Small invasive technique of Internal Iliac Artery ligation for postpartum haemorrhage.

OBJECTIVES: Internal Iliac artery ligation (IIAL) is an effective life-saving method to control obstetric hemorrhage, and a hysterectomy can often be avoided. A standard ligation procedure requires wide tissues dissection: incision in the peritoneum lateral to and parallel with the ureter. That can be traumatic and is difficult in practice what results in a rare use of IIAL in surgical emergency. As an alternative a novel, small invasive technique was used, which protocol is attached to the paper as a video presentation file. MATERIAL AND METHODS: Forty-five women treated by Internal Iliac Artery ligation for postpartum haemorrhage. In 27 patients (Cohort A) standard IIAL procedure by Kelly's method was used. In the remaining 18 patients (Cohort B) a novel, small invasive technique was performed. Time of both surgical procedures of IIAL was measured. RESULTS: Time of Standard technique of IIAL vs Novel small invasive technique of IIAL: 34 (26-41) min. vs 13 (8-16) min. p < 0.001. CONCLUSIONS: The presented novel small invasive technique of Internal Iliac artery ligation can be an easier and safe alternative for standard ligation procedure.

Epidemiology, prevention and management of early postpartum hemorrhage - a systematic review.

Early Postpartum Hemorrhage (EPH) is one of the leading causes of postpartum mortality. It is defined as blood loss of at least 500 mL after vaginal or 1000 mL following cesarean delivery within 24 hours postpartum. The following paper includes literature review aimed to estimate the incidence and predictors of early postpartum hemorrhage (EPH). Available prevention and treatment methods were also assessed. The inclusion criteria for the study were met by 52 studies. The exact frequency of EPH in different populations varies from 1.2% to 12.5%. Maternal, pregnancy-associated, laborcorrelated and sociodemographic risk factors seem to be important predictors of EPH. In these cases appropriate prophylaxis should be considered. However, EPH may occur without previous risk factors. The main reason for EPH is uterine atony which contributes to up to 80% of cases of postpartum hemorrhage (PPH). Other common reasons for PPH include genital tract injuries, placenta accreta or coagulopathies. Interestingly, the majority of uterotonics seem to have a similar effect. However, carbetocin seems to be the most effective in certain situations. Appropriate diagnosis of EPH is the most important issue. The treatment should be causative. The first-line treatment should include uterotonics. Surgical interventions, if required, should be performed without delay, although preoperative uterine tamponade should be considered due to its high effectiveness. Medical staff training in medical simulation centers is an important factor that improves the outcomes of EPH treatment. It provides adaptation to hospital protocols, team work improvement, self-confidence building, more accurate blood loss evaluation and reduced perception of stress. The implementation of systematic trainings provides better outcomes in the future.

Is Portal Venous Pressure Modulation Still Indicated for All Recipients in Living Donor Liver Transplantation?

There is a consensus that portal venous pressure (PVP) modulation prevents portal hypertension (PHT) and consequent complications after adult-to-adult living donor liver transplantation (ALDLT). However, PVP-modulation strategies need to be updated based on the most recent findings. We examined our 10-year experience of PVP modulation and reevaluated whether it was necessary for all recipients or for selected recipients in ALDLT. In this retrospective study, 319 patients who underwent ALDLT from 2007 to 2016 were divided into 3 groups according to the necessity and results of PVP modulation: not indicated (n = 189), indicated and succeeded (n = 92), and indicated but failed (n = 38). Graft survival and associations with various clinical factors were investigated. PVP modulation was performed mainly by splenectomy to lower final PVP to ≤15 mm Hg. Successful PVP modulation improved prognosis to be equivalent to that of patients who did not need modulation, whereas failed modulation was associated with increased incidence of small-for-size syndrome (SFSS; P = 0.003) and early graft loss (EGL; P = 0.006). Among patients with failed modulation, donor age ≥ 45 years (hazard ratio [HR], 3.67; P = 0.02) and ABO incompatibility (HR, 3.90; P = 0.01) were independent risk factors for graft loss. Survival analysis showed that PVP > 15 mm Hg was related to poor prognosis in grafts from either ABO-incompatible or older donor age ≥ 45 years (P < 0.001), but it did not negatively affect grafts from ABO-compatible/identical and young donor age < 45 years (P = 0.27). In conclusion, intentional PVP modulation is not necessarily required in all recipients. Although grafts from both ABO-compatible/identical and young donors can tolerate PHT, lowering PVP to ≤15 mm Hg is a key to preventing SFSS and consequent EGL with grafts from either ABO-incompatible or older donors.

