Additional Hemostasis Research Articles

Efficacy of Topical Metal Polyacrylates for the Prevention and Treatment of Bleeding After Retrograde Cholangiopancreatography

Relevance In recent years, local hemostatic agents have become widespread, as their application at the incision area of the major duodenal papilla can stop or prevent bleeding. Aim of study To study the efficacy of topical application of incomplete silver salt of polyacrylic acid (PAAg) (Haemoblock) for the prevention and treatment of bleeding from the papillosphincterotomy area.Material and methods The prospective study included 211 patients who were hospitalized at the Regional Clinical Hospital in Ryazan from 2020 to 2023. In the main group of patients, for the purpose of hemostasis and prevention of bleeding, the area of the dissected major duodenal papilla was irrigated with 20 ml of an aqueous solution of PAAg. In the control group, irrigation was carried out with 20 ml of 0.9% sodium chloride. The main group included 111 patients (44 men, 67 women, mean age 55.09±20.97), the control group included 100 patients (43 men, 57 women, average age 53.85±20.34).Results In the main group of patients, bleeding from the MDP incision was observed in 83 cases after papillosphincterotomy, and in 82 cases in the control group. After irrigation with an aqueous solution of PAAg, bleeding from the MDP incision was arrested within 120 seconds in the main group in 70 patients, and in 51 patients in the control group, after irrigation with 0.9% sodium chloride solution. Within 300 seconds from the initiation of irrigation, hemostasis occurred in 12 of the 13 remaining patients in the main group with ongoing bleeding and in 27 of 31 patients in the control group. In two patients in the control group, bleeding was managed in 300 seconds without additional methods of endoscopic hemostasis. The use of additional methods of endoscopic hemostasis due to ongoing bleeding in the main group was required in one patient; the incision area was injected with an adrenaline solution. In the control group, additional endoscopic hemostasis was performed on two patients: in one case, injection with an adrenaline solution, in the other, diathermocoagulation of the incision area of MDP. In the early postoperative period, delayed bleeding was detected in 3 patients of the main group, which was significantly lower than the same indicator in the control group (7 observations).Conclusions Local application of PAAg for the treatment of early bleeding in papillosphicterotomy showed a significantly faster onset of hemostasis.

A case of late-onset bleeding from an intercostal artery pseudoaneurysm after hemostasis using soft coagulation

BackgroundThe use of soft coagulation is becoming common in thoracic surgery. Soft coagulation provides rapid hemostasis from small vessels during surgery by dehydrating tissue and denaturing proteins, without burning the tissue.Case presentationA 68-year-old man, with a history of right lower lobectomy 3 years prior, underwent a partial resection of the right upper lobe for a pulmonary nodule suspicious for secondary lung cancer. During the surgery, dissection of the adhesion caused a bleeding from the 6th intercostal artery, and hemostasis was achieved using soft coagulation (some degree of tissue carbonization was noticed at later mortality and morbidity conference). He experienced hemoptysis at postoperative day 18 and was transferred to our hospital. Contrast-enhanced CT scan revealed bleeding from the pseudoaneurysm of the 6th intercostal artery. Embolization was performed by angiography to stop the bleeding.ConclusionsWe experienced a case of late-onset bleeding from a pseudoaneurysm related to soft coagulation hemostasis. Lessons learned from this patient are that additional hemostasis, such as ligation, would be considered for small arteries after hemostasis has been achieved by soft coagulation, especially when some degree of tissue carbonization is suspected.

Prognostic and reproductive outcomes in women who had uterine myomas removed during cesarean section and sutured using different techniques

