following endoscopic treatment of esophageal varices have not been yet established. Authors report the first case of a severe hemophilia A patient with high titer inhibitor (40 BU) treated with repeated injection sclerotherapy. The patient was admitted with symptoms of massive esophageal variceal hemorrhage ceased with emergency sclerotherapy. Bypassing therapy was administered with aPCC at initial dose of 72.5 U/kg and then with average daily dose of 162 U/kg through 5 days. To achieved a total eradication of esophageal varices the patient was then subjected to four elective sclerotherapy procedures. Two were covered by aPCC with daily dose of 120 U/kg and 145 U/kg for 4 and 3 days respectively and the following two procedures were covered by rFVIIa with the initial dose of 116 µg/kg and the next doses of 87 µg/kg administered every 3 hours in procedure day and every 4 hours on the next two days. During all procedures excellent hemostasis was achieved and no hemorrhagic or thromboembolic complications were observed. Bypassing regimen therapy with aPCC and rFVIIa we applied have been shown to be safe and effective in this patient subjected to sclerotherapy procedures.

Laparoscopic cholecystectomy for acalculous cholecystitis in a neutropenic patient after chemotherapy for acute lymphoblastic leukemia.

Acute acalculous cholecystitis (ACC) is most frequently reported in critically ill patients following sepsis, extensive injury or surgery. It is rather uncommon as a chemotherapy-induced complication, which is usually life-threatening in neutropenic patients subjected to myelosuppressive therapy. A 23-year-old patient with acute lymphoblastic leukemia was subjected to myelosuppressive chemotherapy (cyclophosphamide, cytarabine, pegaspargase). After the first chemotherapy cycle the patient was neutropenic and feverish; she presented with vomiting and pain in the right epigastrium. Ultrasound demonstrated an acalculous gallbladder with wall thickening up to 14 mm. The ACC was diagnosed. Medical therapy included a broad spectrum antibiotic regimen and granulocyte-colony stimulating factors. On the second day after ACC diagnosis the patient's general condition worsened. Laparoscopic cholecystectomy was performed. The resected gallbladder showed no signs of bacterial or leukemic infiltrates. The postoperative course was uneventful. In the management of neutropenic patients with ACC surgical treatment is as important as pharmacological therapy.

[Necrotizing gastritis in a patient in severe neutropenia]. / Martwica zoladka u chorej w ciezkiej neutropenia.

One extremely rare complication of chemotherapy for hematologic malignancies that is burdened with a high mortality rate (50%-80%) is necrotizing gastritis and gastric gangrene as result of poor clinical outcome of neutropenic gastritis (NG). We present a unique case of a neutropenic patient with necrotizing full thickness gastritis due to bacterial and fungal infection. Up to date only few such cases have been reported in world literature. A 28-year-old patient was subjected to dose-escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone), (chemotherapy regimen) for Hodgkin lymphoma. In neutropenic patient abdominal pain, bleeding from the alimentary tract was observed. Hemorrhagic gastritis was recognized at endoscopy and CT demonstrated marked gastric wall thickness. Following NG diagnosis intensive treatment was initiated. On day 2 the patient's condition deteriorated (septic shock, multiple organ failure). Repeat endoscopy revealed gastric necrosis and laparotomy was performed. As consequence of cardiac arrest and cardiopulmonary resuscitation the surgical procedure was limited to total gastrectomy, feeding jejustomy and esophageal drainage through nasoesophageal catherization. Roux-loop esophagojejunostomy was performed on day 22 and supplemented 4 days later by endoscopic placement of covered self-expandable stent due to anastomosis leak. The procedure proved successful and oral feeding was well-tolerated. The patient was discharged in 32 days following recognition of gastric necrosis. Chemotherapy complications in neutropenic patients are life-threatening conditions. Immediate pharmacological treatment usually leads to improvement. Surgical management usually the resection of necrotic zones is restricted to cases of poor prognosis or deterioration of patient's condition and complications.

Radiofrequency ablation in the management of Barrett's esophagus - preliminary own experience.

INTRODUCTION: Barrett's esophagus develops as a result of chronic injury of esophagus epithelium from gastroesophageal reflux disease. It is defined when metaplastic columnar epithelium replaces the stratified squamous epithelium which normally lies in the distal esophagus. The condition represents a risk factor for esophageal adenocarcinoma. The aim of the radiofrequency ablation (RFA) method is to destroy metaplastic epithelium with radiofrequency electric current and to stimulate reappearance of the flat multilayer epithelium in the distal esophagus. AIM: To evaluate the efficiency and safety of the RFA technique, newly introduced in Poland, in the management of Barrett's esophagus. MATERIAL AND METHODS: Twelve patients were treated with the RFA method. Patients with Barrett's esophagus confirmed in the histopathological report were qualified for treatment. Two RFA techniques were applied using a BARRX(®) device: circular based on the balloon HALO(360) system or focal based on the HALO(90) system mounted to the endoscopic ending. The procedures were performed at 2-month intervals. The macroscopic and microscopic effects of RFA therapy, the patients' treatment tolerance as well as potential complications were evaluated. RESULTS: In the group of 12 patients subjected to RFA therapy, 10 completed the therapeutic cycle. A total of 37 procedures were performed: 5 HALO(360) and 32 HALO(90). In all patients eradication of the abnormal metaplastic esophageal epithelium was achieved, as confirmed in both endoscopic and histopathological evaluation. In 2 patients with ongoing therapy progressive eradication of metaplastic epithelium was observed. No significant RFA-related complications were reported. CONCLUSIONS: Based on our preliminary results we consider this method to be promising, free of significant complications and well tolerated by patients. In most patients it results in successful eradication of metaplastic epithelium in the distal esophagus.

