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PubMed2004

A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome.

BACKGROUND: Effective hemostatic treatment is mandatory for patients with actively bleeding Mallory-Weiss syndrome. This study evaluated the respective efficacy and the safety of endoscopic band ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome. METHODS: Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine. Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed. RESULTS: The number of elastic bands applied was one or two; the mean volume of epinephrine injected was 18.0 mL: 95% CI[16.8, 19.2]. There was no significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization. Primary hemostasis was achieved in all 17 patients in the band ligation group and in 16 of 17 patients (94.1%) in the epinephrine injection group. There was no recurrence of bleeding or major complication in either group. CONCLUSIONS: In this small study, no difference was detected in the efficacy or the safety of band ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome.

Endoscopy, Gastrointestinal↗
PubMed2004

Endoscopic band ligation without electrosurgery: a new technique for excision of small upper-GI leiomyoma.

BACKGROUND: Leiomyoma is a relatively common submucosal tumor in the upper-GI tract. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated. METHODS: The study included 59 patients with 64 small upper-GI leiomyomas arising in the muscularis propria as determined by endoscopy, EUS, and EUS-guided FNA. The distribution of the 64 leiomyomas was the following: esophageal, 50; gastric, 12; duodenal, 2. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning 2 weeks after banding, the lesions were observed endoscopically once per week until healing was complete. RESULTS: The 50 esophageal leiomyomas sloughed completely. The mean time required for complete healing after band ligation was 3.6 weeks. Nine of the 12 gastric leiomyomas sloughed completely; the resulting ulcer defect was healed at a mean of 4.5 weeks. The other 3 lesions did not slough because they were not completely ligated. The two duodenal lesions sloughed completely after banding, and the mean time until healing of the defect was 4.5 weeks. No perforation occurred. Follow-up ranged from 16 to 31 months, during which time no recurrence was observed. CONCLUSIONS: Endoscopic band ligation is an effective and safe treatment for small upper-GI leiomyoma.

Adult↗
PubMedDate not supplied

Endoscopic esophageal varix ligation: preliminary clinical experience.

Endoscopic variceal ligation (EVL) was performed in 14 consecutive patients who had recently bled from esophageal varices. None was actively bleeding at initial treatment. Ligations were accomplished using an endoscopic ligating device and an overtube. There were no procedural complications. 132 varix ligations were performed during 44 separate EVL sessions. Two patients were lost to follow-up and two died; neither death resulted from hemorrhage or treatment complications. Variceal rebleeding occurred in 2 noncompliant patients (14.3%) and was successfully controlled with emergent EVL. Ten patients achieved complete variceal eradication with from 1 to 6 (mean, 3.9) EVL sessions. No major complications (perforation, secondary bleeding, deep ulceration) resulted and there were no treatment failures. Follow-up of 10 surviving patients ranged from 240 to 370 (mean, 280) days. Endoscopic observation suggested that varices were obliterated by a process of mechanical strangulation, ischemia, superficial ulceration, and scar formation. Preliminary data indicate that EVL is a safe and effective treatment for esophageal varices.

Esophageal and Gastric Varices↗
PubMedDate not supplied

Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy.

Endoscopic variceal ligation has been developed as an alternative to endoscopic sclerotherapy. We report a series of 12 men with a history of bleeding esophageal varices who were treated with endoscopic variceal ligation after they had failed sclerotherapy. Hemostasis was achieved in all 10 patients who were bleeding at the time of initial endoscopy and again in those who subsequently re-bled. Over a follow-up period of up to 22 months, varices have been and remain eradicated in five patients; in four others, a reduction in grade was noted before death (two patients), liver transplant, or loss to follow-up (one patient each); two patients died before they could be re-evaluated, while in the remaining patient, no reduction in variceal grade was noted before loss to follow-up. No complication was recorded after 35 endoscopic treatment sessions involving a total of 245 rubber band ligations. Our results indicate that endoscopic variceal ligation may be used with success in patients who fail sclerotherapy.

Adult↗
PubMedDate not supplied

Comparison and characterization of ulcerations induced by endoscopic ligation of esophageal varices versus endoscopic sclerotherapy.