BackgroundIn this study, the prognostic and reproductive outcomes of women who underwent excision of uterine myomas and were sutured using different techniques while undergoing a cesarean section were investigated.MethodsA total of 299 females who underwent cesarean section between January 2015 and June 2022 due to a scarred uterus were enrolled in this study. These participants were segregated into two categories: the experimental group (comprising 155 cases) in which uterine myoma (single lesion) was excised during the cesarean procedure, and the control group (consisting of 144 cases) in which only the cesarean section was conducted. A comparison between the two groups was carried out based on the following parameters: volume of intraoperative bleeding (mL), additional measures taken for intraoperative hemostasis (n, %), percentage (%) of patients experiencing postoperative fever, duration required for the passage of gas (hours [h]), length of hospital stay (days [d]), weight of newborns (kg) and their Apgar scores, and the reproductive outcomes of the experimental group assessed two years after the surgical procedure.ResultsIn the experimental group, the amount of bleeding during surgery, occurrence of postoperative fever among women, time taken for patients to resume passing gas, and length of hospital stay were 540.65 ± 269.12 mL, 9.03%, 15.99 ± 4.68 h, and 5.08 ± 1.18 days, respectively. In contrast, the control group had values of 409.03 ± 93.24 mL, 2.77%, 16.24 ± 4.92, and 4.47 ± 0.70 days, respectively (P < 0.05). No notable increase was observed in the need for additional intraoperative hemostasis measures, and there was no significant difference in the time it took for patients to pass gas after the surgery. All newborns had positive health status. In the experimental group, 25 patients underwent subsequent pregnancies, and 15 of them successfully reached full-term deliveries, all of which had positive outcomes.ConclusionCombining myomectomy with various suture methods during cesarean delivery did not cause excessive bleeding and resulted in healthy newborns. This approach offers the advantage of avoiding additional surgeries under anesthesia and can be considered a viable option. Subsequent pregnancies after myomectomy were considered high-risk.

Prospective Evaluation of a Defined Replacement Protocol for Peri-Operative Hemostasis in Patients with Severe Hemophilia Α with and without Inhibitors on Emicizumab Prophylaxis Undergoing Elective Major Surgeries. (EmiSurg Study)

Introduction Emicizumab is expected to provide hemostasis equivalent of 10-20% FVIII activity. Major surgical procedures therefore require additional replacement therapy. A defined protocol of replacement therapy for peri-operative hemostasis in patients with hemophilia A on emicizumab prophylaxis undergoing elective major surgery was prospectively evaluated. Patients and methods In this ongoing investigator-initiated study of peri-operative hemostasis in patients with severe haemophilia A with or without inhibitors, aged 2 - 60 years on emicizumab prophylaxis for at least 4 weeks, those requiring elective major surgery were evaluated. Additional hemostasis was provided through standard half-life rFVIII (those without inhibitors) or rFVIIa (those with inhibitors) based on a defined protocol (Table 1). Replacement therapy was stopped after 5 or 7 days in those without or with inhibitors, respectively, unless otherwise indicated. No thromboprophylaxis was used. Outcome measures included efficacy of surgical (post-op assessment by surgeon) and post-operative hemostasis (assessed post wound healing by hematologist), as per ISTH SSC criteria. Other parameters monitored included blood counts, FVIII level, FVIII like activity, modified one stage FVIII assay with emicizumab calibrator, ROTEM, TGT and doppler screening of lower limbs for DVT at defined times. Results Thirty patients (12 with inhibitors), median age 30.5 years (range: 14 - 56) who underwent 32 surgical procedures were included in this analysis. There were 25 (78.1%) orthopedic, 4 (12.5%) abdomino-pelvic, 1 (3.1%) thoracic, 1 (3.1%) neck and 1 (3.1%) inner ear procedures. These included 3 long standing giant body cavity pseudotumors - 2 abdomino-pelvic and 1 thoracic - which were analysed separately as high-risk for surgical hemostasis. Hemostatic efficacy for the 29standard risk procedures was assessed as excellent in 27/29 (93%) and good in 2/29 (7%). It was assessed as fair in 2/3 (67%) and poor in 1/3 (33%) high risk cases. The overall hemostasis at wound healing was assessed as excellent in 28/29 (97%), good in 1/29 (3%) for standard risk procedures and good in 2/3 (67%) and moderate 1/3(33%) for high- risk procedures. Pre-op ROTEM and TGT parameters were normal / near normal after rFVIII or rFVIIa infusion. Breakthrough bleeds (BTB) occurred in a total of 7/29 (24.1%) standard risk procedures, neither requiring additional transfusion support nor affecting wound healing in 6 of them. All BTBs occurred only in total knee replacement (2 unilateral, 3 bilateral) and 2 large thigh pseudotumor excisions. In all except 1, these BTBs occurred after stopping rFVIII/rFVIIa 5- or 7-days post-op. BTBs occurred within day+14 (3 without &amp; 1 with inhibitor) in 4 procedures &amp; beyond day +14 after wound healing (3 without &amp; 2 with inhibitors) in 5, during physiotherapy and mobilization, with some occurring in both phases in 3 procedures. (Table 2) In 2 patients with early BTB after bilateral TKR, the replacement was extended (rFVIIa Q4H from day +8 to day +12, Q6H from day +13 to day+14; &amp; rFVIII Q12H from day +13 to day +15 and single doses on day+9 and day+29). Two patients with lower limb pseudotumor resections required additional support: 1 from day+11 to day +14 (rFVIII Q12H, 4 days for bleeding during physiotherapy) &amp; the other from days +24 - +26 (rFVIIa Q4H, 3 days for re-exploration of a superficial hematoma). For the 3 high-risk patients who underwent abdomino-pelvic or thoracic giant pseudotumor resections (2 without inhibitor &amp; 1 with inhibitor), the rFVIII / rFVIIa support was electively continued till day +21 in 2 and day+21 - 32 in 1. There were multiple BTB requiring additional transfusion of blood products (2 without inhibitors received only packed red cells) while the one with inhibitor had continued bleeding even with global hemostasis parameters in the normal range. This continued post-operatively with septic complications leading to death on day +23. There was no thromboembolism or thrombotic microangiopathy in any patient. Conclusions We have demonstrated a safe and effective protocol for standard risk major surgeries for hemophilia A patients with or without inhibitors on emicizumab prophylaxis with additional replacement therapy during the first 5-7 days post-op. Extended support needs to be individualized as per the surgical procedure and post-op care. Acknowledgements Supported by Roche. Novo Nordisk provided rFVIIa.