Effect of mesh type, surgeon and selected patients' characteristics on the treatment of inguinal hernia with the Lichtenstein technique. Randomized trial.

INTRODUCTION: Though not entirely free of complications, the Lichtenstein technique is still considered the "gold standard" for inguinal hernia repair due to the low recurrence rate. AIM: In our study we determined the effect of mesh type, surgeon and selected patients' characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence. MATERIAL AND METHODS: Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7(th) day as well as in the 3(rd) and 6(th) month after the operation. Statistical analysis was performed with multi-factor regression models. RESULTS: In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patient's general condition and body mass. CONCLUSIONS: Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients' characteristics have a significant impact on the treatment outcome.

[Analysis of the prevalence of HBV markers relevant to the risk of reactivation of infection in patients with hematologic diseases]. / Analiza wystepowania markerów wirusa HBV istotnych dla ryzyka reaktywacji zakazenia u osób z chorobami hematologicznymi.

The study assessed the incidence of HBV markers (HBsAg, anti-HBc, anti-HBs) important for determination of the risk of reactivation of infection, with particular interest of occult infection (presence of HBV DNA in the absence of HBsAg) in patients treated at the Institute of Hematology and Transfusion Medicine. Anti-HBc frequency was correlated with the age and sex of patients. HBsAg was detected in 16/468 examined patients, 98/468 (21%) were anti-HBc positive. HBV DNA was detected in 41/98 anti-HBc positives; in 13 simultaneously with HBsAg. 28 patients had occult HBV infection (HBV DNA+/HBsAg). Antibody to HBsAg was detected in 163/430 (38%) patients, 81 out of them on protective level (> 100 IU/l). It was shown that occult HBV infection occurs in approximately 6% of patients. In most of them the protective levels of anti-HBs are detected.

[Excision of the rectum due to carcinoma in patient with hereditary hemorrhagic teleangiectasia]. / Wyciecie odbytnicy z powodu raka u chorej z wrodzona naczyniakowatoscia krwotoczna.

UNLABELLED: Hereditary hemorrhagic telangiectasia (HHT) also known as Rendu-Osler-Weber disease, is a rare, autosomal dominant disorder of the fibrovascular tissue. Clinically, it is characterized by the triad of symptoms of mucocutaneous telangiectasias and arteriovenous malformations of visceral organs, recurrent hemorrhages from vascular changes at different localization, and familial occurrence. A coexistence of HHT syndrome and malignant neoplasms in various sites, including large bowel, is suggested. The authors describe the case of 67-year old woman with HHT with massive bleeding from digestive tract in history and persistent chronic sideropenic anemia. In upper gastrointestinal endoscopy performed in regional hospital multiple telangiectasias in the stomach were found. These were diagnosed as the possible bleeding source therefore colonoscopy was not performed. After twelve months in diagnostic colonoscopy due to chronic anemia carried out in our Institute, rectal carcinoma was found. The patient were subjected to surgery--lower anterior excision of the rectum. Intra operatively and in the postoperative period complications were not observed. CONCLUSION: In every case of bleeding from digestive tract and also in chronic anemia in patients suffering from Rendu-Osler-Weber disease, beside the endoscopy of esophagus, stomach and duodenum, full visualization of the large bowel is necessary to exclude malignant neoplasm. In the presented case no colonoscopy performed in the regional hospital delayed the carcinoma diagnosis by twelve months.

[Nonoperative management of spontaneous splenic rupture in infectious mononucleosis]. / Leczenie nieoperacyjne samoistnego pekniecia sledziony w przebiegu mononukleozy zakaznej.

UNLABELLED: Spontaneous splenic rupture is a rare complication of infectious mononucleosis observed in 0.1-0.5% of patients with this condition. Mandatory mode of management in hemodynamically stable patients is nonoperative treatment. We report the case of a 19-year old man with splenic rupture, during the course of serological and hematological confirmed infectious mononucleosis, with no history of trauma. Parenchymal and subcapsular splenic hematomas and presence of blood in vesico-rectal recess was demonstrated. Circulatory and respiratory findings and blood cell count were stable. Nonoperative management was instituted which comprised monitoring of valid vital signs, serial USG and tomography scans and vital activity limitation. Imaging radiological investigations demonstrated disappearance of observed abnormalities on post admission day 20. The patient was discharged from the hospital in good general condition. CONCLUSION: Nonoperative management can be a safe alternative to splenectomy in hemodynamically stable patient with spontaneous rupture of the spleen.