Esophageal variceal ligation and esophageal variceal sclerotherapy are two modes of therapy commonly used in the treatment of esophageal varices. The purpose of this study was to compare the local complications of these procedures, with special emphasis on production and healing of ulcerations. Twenty-three patients entered the study. Ten patients were randomized to esophageal variceal ligation and 13 to esophageal variceal sclerotherapy. Esophageal variceal ligation produced shallow (0.6 +/- 0.07 mm) circular ulcerations with a large surface area (85.4 +/- 20.3 mm2) that resolved in 14.4 +/- 1.4 days. Esophageal variceal sclerotherapy produced linear, deep ulcerations (1.8 +/- 0.01 mm) with a smaller surface area (13.3 +/- 2.8 mm2) and resolution in 20.9 +/- 1.3 days. These differences were statistically significant by independent t test (p < 0.0001). Esophageal variceal ligation patients required 3.6 +/- 0.4 sessions to achieve obliteration, whereas esophageal variceal sclerotherapy patients required 6.2 +/- 0.5 sessions (independent t test, p < 0.0001). No significant difference was noted between the two groups with regard to death or stricture formation.

Adult↗
PubMed1998

Emergency endoscopic ligation of actively bleeding gastric varices with a detachable snare.

BACKGROUND: Bleeding gastric varices (BGV) is a challenging condition whose management remains controversial and often empirical. METHODS: Over the past 6 months, emergency ligation of BGV was performed in seven cirrhotic patients (five men, two women; age range 47 to 70 years) using a detachable snare. Child's grade was B in two and C in five patients. Two patients had a concurrent hepatocellular carcinoma. Three patients had been previously treated with either balloon tamponade or injection sclerotherapy for bleeding esophageal varices. RESULTS: Hemostasis was achieved in all patients. Morbidity consisted of fever in one case. Six snares passed spontaneously, one was removed from the stomach on follow-up examination. Post-ligation ulcers were detected in all patients after treatment (mean diameter 7.4+/-2.1 mm) with no stigmata of recurrent hemorrhage. No early rebleeding was observed during hospital stay. On a mean follow-up of 3.8 months (range 2 to 6 months), no digestive hemorrhage was recorded. Ligated gastric varices were significantly 'reduced in size in four patients. CONCLUSIONS: Emergency ligation with detachable snare is feasible and may be an alternative life-saving method of endoscopic hemostasis in BGV.

Aged↗
PubMed1999

Left gastric vein hemodynamics and variceal recurrence in patients undergoing prophylactic endoscopic ligation of high-risk esophageal varices.

BACKGROUND: Early recurrence of esophageal varices remains problematic after endoscopic variceal ligation. To evaluate the efficacy of prophylactic endoscopic ligation for esophageal varices at high risk for bleeding, the relationship between left gastric vein hemodynamics and variceal recurrence was investigated. METHODS: Thirty-five patients with cirrhosis underwent endoscopic variceal ligation. Angiography was performed in all patients before treatment and after eradication of varices to study left gastric vein hemodynamics. RESULTS: Before treatment, 12 patients had hepatopetal flow in the left gastric vein (type I), 17 had hepatofugal flow (type II), and 6 had hepatofugal flow with an extra-esophageal shunt (type III). In type I and III patients, the direction of blood flow in the left gastric vein did not change after eradication of varices. Type II patients showed bi-directional flow in the left gastric vein after treatment. Varices recurred in all but one type II patient and in one type I patient during follow-up (mean 36.7 months). The 2-year recurrence-free rate was higher in type I patients (p = 0.0001) and type III patients (p = 0.0002) than in type II patients. CONCLUSIONS: Prophylactic ligation seems to be a safe and useful procedure, especially in patients with type I or III hemodynamics in the left gastric vein before treatment.

Angiography, Digital Subtraction↗
PubMed1983

Indomethacin versus immediate ligation in the treatment of 82 newborns with patent ductus arteriosus.