The use of distal femoral venous access for pulmonary vein cryoballoon ablation and left atrial appendage occluder implantation: randomized study design and preliminary results

Aim. This study aims to compare the results of the distal femoral access with the classic approach in patients undergoing pulmonary vein cryoballoon ablation and left atrial appendage occluder implantation.Methods. The primary results of the 1:1 randomized single-center study are presented. The study group recruited 47 patients who underwent the catheter-based procedure using ultrasound-assisted distal femoral access. 38 patients with traditional ultrasound-guided proximal femoral access were involved in the control group.Results. Total 85 patients were included: 47 in the study group and 38 in the control group. The median age was 61 years, and pulmonary vein cryo-ablation was performed in 84%. 95% of patients were taking direct oral anticoagulants. In the study group, the most frequent topographic and anatomical variant was the location of the superficial femoral vein on the lateral side from the artery (81%), whereas in the control group it was on the medial side (81%). The median access time was 30 s in the study group for the right leg and 35 s for the left leg. In the control group, access time was 33 s and 39 s for the right and left leg respectively. Unintentional arterial puncture occurred more frequently in both groups when the vein was fully overlapped by the artery for both right and left legs, but the differences were statistical unsignificant (p&gt;0.05 and p=0.09 in the main group, p=0.24 and p=0.72 in the control group). In a correlation analysis, neither body mass index (p=0.19) nor femoral circumference (p=0.19 for right and p=0.06 for left legs) influenced the access time and did not increase the number of unintended arterial punctures. Two patients in the control group required additional manual hemostasis. There was no postprocedural venous thrombosis in both groups. Back pain was observed only in patients in the control group.Conclusion. The efficacy and safety of the distal femoral access approach are comparable to the traditional proximal approach. Earlier postprocedural activation of patients can help improve quality of life.

Blood Pressure Challenge Reduces Hematomas in Gender-Affirming Mastectomy: A Retrospective Chart Review of 92 Consecutive Patients.

Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma. A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non-blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ2, Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05. A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group (P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01-0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004-0.59; P = 0.04). Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

MTA Matrix Technique: Restoration of Teeth with Deep Subgingival Defects Extending Down to the Osseous Crest.

