Cases Of Intraoperative Bleeding Research Articles

IS THERE A PLACE FOR INTRAPERITONEAL ONLAY MESH(IPOM) FOR INGUINAL HERNIA? A SINGLE-CENTRE EXPERIENCE

Abstract Background IPOM is a well-established technique for the laparoscopic treatment of ventral hernias, for which it can also be considered the treatment of choice in selected patients. Its usage for the laparoscopic treatment of inguinal hernia has already been described. The main concern about this technique is the high risk of neurovascular damage since mesh fixation has always been achieved with resorbable tackers. Recently, some new glue-based fixation devices have been introduced that could almost nullify this risk. This study aims to evaluate the feasibility of IPOM techniques for inguinal hernia treatment using only glue-based fixation devices. Materials and Methods Sixteen patients (13 with bilateral inguinal hernias) who underwent IPOM inguinal hernia repair from 2021 to 2023 were included. All patient data were collected from the hospital's medical records. Follow-up appointments were scheduled for clinical visits every 3 months during the first year, and every 6 months thereafter to evaluate long-term outcomes. Results The mean follow-up time was 13.2 ± 6.8 months. The mean operative time was 22.5 ± 6.8 minutes and all the patients were discharged a one-night stay. Only one case of unilateral recurrence was reported. Complications occurred in 2 patients (Grade I according to the Clavien-Dindo scale). No cases of intraoperative bleeding or chronic pain were reported. Conclusion Our experience shows that the IPOM technique with glue-based fixation devices is a safe, feasible and easy-to-master method for the treatment of inguinal hernias. Due to its main characteristic such as the short execution time, it could be considered as an option for selected patients, particularly in cases of synchronous interventions. Further trials are needed to evaluate the clinical outcomes.

Laparoscopic cholecystectomy using the subserosal layer dissection technique in dogs: 34 cases (2015-2021).

To describe a standardised subserosal layer dissection technique and evaluate its outcomes in canine laparoscopic cholecystectomy. Medical records of dogs undergoing laparoscopic cholecystectomy using the standardised subserosal layer dissection technique for the treatment of cholecystolithiasis, cholecystitis, and gall bladder mucocele at a single veterinary hospital from January 2015 to September 2021 were extracted. Operative time, subserosal layer dissection achievement rate, open conversion rate, and complication rate were evaluated. Thirty-four dogs were included. The most common preoperative diagnosis was cholecystolithiasis (n=29). Operative time was 190 minutes (range: 110 to 330 minutes). Subserosal layer dissection of more than 90% of the gall bladder bed was achieved in 27 (79%) dogs. Conversion to open surgery was required in three (8.8%) dogs. There were no cases of intraoperative bleeding, bile duct injury, or reoperation. This study showed that laparoscopic cholecystectomy using the standardised subserosal layer dissection technique could be performed successfully in dogs. Future prospective clinical studies are needed to determine safety and effectiveness of this technique compared to standard techniques.

Endovascular treatment of brain arteriovenous malformations involving the anterior cerebral artery.

To date, at least to the best of our knowledge, there are only limited studies available on the endovascular treatment (EVT) of brain arteriovenous malformations (BAVMs) involving the anterior cerebral artery (ACA), thus termed ACA-BAVMs. The present study retrospectively examined 60 patients with ACA-BAVMs treated with EVT. The patients were aged between 10 and 72 years (mean age, 35.4±7.0 years) and included 28 females (46.7%, 28/60). The ACA-BAVMs were divided into three types: Type I BAVMs were those located below and in front of the corpus callosum genu, type II BAVMs were those located at the upper area of the corpus callosum from the genu to the anterior portion of corpus callosum body, and type III BAVMs were those located from the anterior portion of corpus callosum body to the splenium of the corpus callosum. There were 9 (15%, 9/60), 15 (25%, 15/60) and 36 (60%, 36/60) patients with type I, II and III ACA-BAVMs, respectively. Statistical analysis revealed that the posterior cerebral artery (PCA) tended to be involved in type II and III BAVMs. All patients were treated using EVT. During EVT, there were 3 cases of intraoperative bleeding (5%, 3/60), which tended to occur in type I and II ACA-BAVMs. The other 57 cases (95%, 57/60) had no complications and new neurological deficits. At the time of discharge, 48 (80%, 48/60) patients had a Glasgow Outcome Scale score of 5. During the clinical follow-up period, 47 patients were classified according to the modified Rankin Scale (mRS) score; 39 (83%, 39/47) patients presented with an mRS score of 0. On the whole, the present study demonstrated that EVT may be a safe treatment for ACA-BAVMs.