In the past 10 years, echocardiography and prostaglandin inhibition have changed the management of the patent ductus arteriosus (PDA) in newborns with respiratory distress syndrome (RDS). To judge the results of our present management for morbidity and survival, we analyzed data retrospectively on 82 newborns who were treated from 1977 to 1983 for PDA. We compared their hospital courses and outcomes with a similar group of 45 infants reported by us 10 years ago who were treated by early ductal ligation. The 82 recent patients were divided into two groups, A and B. Group A, 62 consecutive newborns with PDA, was treated primarily with indomethacin. A subsequent group of 20 newborns was treated for PDA primarily with early ductal ligation, group B. There was a 67.8% survival in group A versus 66.7% in the original group of patients 10 years ago--no significant improvement in survival in recent patients using indomethacin. Group B, with early ductal ligation similar to the original patients, had a survival rate of 75%. We identified a group of high-risk infants under 1500 grams with severe RDS whose prognoses varied significantly, depending on the treatment. In the original patients 10 years ago, 41.2% of newborns under 1500 grams with severe RDS survived; 33.3% survived in group A whereas, 71.4% survived in group B. In this high-risk group, treatment for PDA with indomethacin had the worst prognosis, and treatment with ductal ligation combined with modern supportive measures had the best prognosis.

Ductus Arteriosus, Patent↗
PubMed1986

Ligation of the patent ductus arteriosus in newborn respiratory failure.

Patent ductus arteriosus (PDA) is commonly associated with respiratory disease in newborn infants and may require ligation. Surgical ligation of the PDA can be done in small infants with low operative risk and minimal complications. The outcome of patients after ligation depends primarily on the severity of the underlying pulmonary disease. One hundred fifty-one patients have undergone ligation in an eight-year period at this center. A simplified technique performed in the neonatal intensive care unit with the use of local anesthesia and conventional ventilator management is described.

Birth Weight↗
PubMed1997

Fetal lung growth after tracheal ligation is not solely a pressure phenomenon.

Fetal tracheal ligation increases lung growth in utero, making it potentially applicable for antenatal treatment of diaphragmatic hernia. This phenomenon has been ascribed to increased intratracheal pressure, which activates as yet unidentified pulmonary stretch receptors. The purpose of this study was to determine whether the composition of lung fluid has any effect on fetal lung development after tracheal obstruction. Six sets of fetal lamb twins underwent tracheal ligation with placement of intratracheal catheters at 122 days' gestation (term, 145 days). In group 1 (n = 6), tracheal fluid was aspirated daily, measured, and replaced with equal volumes of saline. Their respective twins (group 2, n = 6) had daily reinfusion of their own tracheal aspirates. Intratracheal pressure was recorded daily in both groups. Unobstructed fetal lambs (n = 7) were used as negative controls. Animals were killed on postoperative day 14 (136 days). Lungs were weighed, perfusion fixed at 25 cm H2O, and processed for standard morphometric analysis. Intratracheal pressure remained between 3 and 5 torr in both experimental groups throughout the entire postoperative period. In all 12 experimental fetuses, tracheal ligation resulted in an almost threefold increase in lung fluid volume by day 1; a slight decrease at a mean of 2.4 days; and a second surge from day 4 on. Lung fluid volume was significantly higher in group 2 than in group 1 at all measured time points (P < .05, Wilcoxon rank sum test) except on days 3, 4, and 8 (P = .06). Lung weight per body weight (LW/BW) at delivery was 0.045 +/- 0.008 in group 1, not significantly different from unobstructed controls (0.038 +/- 0.006). LW/BW in group 2 was 0.055 +/- 0.010, significantly larger than either group 1 or control (P < .05, single factor analysis of variance). Air space fraction was comparable between the three groups. Alveolar numerical density was significantly lower in groups 1 and 2 than in unobstructed controls (P < 0.05). Replacement of tracheal fluid with saline inhibits the lung hypertrophy seen after tracheal ligation. This phenomenon therefore appears more dependent on tracheal fluid growth factors than on increased intratracheal pressure after obstruction. The immediate decrease in net lung fluid production after saline exchange suggests that these humoral factors play an important role in the initiation of lung cell proliferation.

Animals↗
PubMed1997

Tracheal ligation: the dark side of in utero congenital diaphragmatic hernia treatment.