To present a new restorative technique for the restoration of teeth with deep subgingival hard tissue defects extending down to the osseous crest without additional surgical or orthodontic interventions by combining mineral trioxide aggregate (MTA) and composite material. The MTA matrix technique starts by deeply inserting a metal matrix as far down to the bone level as possible. The matrix should then be fixated with a matrix holder in its end position. If the matrix band does not seal tightly in the deepest area of the cavity, small portions of MTA are carefully applied to the lower end of the inner side of the matrix band. The MTA acts as a barrier for fluid control. Additional haemostasis is not necessary. Subsequently, the tooth is restored with an etch-and-rinse adhesive and composite resin. The clinical effects were observed in a case series of three patients over a period of 3 to 4.5 years. Excellent outcomes were observed clinically and radiologically. Teeth restored with the MTA matrix technique showed no failures due to the materials used or due to secondary caries or periodontal inflammation after an observation period of 3 to 4.5 years. Probing depths ranged from 2 to 4 mm without bleeding on probing, including the subgingivally restored areas. Although only a few casuistic observations are available to date, by using the MTA matrix technique, successful restoration of teeth with subgingival defects down to the alveolar bone crest seems possible without the need of additional surgical or orthodontic measures. Further clinical studies are necessary to confirm the feasibility of this technique.

The learning curve of BiZact™ tonsillectomy

ObjectiveTo evaluate the learning curve of BiZact™ tonsillectomy amongst trainees and fellows as a further technical skill. MethodsProspective audit of consecutive BiZact™ tonsillectomies undertaken by a trainee and fellow at Starship Children's Hospital. Primary outcomes measured were operative time from gag open to gag closed, readmission and post tonsillectomy bleed rates. Secondary outcomes included need for bipolar rescue dissection, bipolar haemostasis including site and side, tonsil size (Brodsky grade 1–4) and depth (shallow or deep). Operative time was plotted against number of procedures performed and moving averages was used to investigate the learning curve. Generalised linear model was applied to examine the association between operation time and tonsil depth. ResultsMean operative time for the trainee and fellow was similar (07 min 34 s versus 07min and 37 s). We observed a trend of decreased operative time over number of procedures performed by the trainee but the learning curve was short. The fellow's initial time was lower than the trainee's and remained similar over time. No bipolar rescue dissection was required. Additional bipolar haemostasis was required 95% of the time, but the majority involved the superior pole only (87.5%, p = 0.0001). The overall operative time for shallow tonsils was shorter than for deep tonsils (06 min 31 s versus 08 min 09 s, p = 0.0066). A learning curve was evident for both shallow and deep tonsils for both surgeons combined but was steeper for deep. There were no primary bleeds and the secondary haemorrhage rate was 5.8% (3/51 cases) with no returns to theatre. ConclusionThis is the first study to investigate the BiZact™ tonsillectomy learning curve. BiZact™ tonsillectomy is safe and easy to learn. We observed a clear trend of shallow tonsils being quicker to remove than deep tonsils using this technique. The secondary bleed rate of 5.8% is comparable to the previously published Starship rate of 4.7% for all tonsillectomies performed over a 10 year period. Moving averages is a useful method to assess operative learning curves during training and beyond.

Hysterectomy strategies for cesarean scar ectopic pregnancy

The objectives of this film are to discuss both medical and surgical management options for c-section scar ectopic pregnancy and understand the importance of hemostatic control and methods to decrease bleeding. Although there is no consensus on appropriate management, there are several options. Expectant management is reported, but successful outcome with no complications is unlikely. Systemic methotrexate and local injection have low success rates. Uterine artery embolization is an adjuvant treatment used to decrease bleeding. Dilation and curettage can be combined with methotrexate. Hysteroscopic resection and laparoscopic resection are additional options. If patient no longer desires fertility, hysterectomy is considered. This is the case of a 34 year old G6P3 at 7 weeks and 5 days gestation with cesarean section scar ectopic found incidentally on ultrasound during prenatal visit. She had a history of three cesarean sections. Patient declined methotrexate and desired hysterectomy. When performing a hysterectomy for a c-section scar ectopic, it is important to prioritize bleeding control. In this case, the uterine manipulator was not placed into the uterus initially, to avoid perforating the pregnancy. Instead, an EndoPaddle was used from above through an assist port to manipulate the uterus without causing trauma and bleeding. The goal is to achieve hemostasis before introducing a uterine manipulator by ligating the uterine arteries at the origin via retroperitoneal dissection. Vasopressin injection into pregnancy implantation site achieves additional hemostasis. In conclusion, taking extra precautions to control bleeding is essential during a hysterectomy for cesarean scar ectopic pregnancy.