Hemorrhoids: Diagnosis and Treatment Options.

Many Americans between 45 and 65 years of age experience hemorrhoids. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures; therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue; however, this procedure has several potential postoperative complications. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.

A novel method for multiple bowel injuries: a pilot canine experiment.

BACKGROUND: Intestinal ligation is the cornerstone for damage control in abdominal emergency, yet it may lead to bowel ischemia. Although intestinal ligation avoids further peritoneal cavity pollution, it may lead to an increased pressure within the bowel segments and rapid bacterial translocation. In this study, we showed that severed intestine could be readily reconnected by using silicon tubes and be secured by using rubber bands in a canine model. METHODS: Adult Beagle dogs, subject to multiple intestinal transections and hemorrhagic shock by exsanguination, randomly received conventional ligation vs. silicon tubes reconnecting (n = 5 per group). Intestinal transections were carried out under general anesthesia after 24-h fasting. The abdomen was opened with a midline incision. The small intestine was severed at 50, 100, and 150 cm below the Treitz ligament. Hemorrhagic shock was established by streaming blood from the left carotid artery until the mean arterial pressure reached 40 mmHg in 20 min. Fluid resuscitation and surgery began 30 min after the establishment of hemorrhagic shock. Severed intestines were ligated or connected with silicon tubes. Definitive repair was conducted in subjects surviving for at least 48 h. RESULTS: Operation time was comparable between the two groups (39.6 ± 8.9 vs. 36.6 ± 7.8 min in ligation and reconnecting groups, respectively; p = 0.56). The time spent in managing each resection was also comparable (4.6 ± 1.1 vs. 3.8 ± 0.84 min; p = 0.24). Blood loss (341.2 ± 28.6 vs. 333.8 ± 34.6 ml; p = 0.48), and fluid resuscitation within the first 24 h (1676 ± 200.6 vs. 1594 ± 156.5 ml; p = 0.46) were similar. One subject in the ligation group was sacrificed at 36-h due to severe vomiting that led to aspiration. Four remaining dogs in the ligation group received definitive surgery, but two out of four had to be sacrificed at 24-h after definitive repair due to imminent death. All five dogs in the reconnecting group survived for at least a week. Radiographic examination confirmed the integrity of the GI tract in the reconnecting group. In both groups, plasma endotoxin concentration increased after damage control surgery, but the increase was much more pronounced in the ligation group. Microscopic examination of the involved segment of the intestine revealed much more severe pathology in the ligation group. CONCLUSION: The current study showed that the reconnecting resected intestine by using silicon tubes is feasible under emergency. Such a method could decrease short-term mortality and minimize endotoxin translocation.

First 10-month results of the Vascular Quality Initiative Varicose Vein Registry.

OBJECTIVE: The Vascular Quality Initiative Varicose Vein Registry (VQI VVR) represents a new Patient Safety Organization database launched in January 2015 as a collaborative effort between the American Venous Forum and the Society for Vascular Surgery. This study was undertaken to identify real-world trends among treatment choices and outcomes of varicose vein patients. METHODS: Registry data prospectively captured anatomic, procedural, and outcome data for patients with C2 or more severe disease undergoing intervention for venous varicosities from January to November 2015. Univariate descriptive statistics of demographic and procedural data was performed. Preprocedural and postprocedural comparisons were performed with t-test or χ2 analysis as appropriate. RESULTS: In total, 2661 veins in 1803 limbs of 1406 patients were treated for varicose vein disease. The majority of patients were female (71.5%) and white (78.3%). Previous varicose vein treatment had been undertaken by 31.2%. The most common site of reflux was the great saphenous vein in 74.4%, with 31% of patients having coexisting deep venous reflux. The right and left extremities were affected equally. Endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation (55.2%) and endovenous laser ablation (33.9%). Clusters were often treated concomitantly with truncal reflux (n = 488 [76%]). The majority of cluster treatments were performed in an office-based setting (78.1%). The majority of clusters were located at the calf (89.7%) and treated with stab phlebectomy (84.8%). For all patients undergoing intervention for varicose veins, Venous Clinical Severity Score (VCSS) improved on average 4.68 ± 3.35 (n = 719; P < .001) postoperatively from a mean preoperative VCSS of 9.39 ± 3.87 to a mean postoperative VCSS of 4.71 ± 3.83. Improvements were seen in patient-reported outcomes (PROs) of heaviness, achiness, throbbing, swelling, itching, appearance, and work impact (total score change, 10.75 ± 6.94; n = 607; P < .001) from a mean preoperative PRO score of 16.48 ± 6.23 to a mean postoperative PRO score of 5.73 ± 5.80. CONCLUSIONS: The VQI VVR provides detailed assessment of varicose vein interventions and is useful for monitoring of changes after treatment. Modern-day varicose vein surgery is characterized by predominantly endovenous treatment of axial vein reflux, phlebectomy of clusters, and substantial improvements in both VCSS and PROs.