Currently there are two in utero procedures that have been proposed for the treatment of Congenital diaphragmatic hernia (CDH); reduction of the herniated viscera with repair of the diaphragmatic defect (CDH repair) and stimulation of lung growth by ligation of the fetal trachea (CDH + TL). Recent studies have shown that CDH + TL may result in a significant surfactant deficiency. The aim of this study was to compare the postnatal lung function of these two interventions using the fetal lamb model of CDH. CDH was created in 14 lambs at 78 days' gestation. At 110 days, seven lambs had their trachea ligated through a transverse neck incision and seven had repair of their diaphragmatic defect via a left subcostal incision. At term the lambs were instrumented with the umbilical circulation intact, then delivered and ventilated to a standard protocol for 4 hours. Pulmonary hemodynamics and blood gas levels were measured and compared every 30 minutes. Four lambs in the CDH repair group and five lambs in the CDH + TL group survived to be studied. After the initial data were analyzed, a further group of CDH + TL lambs (n = 4) were studied. In this group a replacement dose of surfactant (Infasurf, Ony Inc, Buffalo, NY) was administered. These initial results cast doubt on tracheal ligation as an in utero therapy for CDH, and indicate that the lung produced by this intervention is not physiologically normal as previously thought. However, the function of these lungs can be normalized if the surfactant deficiency is corrected. If this improvement can be maintained and there is recovery of the endogenous surfactant system, then in utero tracheal ligation may become a viable treatment for fetal CDH.

Analysis of Variance↗
PubMed1998

Comparison of muscle-sparing thoracotomy and thoracoscopic ligation for the treatment of patent ductus arteriosus.

PURPOSE: We reviewed our experience with the treatment of patent ductus arteriosus (PDA), and compared two therapeutic techniques; muscle-sparing thoracotomy (MST) and thoracoscopic PDA ligation (TPDAL). METHODS: We reviewed the clinical records and operative reports of 19 nonnewborn patients who were treated at our institution for PDA. Eleven patients underwent TPDAL and eight patients MST. The TPDAL patients underwent thoracoscopic clipping (ligation) of the PDA, whereas the MST group had a complete division of the ductus. A two-tailed Student's t test was used to calculate the 95% confidence intervals for length of operation, number of doses of intravenous narcotics and hospital stay. Costs were also compared. RESULTS: All patients underwent diagnostic echocardiography in the evaluation of an asymptomatic murmur. Both groups were similar in age (average, 4 years) and gender. All procedures were performed electively. Two thoracoscopic attempts were aborted, one for bleeding and the other for inadequate clip size. The length of the procedure averaged 1.3 hours +/- 0.330 SD for TPDAL versus 1.4 hours +/- 0.335 SD for MST. Five of the nine successful TPDAL patients were admitted to the Pediatric Intensive Care Unit (PICU) with an average length of stay of 20 hours, and two of eight MST patients stayed in the PICU for average of 18 hours. All patients were extubated after the procedure. Chest tubes were placed in two TPDAL patients and three MST patients. However, two patients who underwent TPDAL required tube thoracostomy for persistent postoperative pneumothorax. Average number of intravenous narcotics administered for the TPDAL was 1.2 doses per patient and for MST, 1.75 doses per patient. Mean hospital stay for TPDAL was 1.33 +/- 0.71 SD days and for MST 1.8 +/- 0.83 SD days. Ninety-five percent (95%) confidence intervals for the difference in means demonstrated no difference between the two groups for length of operation, hospital stay, or number of doses of intravenous narcotics administered. CONCLUSIONS: The authors were unable to identify any benefit to thoracoscopic patent ductus arteriosus ligation versus muscle-sparing thoracotomy in terms of hospital stay, length of operation, or morbidity. Additionally, with MST there is a complete division of the PDA theoretically decreasing the risk of recurrence in comparison with clip ligation.

Case-Control Studies↗
PubMed1998

Endoscopic variceal ligation in the management of gastroesophageal varices in postoperative biliary atresia.