MANAGEMENT OF TOOTH EXTRACTIONS IN PATIENTS RECEIVING THE NEW ORAL ANTICOAGULANTS

Introduction: High bleeding risk procedures pose a serious challenge for dental practitioners treating patients taking some of the novel oral anticoagulants. Aim: The aim of the present study was to assess clinically the bleeding risk in a typical tooth extraction in patients on monotherapy with one of the new oral anticoagulants rivaroxaban (Xarelto), apixaban (Eliquis), and dabigatran (Pradaxa). Materials and methods: The study included 30 patients on these anticoagulants who underwent a typical tooth extraction. Local hemostasis was achieved using Surgicel, Haemocollagen or Gelaspon, and suturing the edges of the wound. Clinical evaluation of the bleeding was performed at 10 and 30 minutes, and 24 hours after the extraction. Anticoagulants were discontinued for the day of extraction. Results: Post-extraction bleeding in the first 10 minutes was observed in 17 patients (56.66%). Bleeding within 30 minutes was observed in 11 patients (36.66%). Two (6.66%) patients reported having only mild oozing within 24 hours. No additional haemostasis was required for any of the patients. Bleeding in a typical tooth extraction is of capillary origin. Bleeding sites are easily accessible and local hemostatic agents are effective enough to control the bleeding. Discontinuation of the anticoagulant on the day of extraction is sufficient to prevent any adverse events. No abnormal post-extraction bleeding was observed in our study. Conclusions: If tooth extraction is required in patients taking the new oral anticoagulants rivaroxaban (Xarelto), apixaban (Eliquis) or dabigatran (Pradaxa), the patient can cease the reception of the drug only for the day of the procedure.

PD48-10 MULTIPLE TRANSVERSE INCISIONS PATCHED WITH TACHOSIL® IN PEYRONIE’S DISEASE: PRELIMINARY DATA OF AN ONGOING, PROSPECTIVE, NON-RANDOMIZED STUDY