[Surgical treatment of postpartum hemorrhage]. / Prise en charge chirurgicale d'une hémorragie du post-partum.

OBJECTIVE: Systematic revue of different conservative and non-conservative surgical treatment of postpartum hemorrhage (PPH). Elaboration of surgical strategy after failed medical treatment of PPH. METHODS: French and English publications were identified through PubMed and Cochrane databases. RESULTS: Each obstetrical unit has to rewrite a full protocol of management of PPH depending on local environment quickly available in theatre (professional consensus). Conservative surgical treatment of PPH: efficacy of vascular ligature (bilateral uterine artery ligation (BUAL) or bilateral hypogastric artery ligation (BHAL)) as a first line of surgical treatment of PPH is about 60 % to 70 % (EL4). Bilateral uterine artery ligation (BUAL) is easy to perform with low rate of immediate severe complication (professional consensus). BUAL as BHAL seems not to affected fertility and obstetrical outcomes of next pregnancies (EL4). Efficacy of haemostatics brace suturing in case of failed medical treatment of PPH is about 75 % (EL3), without risk of major obstetrical complications at the next pregnancy (EL4). Radical surgical treatment of PPH: total hysterectomy is not significantly associated with more urinary tract injury in comparison with subtotal hysterectomy (EL3). Choice of surgical procedure of hysterectomy (total or subtotal) will depend on local consideration and clinicians habits (professional consensus). Surgical strategy: conservative surgical treatment are efficient and associated with low morbidity, they have to be primarily performed in women with further fertility desire. Specific medical consideration as massive PPH or cardiovascular instability has to consider performing haemostatic hysterectomy as the first line surgical treatment of PPH. PPH during caesarean delivery: in case of PPH during caesarean section, embolisation is not recommended, surgical treatment using vascular devascularisation or compression brace suturing should be performed (professional consensus). Surgical conservative technique will depend on local considerations and clinicians habits (professional consensus). PPH diagnosed after caesarean section should indicate relaparotomy. Arterial embolisation, if quickly vacant in the same hospital, may be performed in case of cardiovascular stability without surgical complication diagnoses on intraperitoneal hemorrhage (professional consensus). PPH during vaginal delivery: cardiovascular instability centre indicate the interhospital transfer and must lead to achieve haemostatic surgery on site (professional consensus). In the presence of a unit of embolisation in the maternity delivery, it is preferable to move towards embolisation, if maternal hemodynamic status permits (professional consensus). In case of cardiovascular stability associated with absence of heavy bleeding, the interhospital transfer may be considered for arterial embolisation (professional consensus). CONCLUSION: When medical treatment of PPH failed, conservative surgical treatment has a 70 % efficacy to stop hemorrhage whatever treatment used (vascular ligature or haemostatics brace suturing). In absence of rapid response to conservative medical and surgical treatment, hysterectomy should be performed without delay (professional consensus).

The timing of cord clamping and oxidative stress in term newborns.