BACKGROUND/PURPOSE: Gastroesophageal variceal bleeding is a serious and difficult problem in the long-term management of biliary atresia (BA). Recently, endoscopic approaches have been attempted to manage this problem. The authors have attempted endoscopic variceal ligation (EVL), a less invasive procedure than endoscopic sclerotherapy. METHODS: In the past 5 years, 66 EVL procedures using standard flexible endoscope with a diameter of 9 mm (type p-30, XQ200, or XQ240; Olympus, Tokyo, Japan) were performed in 30 separate sessions on 11 postoperative BA patients. The mean age of the children was 7.8 (range, 3 to 15) years. The EVL device was a small elastic O-ring or a loop ligator. RESULTS: EVL was performed for emergency hemostasis in two patients and prophylaxis for impending rupture in nine with large, blue varices, or with red spots on the variceal surface. During the initial procedure, all varices were ligated successfully, and reduction in size was noted. Of eight patients who were examined 7 to 14 days after treatment, seven (87.5%) had improved. Eight of 11 patients (72.7%) were finally cured or at least had improved after one to seven sessions of EVL. However, three patients did not show improvement after four to seven sessions because of the reappearance of the varices, development of distal lesions such as gastric varices, and acute gastric mucosal lesions. A technical complication encountered was a slippage of the O-ring in one patient. A technical difficulty was seen in ligating the giant gastric varix in one patient. There was no deterioration of liver function induced by EVL in this entire series. CONCLUSIONS: EVL is an effective and feasible treatment of gastroesophageal varices in postoperative BA patients. However, reappearance or reactivation of the varices or emergence of the more distal lesions is likely to occur even after repeated EVL.

Adolescent↗
PubMed1982

Physiologic changes associated with ligation of the ductus arteriosus in preterm infants.

Cardiorespiratory and transcutaneous oxygen monitors were used on 13 preterm neonates to examine physiologic changes during ductus arteriosus ligation. Transcutaneous oxygen decreased 30 seconds after left lung deflation; all infants required increases in inspired oxygen and ventilation to correct abnormal values after the left lung was compressed. Transcutaneous oxygen decreased 30 seconds after ductus arteriosus ligation (mean delta tcPO2 = -17 mm Hg +/- 11.4) but increased 150 seconds after left lung inflation (mean delta tcPO2 = 46.9 mm Hg +/- 28.8). Arterial blood pressure increased (mean delta systolic BP = 17.9 mm Hg +/- 9.5) and heart rate decreased 10 seconds after ductus arteriosus ligation. In five neonates, gradual closure of the ductus arteriosus over 40 to 75 seconds resulted in a more gradual increase in blood pressure. Intraventricular hemorrhage was confirmed in two patients after surgery. Ligation of the ductus arteriosus results in an abrupt increase in blood pressure, which may be related to the pathogenesis of intraventricular hemorrhage. We suggest that the ductus arteriosus be closed gradually to allow a more gradual increase in blood pressure.

Blood Pressure↗
PubMed1996

Cost and efficacy of surgical ligation versus transcatheter coil occlusion of patent ductus arteriosus.

OBJECTIVE: The purpose of this study was to compare cost and efficacy of surgical closure of patent ductus arteriosus using new critical pathway methods with outpatient transcatheter coil occlusion of patent ductus arteriosus. METHODS: Surgical techniques included a transaxillary, muscle-sparing thoracotomy, triple ligation of the patent ductus arteriosus, no chest tube, and discharge from the hospital within 24 hours. Transcatheter coil occlusion of patent ductus arteriosus was done as an outpatient procedure. Costs were compared with inclusion of all hospital and professional charges. RESULTS: From July 1994 until March 1996, 20 patients underwent coil occlusion of patent ductus arteriosus and 20 patients underwent surgical closure of patent ductus arteriosus. Duration of hospitalization was significantly less for the patients receiving coil occlusion (11 +/- 6 hours) as compared with that for the patients having surgical ligation (28 +/- 7 hours, p < 0.05). Total charges were similar for surgical ligation ($7101 +/- $408) as compared with those for coil occlusion ($7104 +/- $886, p > 0.05). Morbidity in coil occlusion included inability to occlude the patent ductus arteriosus in two patients (2/20, 10%) and residual patency in two patients (2/18, 11%). Morbidity in the surgical group included nausea and vomiting necessitating hospitalization for more than 36 hours in one patient (1/20, 5%), transient left recurrent laryngeal nerve palsy in one (1/20, 5%), and pneumothorax in two patients (2/20, 10%). There were no instances of residual patency in the surgical group. CONCLUSIONS: Transaxillary thoracotomy without tube thoracostomy and with critical pathway methods allows safe and effective ligation of a patent ductus arteriosus with early hospital discharge. This surgical method has similar cost, higher efficacy rate, and applicability in all patients as compared with newer transcatheter coil occlusion techniques for closure of a patent ductus arteriosus.