Randomized clinical trial comparing inguinal hernia repair with Lichtenstein technique using non-absorbable or partially absorbable mesh. Preliminary report.

INTRODUCTION: The Lichtenstein technique is currently considered the "gold standard" of open, anterior inguinal hernia repair. It is not free, however, of adverse effects, which may be caused by the implemented synthetic material. AIM: Determination the influence of the mesh employed on treatment results including immediate complications, return to everyday activities, chronic pain occurrence and hernia recurrence. MATERIAL AND METHODS: Tension-free hernia repair using the Lichtenstein technique was performed in all the 59 patients randomized to trial groups. Group P with heavyweight polypropylene mesh contained 34 patients; group V with lightweight, partially absorbable mesh (polypropylene/polyglactin 910) consisted of 25 people. Controlled, scheduled follow-up appointments took place after the 7(th) day and the 3(rd) and 6(th) month. Patients were clinically assessed and pain intensity was determined on an analogue-visual scale. RESULTS: No statistically significant influence of the type of mesh on the risk of early complications, severe pain intensity, the length of hospital stay, time of recovery, or patients' satisfaction with treatment was observed. After 6 months also no statistically significant differences were observed between groups with regard to recurrence rate (P 3.4% vs. V 4.0%), chronic pain (P 5.9% vs. V 4.0%) and ailments such as "foreign body presence" (V vs. P, OR = 0.30, 95% CI 0.077-1.219, p = 0.093) incidence, although their probability was 70% lower for V mesh. CONCLUSIONS: The preliminary results confirm the effectiveness of the Lichtenstein technique for hernia repair with both types of meshes. It appears that use of a partially absorbable mesh is connected with lower risk of postoperative complications, but the final results require multicentre trials in a larger series of patients.

[Laparoscopic cholecystectomy with single incision laparoscopic surgery]. / Cholecystektomia laparoskopowa wykonywana metoda jednego ciecia.

UNLABELLED: For the last seventeen years laparoscopic cholecystectomy has remained the gold standard procedure for gallbladder surgery The single incision laparoscopic surgery (SILS) approach is a step toward less invasive surgery and the intraumbilical access improves the cosmetic effect (no scar surgery). The aim of the study was to present our preliminary experience in laparoscopic cholecystectomy through single intraumbilical incision. MATERIAL AND METHODS: Three patients with gallbladder symptoms (2 female, 1 male) underwent surgery through single intraumbilical incision. In two cases the procedure was performed with three 5 mm Dexide port approach and in one, with a flexible rubber/gel SILSTM-Port (Covidien, USA) access. A simple 5 mm optics was employed. In two procedures the following disposable instruments were used: roticulator Endo dissect, roticulator Endo grasp, mini Sears scissors as well as standard hook and clips while for the third procedure, a conventional multi-use grasp and roticular Endo dissect. The gallbladder was elevated to the integuments by two sutures to expose Calot's triangle and bladder site. Following exposure, the bile duct and the vesical artery were clipsed and cut routinely to remove the gallbladder in a plastic bag through the bell-button. After procedures no drains were left in the peritoneal cavities. RESULTS: In all three cases the laparoscopic procedure was performed. The median operative time was 88 min. In one female patient, bleeding into the peritoneal cavity was reported and called for laparotomy within a few hours of laparoscopic procedure. Intraoperatively, the branch of vesical artery was sutured to arrest bleeding. The median hospital stay following procedure was 3, 8 and 5 days respectively. After the procedure, the last female patient was observed to have pharyngitis and enlarged jugular lymph nodes that abated after antibiotic therapy. CONCLUSIONS: Single-incision laparoscopic cholecystectomy should be performed by experienced laparoscopic surgeons. For adequate evaluation of the efficacy and safety of this procedure it is necessary to perform further clinical studies on a larger number of patients.

[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.

[Partial splenectomy for splenic cyst--fifteen years follow-up of surgical treatment]. / Czesciowe wyciecie sledziony z powodu torbieli--pietnastoletnia ocena leczenia operacyjnego.

UNLABELLED: Secondary cysts of the spleen are uncommon and usually result from blunt abdominal trauma. Symptomatic cysts and those with diameter above 5 cm are indications for surgical treatment. Spleen parenchyma preserving operations, currently recommended, reduce the risk of early and late septic complications, particularly overwhelming postsplenectomy sepsis. Partial splenectomy offers a definitive treatment of a splenic cyst while preserving splenic functions. The author describes the case of a patient with spleen lower pole pseudocyst, 14 cm in diameter, subjected to partial splenectomy in 1992. Healthy spleen parenchyma was cut with an electrocoagulation knife at a distance of 1.5 cm from the cyst edge. Local hemostasis was assured with mattrees absorbable tape polyglycolic acid sutures and fibrin glue injection into resection plane. Complications were not observed. Long-term, fifteen years follow-up revealed preservation of splenic function and no septic complications. CONCLUSION: Partial splenectomy, demanding high technical experience procedure, is the treatment of choice of the splenic cyst.

[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.