BACKGROUND: Clamping and cutting of the umbilical cord is the most prevalent of all operations, but the optimal timing of cord clamping is controversial, with different timings offering advantages and disadvantages. This study, for the first time, compares the influence of early and late cord clamping in correlation with oxidative stress and inflammation signaling, Because cord clamping timing may have a significant influence on placenta-to-infant blood transfer, thereby modifying oxygenation of maternal and fetal tissues, and on the transfer of inflammatory mediators throughout the placenta. METHODS: Sixty-four pregnant subjects were selected at the Gynecology and Obstetrics Services Department of the Clinico San Cecilio Hospital, Granada, Spain, based on disease-free women who experienced a normal course of pregnancy and a spontaneous, vaginal, single delivery. Half of the subjects had deliveries with early-clamped newborn infants (at 10 s), and the other half had late-clamped deliveries (at 2 min). RESULTS: Erythrocyte catalase activity was significantly greater in the late-clamped group than in the early-clamped group (P < .01 for the umbilical vein and P < .001 for the artery). The values for superoxide dismutase, total antioxidant status, and soluble tumor necrosis factor receptor II were all significantly higher in the late-clamped group compared with the early-clamped group (P < .01, P < .001, and P < .001, respectively). CONCLUSIONS: The results suggest a beneficial effect of late cord clamping, produced by an increase in antioxidant capacity and moderation of the inflammatory-mediated effects induced during delivery of term neonates.

Umbilical cord clamping at birth--practice in Norwegian maternity wards.

BACKGROUND: The timing and practice used for umbilical cord clamping of neonates are controversial internationally as well as in Norway. We therefore wished to investigate routines and practices for umbilical cord clamping of neonates in Norway. MATERIAL AND METHOD: A web-based questionnaire was sent to heads of departments of all maternity wards in Norway (n = 52). They were asked about their practice with regard to umbilical cord clamping of neonates and whether written routines had been prepared for this purpose. We defined early umbilical cord clamping as immediate or within 30 seconds and late clamping as ≥ 1 minute or not until pulsation in the umbilical cord had ceased. RESULTS: Fifty (96%) of the maternity institutions returned a completed questionnaire. Twelve institutions (24%) reported to clamp the umbilical cord of full-term neonates early, and 38 (76%) reported to practise late clamping. Nineteen maternity wards (38%) followed written routines for umbilical cord clamping of full-term neonates, and among these, early umbilical cord clamping was practised in nine (47%). In the 31 maternity wards that had no written routines, early umbilical cord clamping was practised in three (10%). Twenty-seven of the maternity wards reported that the child is placed on the maternal abdomen before clamping of the umbilical cord, 14 reported that the child commonly is held below the introitus before umbilical cord clamping, and the rest did not report any consistent practice. INTERPRETATION: There is wide variation in the practice for umbilical cord clamping in Norwegian maternity wards, many of which have no written guidelines. We argue that national guidelines for umbilical cord clamping of neonates should be established.

[Advantage of delayed umbilical cord clamping in the newborn infant]. / Intérêt du clampage retardé du cordon ombilical chez le nouveau-né

The timing of umbilical cord clamping remains controversial. Although most maternity wards use the early clamping (5-15s), randomized studies and meta-analyses have demonstrated the benefit of delayed clamping for term and preterm newborn infants over the past 10 years. Indeed, placentofetal transfusion of 20-30 ml/kg in 2-3 min improves the iron status of term infants and prevents infant hypochromic anemia. Infant anemia is a public health problem in many developing countries. For preterm newborns, placental transfusion for 45 s or milking the cord for 15 s improves cardiovascular adaptation, with better hemodynamic stability, as well as decreased intraventricular hemorrhages, need for transfusion, and late-onset sepsis. A new look at this symbolic act is needed and professionals need to be persuaded of the importance of the "wait a minute" policy for a better physiological delivery.

Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes.