You have accessJournal of UrologySexual Function/Dysfunction: Peyronie's Disease (PD48)1 Sep 2021PD48-10 MULTIPLE TRANSVERSE INCISIONS PATCHED WITH TACHOSIL® IN PEYRONIE’S DISEASE: PRELIMINARY DATA OF AN ONGOING, PROSPECTIVE, NON-RANDOMIZED STUDY Afonso Castro, Miguel Fernandes, Miguel Miranda, Pedro Simões Oliveira, Natalia Martins, José Palma dos Reis, and Francisco E. Martins Afonso CastroAfonso Castro More articles by this author , Miguel FernandesMiguel Fernandes More articles by this author , Miguel MirandaMiguel Miranda More articles by this author , Pedro Simões OliveiraPedro Simões Oliveira More articles by this author , Natalia MartinsNatalia Martins More articles by this author , José Palma dos ReisJosé Palma dos Reis More articles by this author , and Francisco E. MartinsFrancisco E. Martins More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002070.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peyronie’s disease (PD) can be both physically and psychologically distressing to the patient. Although invasive, surgery remains the most reliable and effective treatment option. However, complications are not negligible. We present our preliminary data of an ongoing, prospective, non-randomized study of potent patients with PD who underwent multiple transverse incisions (MTI) covered with Tachosil®. Severe dorsal/dorsolateral deformity and/or further penile shortening were the primary therapeutic endpoints. METHODS: Between January 2018 and February 2020, patients with dorsal/dorsolateral deformity and stable PD were included in this analysis. All patients underwent a penile duplex ultrasound study (PDUSS) and SHIM-5 (Sexual Health Inventory for Males) questionnaire to assess erectile function both objectively and subjectively before and after surgery. PGI-I (Patient Global Impression of Improvement) was used to assess patient satisfaction. RESULTS: 23 patients underwent MTI+Tachosil® (median 4 incisions; range 3-6) after ≥12 months of deformity duration and without evidence of progression. Median age was 66 years (range 49 - 76). Median preoperative compound curvature was 60 degrees (range 30-90), 19 (83%) had dorsal curvature, 3 patients (13%) had dorsolateral deformity and 1 had lateral curvature (4%). Total straightness was achieved in 20 patients (87%) and residual curvature was evidenced in 3 (13%). Erectile rigidity sufficient for penetrative intercourse was maintained in all patients at last follow-up, not displaying erectile dysfunction progression. There were no significant changes in PDUSS scores post-operatively. SHIM-5 scores improved from 13 (range 12-16) pre-operatively, to 19 (range 18-21) post-operatively. Median postoperative PGI-I scores were 2 (much better). No penile length reduction was observed. One patient experienced self-resolution of penile hematoma, 5 patients noted transient glandular hypoesthesia with only 1 developing prolonged sensation impairment. CONCLUSIONS: MTI with Tachosil grafting is feasible, well tolerated, easy and quick to perform surgical technique for the treatment of PD. It avoids creation of large tunical defects with subsequent veno-occlusive dysfunction, and provides additional hemostasis, while preserving erectile function. Most complications were minor and transient (Clavien-Dindo I or II). Source of Funding: The authors received no specific funding for this work © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e842-e842 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Afonso Castro More articles by this author Miguel Fernandes More articles by this author Miguel Miranda More articles by this author Pedro Simões Oliveira More articles by this author Natalia Martins More articles by this author José Palma dos Reis More articles by this author Francisco E. Martins More articles by this author Expand All Advertisement Loading ...

New Developments in Diagnosis and Management of Acquired Hemophilia and Acquired von Willebrand Syndrome.

Acquired hemophilia A and acquired von Willebrand syndrome are rare, but life-threatening bleeding disorders that require prompt diagnosis and treatment by hematologists. Acquired hemophilia A is defined as an acquired severe bleeding tendency caused by autoantibody formation against coagulation factor VIII. Acquired von Willebrand syndrome is characterized by a new onset bleeding tendency caused by a reduced concentration and/or function of von Willebrand factor. These disorders are associated with a variety of underlying disorders, including various hematological malignancies, for example, plasma cell disorders, lymphoproliferative disorders, monoclonal gammopathy of undetermined significance, and myeloproliferative neoplasms. It is of utmost important to recognize these acquired bleeding disorders in these patients who are at risk for severe bleeding, and to perform additional diagnostic hemostasis laboratory evaluation. This will enable immediate diagnosis of the acquired bleeding disorder and management of both the bleeding episodes and the causative underlying disorder. In recent years, several new etiological factors for acquired hemophilia A, such as treatment with immune checkpoint inhibitors or DPP-4 inhibitors and SARS-CoV2 infection, and for acquired von Willebrand syndrome, for example, left ventricular assist devices, have been identified and also new treatment options have become available. In this concise review, the most recent data on etiology, diagnosis, and treatment of acquired bleeding disorders are presented and discussed.

A retrospective analysis of dental implantation under anticoagulant treatment.

To present our experience treating patients who have undergone dental implantation under no change in their constant anticoagulant treatment. A retrospective study on patients who have undergone dental implantation. The study group consisted of patients under oral anticoagulants for at least 6months before dental implantation. The control group was consisted of healthy patients with no oral anticoagulant treatment. Bleeding events were recorded and treated during the first 2weeks postoperatively. A total of 193 patients were included in the study. Seventy-two of them who were under anticoagulants served as a study group and the rest (121 patients) served as a control group. Mean age: 65years old in the study group and 59years old in the control group. Gender: male to female ratio was higher in the study group and lower in the control group. Four patients in the study group and 7 patients in the control group presented postoperative bleeding and were treated successfully by additional local hemostasis methods. With the limitation of this study, it can be concluded that patients under oral anticoagulant treatment can undergo dental implantation safely. Bleeding events are rare and can be controlled by local hemostasis. Prior to dental implant insertion, patients under oral anticoagulants can continue their constant medical treatment. The procedure can be performed on outpatient basis under local hemostasis.

