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.

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.

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.

[Thrombocytopenia in a patient with hemophilia and HIV infection treated with intravenous immunoglobulin and splenectomy]. / Maloplytkowosc u chorego na hemofilie z zakazeniem HIV leczona dozylnie immunoglobulina i splenektomia.

In a patient with haemophilia B who had developed immune thrombocytopenia following HIV infection, high doses of intravenous immunoglobulin were administered. The therapy brought about only a temporary rise in platelet counts. No beneficial effects were also obtained during a 3-month treatment with corticosteroids. Since there was no response to the conservative therapy, the patient was splenectomized under the cover of factor IX concentrate and the surgical procedure resulted in a complete remission of the thrombocytopenia.

[Hematologic and surgical problems connected with splenectomy in elderly patients]. / Hematologiczne i chirurgiczne problemy zwiazane ze splenektomia u osób starszych

The authors carried out a clinical analysis of problems connected with splenectomy in elderly patients treated surgically at the Institute of Haematology in the years 1965-1972. Out of 24 patients aged above 60 years 12 were analysed clinically (8 females and 4 males). Splenectomy was done in these patients from haematological indications (haemolytic anaemia, thrombocytopenia, pancytopenia). In all these cases indications to splenectomy, the course of operation and postoperative period as well as late therapeutic results were assessed. The analysis of these elderly patients showed that the criteria of indications for splenectomy were the same as in other age groups. The choice of surgical method depended in these cases on the clinical and haematological findings, a lack of permanent improvement after conservative treatment, contraindications to immunosuppressive treatment and results of isotope investigations (particularly the values of the spleen-liver index). In most splenectomized patients there were no complications during the operation and in the postoperative period. In 2 cases only acute circulatory failure was observed immediately after the operation. Evaluation of late results showed that the effects of the operation were similar to those in other age groups.

[Polish hydroxyethyl starch preparation: a clinical study]. / Badania kliniczne polskiego preparatu hydroksyetylowanej skrobi.

The 6% solution of hydroxyethyl starch (MS = 0.47-0.7, Mw = 120,000-220,000) prepared at the Department of Biochemistry, Institute of Haematology in Warsaw was administered in infusions to a group of surgical patients. It was found that the preparation complied with the conditions and requirements for plasma-replacing agents. In none of the treated patients any side effects were observed. Further investigations will be continued infusing greater volumes of HES to patients with hypovolaemia of different origin.

[Role of spleen in leukocyte kinetics in dog]. / Rola sledziony psa w kinetyce krwinek bialych

In 9 dogs blood samples were obtained from the splenic vein and artery under general anaesthesia with Eunarcon, the quantitative and qualitative composition of white blood cells was compared and it was found that canine spleen can release or retain granulocytes and mononuclear cells simultaneously or any of these cells separately.

[Role of human spleen in the release and sequestration of white blood cells]. / Rola sledziony czlowieka w uwalnianiu i zatrzymywaniu krwinek bialych

In 21 patients during operation blood samples were obtained from splenic vein and artery immediately before splenectomy for determination of qualitative and quantitative composition of white blood cells to establish the role of the spleen in their release and sequestration. It was found that the spleen released into circulation mononuclear cells whose number, size of nucleus and glycogen content of the cytoplasm varied individually in various cases. Besides that the spleen releases and sequestrates granulocytes, most probably as a result of intravascular shifts in the marginal and circulating cell pools induced, among others, by contractions of the spleen.

[Effect of stroma-free hemoglobin solution on oxygen consumption in some tissues]. / Wplyw roztworu hemoglobiny pozbawionej zrebu komórkowego na zuzycie tlenu w niketórych tkankach

50 cc of a 6%, oxygenated or non oxygenated stroma-free heamoglobin solution was transfused in rabbits after previous removal of about one third of the circulating blood volume. The experimental investigations were carried out on animals under barbiturate anaesthesia. Oxygen consumption was determined using a Warburg microrespirator. Posthaemorrhagic hypotension developing after bleeding caused a significant increase in oxygen consumption by liver tissue. Transfusion of non oxygenated stroma-free haemoglobin solution caused a further increase of oxygen consumption, while transfusion of oxygenated stroma-free haemoglobin solution slightly decreased oxygen consumption compared to the values observed during the post haemorrhagic hypotension.