BACKGROUND: Optimal timing for clamping the umbilical cord at preterm birth is unclear. Early clamping allows for immediate transfer of the infant to the neonatologist. Delaying clamping allows blood flow between the placenta, the umbilical cord and the baby to continue. The blood which transfers to the baby between birth and cord clamping is called placental transfusion. Placental transfusion may improve circulating volume at birth, which may in turn improve outcome for preterm infants. OBJECTIVES: To assess the short- and long-term effects of early rather than delaying clamping or milking of the umbilical cord for infants born at less than 37 completed weeks' gestation, and their mothers. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 May 2011). We updated this search on 26 June 2012 and added the results to the awaiting classification section. SELECTION CRITERIA: Randomised controlled trials comparing early with delayed clamping of the umbilical cord and other strategies to influence placental transfusion for births before 37 completed weeks' gestation. DATA COLLECTION AND ANALYSIS: Three review authors assessed eligibility and trial quality. MAIN RESULTS: Fifteen studies (738 infants) were eligible for inclusion. Participants were between 24 and 36 weeks' gestation at birth. The maximum delay in cord clamping was 180 seconds. Delaying cord clamping was associated with fewer infants requiring transfusions for anaemia (seven trials, 392 infants; risk ratio (RR) 0.61, 95% confidence interval (CI) 0.46 to 0.81), less intraventricular haemorrhage (ultrasound diagnosis all grades) 10 trials, 539 infants (RR 0.59, 95% CI 0.41 to 0.85) and lower risk for necrotising enterocolitis (five trials, 241 infants, RR 0.62, 95% CI 0.43 to 0.90) compared with immediate clamping. However, the peak bilirubin concentration was higher for infants allocated to delayed cord clamping compared with immediate clamping (seven trials, 320 infants, mean difference 15.01 mmol/L, 95% CI 5.62 to 24.40). For most other outcomes (including the primary outcomes infant death, severe (grade three to four) intraventricular haemorrhage and periventricular leukomalacia) there were no clear differences identified between groups; but for many there was incomplete reporting and wide CIs. Outcome after discharge from hospital was reported for one small study; there were no significant differences between the groups in mean Bayley II scores at age seven months (corrected for gestation at birth (58 children)).No studies reported outcomes for the women. AUTHORS' CONCLUSIONS: Providing additional placental blood to the preterm baby by either delaying cord clamping for 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion, better circulatory stability, less intraventricular haemorrhage (all grades) and lower risk for necrotising enterocolitis. However, there were insufficient data for reliable conclusions about the comparative effects on any of the primary outcomes for this review.

To knot or not to knot? Sutureless haemostasis compared to the surgeon's knot.

INTRODUCTION: The aim of this study was to carry out an independent evaluation of the efficacy and security of a number of vessel ligation devices and ligatures. MATERIALS AND METHODS: A vascular ligation model was devised using fresh, ex vivo porcine internal carotid arteries of varying external diameters. Coloured normal saline was infused via a pressure/monitor device through the artery. The end lumen was occluded by five different techniques: (i) braided suture in a surgeon's knot; (ii) a monofilament suture in a granny knot; (iii) a metallic clip (Ligaclip, Johnson and Johnson); (iv) a bipolar diathermy system (Ligasure, ValleyLab); and (v) an ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson). The vessels were subjected to supraphysiological pressures. Loss of haemostasis was evident by leakage of coloured perfusion fluid. RESULTS: Secure haemostasis was obtained with all the techniques in all vessels below 5 mm in diameter. In vessels over 5 mm, secure haemostasis was obtained with all modalities except harmonic scalpel. With the harmonic scalpel, leaks occurred in 3/27 (11%) vessels between 5-6 mm and 3/5 (60%) vessels over 6 mm, confirming the manufacturer's instructions. CONCLUSIONS: In this first, independent, randomised study comparing vessel ligation devices and ligatures, the manufacturer's claims for each of the haemostatic methods were accurate. We find that all the modalities tested perform as well as the traditional surgeon's knot in vessels of 5 mm and below.

Assessing the technical skills of surgical trainees.

BACKGROUND: The aims were to determine whether tests of technical skill on simple simulations can predict competence in the operating theatre and whether objective assessment in the operating theatre by direct observation and video recording is feasible and reliable. METHODS: Thirty-three general surgical trainees undertook five simple skill simulations (knotting, skin incision and suturing, tissue dissection, vessel ligation and small bowel anastomosis). The operative competence of each trainee was then assessed during two or three saphenofemoral disconnections (SFDs) by a single surgeon. Video recordings of the operations were also assessed by two surgeons. RESULTS: The inter-rater reliability between direct observation and blinded videotape assessment was high (alpha = 0.96 (95 per cent confidence interval 0.92 to 0.98)). Backward stepwise regression analysis revealed that the best predictors of operative competence were the number of SFDs performed previously plus the simulation scores for dissection and ligation, the key components of SFD (64 per cent of variance explained; P = 0.001). CONCLUSION: Deconstruction of operations into their component parts enables trainees to practise on simple simulations representing each component, and be assessed as competent, before undertaking the actual operation. Assessment of surgical competence by direct observation and video recording is feasible and reliable; such assessments could be used for both formative and summative assessment.

