Ectopic intestinal varices in cirrhotic patients; an infrequent cause of severe intestinal bleeding

We report on a cirrhotic patient, with history of colecistectomy, admitted for acute digestive bleeding. Esogastric causes were excluded by endoscopy; due to continuous hemorrhage, the patient was operated in the next 20 hours. The cause was established during the operation; solitary omfalo-enteric varices, with active vascular fistula. Preoperative etiology of acute intestinal bleeding may be difficult to establish, sometimes even during the surgical intervention. We comment upon rare causes of acute intestinal bleeding, mainly ectopic varices determined by portal hypertension.     

Urodynamic studies of women with prolapse and stress incontinence before and after surgical repair

Twenty-one women, 11 suffering from both prolapse and stress incontinence and 10 with prolapse only were investigated before and at different intervals after surgical repair of the disorders. The investigations comprised a gynaecological examination, urine culture, observation of residual urine and simultaneous urethro-cystometry including measurement of the urethral pressure profile.--The prolapse patients were operated upon by conventional Manchester technique. The patients suffering from both prolapse and stress incontinence were operated with a combined vaginal-abdominal repair using Lyodura slings.--It was found that the pre-operative urethral pressure at rest was lower in the inconinent-prolapse patients compared with that in patients suffering from prolapse only. After surgery the urethral pressure at rest was significantly decreased in the incontinent-prolapse patients whereas it did not change in patients operated because of prolaspe only.--Prior to the operation, all incontinent-prolapse women had a negative urethral closure pressure at stress. After surgery the closure pressure became positive in all patients and none complained about urinary incontinence. In all patients suffering from prolapse only the urethral closure pressure was positive at stress before as well as after surgery. The functional and the absolute urethral lengths increased in both categories of patients after the operation.     

Prevalence of stress incontinence among women delivered by elective cesarian section

A retrospective investigation into the prevalence of stress incontinence in women delivered by elective cesarian section (without experience of labor) in Lund from 1974 to 1979, was carried out in 1980. Of 264 women whose replies were solicited, 204 responded. The others had moved about and could not be reached. Permanent stress incontinence was reported by a significant number of patients without experience of labor. This supports our earlier findings which indicated that pregnancy and hereditary factors are more decisive in bringing about stress incontinence than the delivery itself.     

Early results for below-knee bypasses using Distaflo

In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses.     

Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation

Background Intractable reflux, either due to gastric prolapse or concentric pouch dilatation has been the most common indication for reoperation or band removal after laparoscopic adjustable gastric banding (LAGB). We have previously found that a simple hiatal hernia repair (HHR) leads to remission of these symptoms minimizing the need for band removal. We have subsequently added crural repair/HHR at the initial operation, where indicated. In this study compare the rate of reoperation in patients who underwent LAGB alone, or with concurrent HHR. Methods A retrospective review of a prospective database of all patients undergoing LAGB was performed to determine the incidence of reoperation in the two groups. Results Between July 2001 and August of 2006, 1298 patients underwent LAGB and 520 patients underwent LAGB with concurrent HHR (LAGB/HHR). The mean initial weight and BMI were 128 kg (range, 71.1–245.7 kg) and 45.4 kg/m² (range, 28–75 kg/m²). Average follow-up for the LAGB and LAGB/HHR groups was 24.8 and 20.5 months, respectively. Rate of reoperation for HHR alone, or with band slip or concentric pouch dilatation, for LAGB and LAGB/HHR groups was 5.6% and 1.7% respectively (p < 0.001). Total reoperation rate for slip, HHR and pouch dilatation was 7.9% and 3.5%, respectively (p < 0.001). There was no significant difference in rate of slip repair alone between the two groups: 2.3% and 1.7%, respectively (p < 0.44). Conclusions Adding HHR to LAGB where indicated significantly reduces reoperation rate. Every effort should be made to detect and repair HHR during placement of the band, as it will decrease future need for reoperation.