Application of citrate dialysis in the treatment of puerperal sepsis

Aim. To describe the results of applying citrate dialysis in the complex therapy of a patient with postpartum sepsis.Materials and methods. This paper presents an analysis of a case of the successful treatment of patient P. with the diagnosis “Childbirth 3 urgent. Pfannenstiel laparotomy. Caesarean section in the lower uterine segment. Hypotonic bleeding. Relaparotomy: ligation of the internal iliac arteries, hemostasis. Relaparotomy: additional hemostasis, pelvic tamponade, abdominal cavity tamponade. Hemorrhagic shock of fourth category. Extirpation of the uterus with tubes. Sepsis. Septic shock. DIC syndrome”. Citrate dialysis was included as part of intensive care therapy.Results. Citrate dialysis allowed the patient with multiple organ failure, against the background of complex intensive care therapy, to restore kidney function after 28 sessions of renal replacement therapy. Diuresis was completely restored on day 42. Biochemical parameters, such as urea and creatinine, were normalized on day 45. The duration of treatment in the anesthesiology and resuscitation departments was 47 days, out of which lung mechanical ventilation lasted for 17 days. The total duration of treatment in the hospital was 54 bed days. The patient was discharged in satisfactory condition.Conclusion. The methods of extracorporeal detoxifi cation can signifi cantly improve treatment outcomes in this category of patients and reduce maternal mortality rates.

Training in endotherapy for acute upper gastrointestinal bleeding: a UK-wide gastroenterology trainee survey

IntroductionCompetence in endoscopic haemostasis for acute upper gastrointestinal bleeding (AUGIB) is typically expected upon completion of gastroenterology training. However, training in haemostasis is currently variable without a structured training pathway....

Prospective outcomes following drainless superficial parotidectomy with sternocleidomastoid flap reconstruction

BackgroundPatients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey’s syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement.MethodsAll patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010–2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement.ResultsFifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient’s (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey’s Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery.ConclusionIn the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.

The Use of Three Different Hemostatic Agents during Laparoscopic Partial Nephrectomy: A Comparison of Surgical and Early Renal Functional Outcomes.

This study aimed to compare the effects of three different hemostatic agents on surgical and early renal functional outcomes after laparoscopic partial nephrectomy (LPN). A total of 126 cases of LPN performed between November 2008 and September 2016 were enrolled in this study. Spongostan™ Absorbable Hemostatic Gelatin Sponge (Ethicon, Somerville, NJ, USA) or Surgicel® Original Absorbable Hemostat (Ethicon, Somerville, NJ, USA), or a total of 5 mL of Floseal® Hemostatic Matrix (Baxter Healthcare, Deerfield, IL) was used for additional hemostasis. According to the hemostatic agent used, patients were divided into three groups; and patient characteristics, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor characteristics, perioperative parameters, serum creatinine levels, and complications were compared among these three groups. Age, BMI, ASA score, tumor characteristics, operative time, warm ischemia time, complication rates, and length of hospital stay were similar among the groups, whereas estimated blood loss was significantly lower in the Floseal Group (p=0.01). Postoperative serum creatinine levels and differences between preoperative and postoperative serum creatinine levels were also similar among the groups. The type of hemostatic agent used in LPN may affect the estimated blood loss. However, it has no substantial effect on other surgical parameters and early renal functional outcomes.