Left Atrial Appendage Occlusion Study (LAAOS): a randomized clinical trial of left atrial appendage occlusion during routine coronary artery bypass graft surgery for long-term stroke prevention.

BACKGROUND: Many patients undergoing coronary artery bypass graft (CABG) surgery have risk factors for both atrial fibrillation (AF) and stroke. The left atrial appendage (LAA) is a main source of thrombus coming from the left atrium. LAA occlusion should be tested as a means to reduce future cerebral ischemic events in these patients. METHODS: The Left Atrial Appendage Occlusion Study (LAAOS) is a randomized clinical trial designed to evaluate the feasibility, safety, and efficacy of LAA occlusion for prevention of ischemic stroke in patients undergoing CABG. The target population consists of patients at risk of AF and stroke who are having routine CABG surgery. The main study will be a prospective, controlled, unblinded trial. Patients at risk of future development of AF, or having AF, will be randomly assigned to undergo or not undergo LAA occlusion. A total of 2500 patients will be randomly assigned and followed for 5 years for the primary outcome of stroke. This study of 2500 patients will have 90% power to detect a relative reduction of 20% in stroke, from a 5-year incidence of 20% in the control group to 16% in the intervention group. Currently, a pilot trial is underway that will enroll 100 patients to assess feasibility, safety, and rates of successful LAA occlusion as assessed by postoperative transesophageal echocardiography. The most suitable surgical technique will also be assessed during the pilot trial. In the pilot study, the main outcomes are safety and rate of successful obliteration of the LAA after surgical occlusion. CONCLUSIONS: The clinical trial designed to evaluate LAA occlusion at the time of routine CABG surgery is currently in the pilot phase.

Oesophageal variceal banding: report of the first eight cases in Kenya.

Twenty variceal banding sessions were performed in eight patients between February 1995 and September 1996. A total of 69 rings were used to band the varices and at each session between two to six rings were used. Two of the eight had active bleeding and both underwent variceal banding to successfully arrest their bleeding as inpatients. Sixteen other variceal banding sessions were performed on an outpatient basis to obliterate their varices. Four of the eight patients had had sclerotherapy before and varices were still present. No acute or long term complications were noted. In one patient, variceal banding could not be performed as he developed stridor upon placement of the overtube. All the patients had advanced varices (Grade III or IV) and extended for more than 15 cms in the oesophagus. Endoscopic variceal obliteration remains the treatment of choice for patients with portal hypertension with variceal bleeding. Variceal banding is associated with a superior outcome when compared with sclerotherapy; the variceal kill time is shorter, infective complications less, rebleeding occurs less commonly and transfusion requirements are lower.

Technology assessment status evaluation: endoscopic band ligation of varices.

On the basis of limited available data, band ligation appears to be effective for control of active esophageal variceal bleeding and for prevention of recurrent bleeding. It has minimal morbidity and no reported mortality. Preliminary results of a randomized-trial comparing this technique to sclerotherapy show comparable efficacy but band ligation may carry a lower complication rate. Long-term results of ligation are pending.

Ligadura de hipogástricas en manejo de hemorragias ginecobstétricas

Presentamos 17 casos de pacientes ginecobstétricas en las cuales se practicó ligadura de arteria hipogástricas de urgencia o electiva, desde 1985 hasta 1988 en 2 instituciones, el Instituto Materno Infantil y Hospital regional San Rafael de Facatativá. Se hace una revisión de la anatomía pélvica retroperitoneal, los mecanismos henodinámicos resultantes de la ligadura que influirán sobre el control de la hemorragia. Se revisan sus complicaciones y la literatura sobre el tema. Nueve casos fueron Obstétricos y ocho ginecológicos; ocupando el primer lugar de los obstétricos la atonía uterina, y de los ginecológicos el uso intraoperatorio profiláctico seguido del uso en sangrado de cúpula vaginal posthisterectomía. Se demostró efectividad para cohibir hemorragia en el 88 por ciento de los casos y las complicaciones intraoperatorias desaparecieron a medida que aumentó la experiencia de los cirujanos. Las complicaciones postoperatorias fueron transitorias y no aumentaron la estancia de las pacientes