Adolescent↗
PubMed1994

Investigation of vascular changes following penile vein ligation.

In an effort to characterize the changes in penile vasculature that occur following penile vein ligation, we performed pharmaco-cavernosometry and pharmaco-cavernosography on 20 patients after penile vein ligation for comparison with preoperative studies. Three patients with return of erectile function underwent repeat study: 2 were completely normal and 1 had a mild leak from the deep dorsal vein. The remaining 17 patients had continued complaints of erectile impairment. Of these studies 4 showed no evidence of venous leakage, 11 identified a new site of leakage (7 corporo-spongiosal shunts, 2 crural veins and 2 with multiple sites of involvement) and 1 revealed persistent leak through the proximal stump of the resected deep dorsal vein, while 1 patient had an iodine allergy and underwent pharmaco-cavernosometry only. A repeat study in the latter patient showed flow volumes consistent with continued venous leakage. In summary, penile vein ligation appears to be effective at correcting venous leakage noted on cavernosography. However, new sites of leakage frequently appear postoperatively. A corporo-spongiosal shunt was the most frequent site of recurrent venous leakage. A surprisingly high percentage of patients with continued complaints of erectile dysfunction following penile vein ligation demonstrate no venous leakage on subsequent pharmaco-cavernosography.

Erectile Dysfunction↗
PubMed1993

Varicocele vein ligation in 565 patients under local anesthesia: a long-term review of technique, results and complications in light of proposed management by laparoscopy.

Several recent reports have suggested that laparoscopic internal spermatic vein ligation provides a simpler, less debilitating and more cost efficient method of varicocele ligation than conventional surgical techniques. We analyzed the results of open varicocele ligation using local anesthesia in 565 patients for 10 years. All surgery was performed in the outpatient setting using 0.5% lidocaine. In most patients 50 to 200 mcg. fentanyl or 3 to 7 mg. midazolam were used for intravenous sedation. The average operating time, including the administration of anesthesia, was 39 minutes for unilateral and 71 minutes for bilateral procedures. All patients returned to light duty work in 24 to 48 hours and full strenuous physical activity within 1 week. The only complications encountered were 2 wound hematomas (0.3%), 4 minor wound separations (0.7%) and 41 hydroceles (7.3%). Semen improvement and pregnancy rates were similar to those reported in prior series. This study demonstrates that varicocele vein ligation can be done rapidly, efficiently and safely using local anesthesia with time of recovery and return to work comparable to those reported for laparoscopic techniques.

Adolescent↗
PubMed2002

Vaginal uterine artery ligation avoids high blood loss and puerperal hysterectomy in postpartum hemorrhage.

OBJECTIVE: To describe a novel, effective, and minimally invasive surgical technique for avoiding excess blood loss and hysterectomy in intractable postpartum hemorrhage. Previously described techniques-uterine artery ligation at various levels, hypogastric (internal iliac) artery ligation, uterine compression-all require an abdominal approach. METHODS: This procedure, which is quickly learned, is performable in the delivery room with minimal preparation, with or without bladder retraction. A 2-cm horizontal incision is made in the anterior cervix 1 cm beneath the estimated vaginocervical fold and the bladder reflected in the natural plane. Firm but gentle downward traction on the uterus to the contralateral side of the intended ligature maximizes cephalad and lateral access, permitting bilateral uterine artery ligation from laterally under direct vision and/or indirect transcervical palpation. RESULTS: Between November 1997 and June 2001, 13 women with intractable postpartum hemorrhage chose the vaginal route over laparotomy as a uterus-preserving procedure. Hysterectomy proved necessary in only one case (8%) because of placenta percreta. One woman has since delivered a healthy term infant by cesarean, and uterine vascularization was unimpaired. CONCLUSION: The vaginal route offers a novel, simple, effective, and minimally invasive technique for treating intractable puerperal hemorrhage by uterine artery ligation. Timely intervention avoids hysterectomy and consumption coagulopathy and preserves reproductive potential.

Arteries↗