COMPARISON OF CERVICAL BIOPSY USING PUNCH BIOPSY FORCEPS VERSUS LOOP ELECTRODE

Context: The biopsy of cervix can be obtained by various methods with availability of newer modalities like loop electrode. Objectives: To compare the histo-pathological parameters and clinical outcome of cervical biopsy obtained using punch biopsy forceps versus loop electrode. Methods: Women attending OPD were screened for cervical pathology, and colposcopy was done for those who screened positive. Patients who required cervical biopsy after colposcopy were allocated into 2 group; one undergoing LEEP biopsy and other half biopsied with Punch forceps. During procedure patients were evaluated for the intra-op pain and bleeding and their severity. The histo- pathological diagnosis was carried out and the sample was studied for its size, adequacy, and presence of any thermal or crush artefacts. Result: The two methods of biopsy were comparable in intra-op parameters, except for the increased requirement for additional haemostasis in LEEP biopsy. There was no case of bleeding from biopsy site at the follow-up visit. LEEP biopsy was associated with continued vaginal discharge more often than punch biopsy. An adequate sample for histopathological diagnosis was obtained in 91.25% of all cases. The comparative findings were reflective of comparable efficacy of both methods in providing an acceptable tissue sample for diagnosis. Conclusion: After analysing and comparing the aforementioned parameters, we opined that neither method can be deemed clearly superior to the other as a cervical biopsy procedure.&#x0D; Keywords: Punch biopsy forceps; Loop electrode; Cervical biopsy.

Evaluation of a shortened course of tranexamic acid for patients with inherited bleeding disorders following dental procedures

Abstract People with Inherited Bleeding Disorders (IBD) are often prescribed a course of Tranexamic Acid (TXA) mouthwash for five to seven days following dental procedures to reduce the risk of bleeding. Informal discussions with patients suggested that many do not complete the prescribed course of treatment. A literature review indicated that TXA was prescribed inappropriately for procedures with a low bleeding risk, and that there are inconsistencies in the recommended dose, mode of administration and duration of TXA for this patient group. A new protocol was implemented in the haemophilia centre at St George’s University Hospital NHS Foundation Trust, London, to rationalise the prescribing of TXA in dental procedures. A study was conducted to explore patients’ experience of this new guideline in the form of a service evaluation. Structured telephone interviews were completed following 39 dental procedures to collect data on concerns about bleeding; whether TXA was taken as prescribed and reasons for non-adherence; and any unplanned post-operative treatment. The financial impact of the new guideline was also explored. Patients were supportive of the new regimen, although almost half (46%) did not complete the prescribed course of TXA. The majority (37/39) were prescribed tablets rather than mouthwash. No patients required additional unplanned haemostasis support to control haemorrhage. Cost savings were made by replacing a five- to seven-day course of TXA mouthwash with a three-day course of TXA tablets. Although the data collected from patient interviews supports the new guideline, patients appear to be making decisions about taking TXA based on their own experience rather than following the prescribed regimen. Prescribers should support patients to make informed decisions about their medicines and incorporate patient experience into individualised regimens. Given the lack of bleeding complications experienced in this cohort of patients, it is possible that TXA is being overprescribed. Further work exploring how patients with IBDs make decisions about taking medicines is needed.

Subtotal Cholecystectomy in Surgery for Pancreatic Head and Periampullary Zone Masses

Aim. To develop and evaluate efficacy of new method of subtotal cholecystectomy in surgical treatment of patients for pancreatic head and periampullary zone masses. Material and Methods . For the period 2004–2014 subtotal cholecystectomy has been used in 23 cases of diffuse intraoperative bleeding, portal hypertension and extensive fibrosis of gallbladder caused by chronic inflammation. In the second group (n = 236) standard cholecystectomy was performed regardless surgical conditions. In both groups cholecystectomy was a stage of pancreatoduodenectomy or billiary bypass. Comparative analysis was made regarding intra- and postoperative bleeding. Results. Subtotal cholecystectomy was not followed by intra- or postoperative bleeding required additional hemostasis. Standard cholecystectomy was accompanied by bleeding from gallbladder bed in 8 (3.9%) cases that required additional hemostasis. Postoperative bleeding was observed in 4 (1.7%) patients including 2 of them after additional hemostasis. Redo interventions were performed in 3 patients. One patient died after re-laparotomy. Conclusion. Subtotal cholecystectomy is effective measure for prevention of intra- and postoperative bleeding from gallbladder bed in case of difficult surgical conditions.