Redo-laparoscopic cholecystectomy: is it applicable

Background Laparoscopic cholecystectomy is the treatment of choice for symptomatic gall stone disease. Laparoscopic cholecystectomy is done worldwide by general surgeons, but difficult cases remain challenging even to experts in laparoscopic surgery. Redo-cholecystectomy is done owing to either interval cholecystectomy after first surgery or stone in cystic duct stump or remnant gall bladder. The most important investigation done for the patients is magnetic resonance cholangiogram. Redo-surgery is applicable to be done laparoscopic. Patients and methods A retrospective study was conducted on 11 patients whom underwent to cholecystectomy either open or laparoscopic, where one case could undergo cholecystostomy by Foley’s catheter and second one could not reach the gall bladder, and nine cases could undergo laparoscopic (four cases postpone from the start and five cases have remnant of gall bladder or retained stone in it). Clinical examination, laboratory, and radiological evaluation was done. All cases of redo-surgery were by laparoscopy. Results One case needed to convert to open surgery. Time of surgery ranged from 1 to 3 h. There is no bile leakage or common bile duct injury. There were two cases of intraoperative bleeding and one case with postoperative bleeding. Postoperative stay in hospital was 1–2 days, except a case that was converted to open, which had 3 days of hospital stay. Conclusion Redo-laparoscopic cholecystectomy is applicable and safe but needs experience in laparoscopic skills.

Three ports versus conventional five ports laparoscopic sleeve gastrectomy for treatment of morbid obesity; a retrospective study.

Abstract Aim: To assess and compare the feasibility and efficacy of three-port laparoscopic sleeve gastrectomy (3P LSG) and conventional 5 ports laparoscopic sleeve gastrectomy (5P LSG).Patients and Methods: A prospective comparative randomized clinical trial to compare patients who underwent 3P LSG versus conventional 5P LSG, each group contain 120 patients.Results: The follow-up was 12 months for both groups. Mean operative time was longer in 3P LSG (65.5 ± 10.24 min) vs. (55.9± 5. 2 min) in 5P LSG, (P < 0.000). There were 2 cases of intraoperative bleeding in each group. One case of leak in each group. Wound infection at port site was observed in 1 and 2 trocar sites in 3P LSG and 5P LSG (P = 1.000), respectively. At mean 12 months follow-up, with no lost, excess weight loss percentage (%EWL) was 40.44 ±6.34 in 3P LSG and 41.62±5.74 in 5P LSG ( P= 0.127).Conclusion: Three-port laparoscopic sleeve gastrectomy (3P LSG) is a feasible technique without affecting (%EWL) rates, with acceptable complication rate, but with longer operative time.

Traction-assisted endoscopic full-thickness resection followed by O-ring and over-the-scope clip closure in the stomach: an animal experimental study.

Background and study aims Exposed endoscopic full-thickness resection (EFTR) enables the operator to obtain a sufficient surgical margin. However, insufflation leakage and secure endoscopic full-thickness closure (EFTC) remain problematic. This study aimed to evaluate the safety and feasibility of a new exposed EFTR. Patients and methods Exposed EFTR was performed for 2-cm virtual lesions in different locations of the upper stomach in four dogs. EFTR mainly involved half-circumferential EFTR of the endpoint and clip-line traction. Pulley traction was applied with the forward approach for the greater curvature. EFTC involved endoscopic ligation with O-ring closure to diminish insufflation leakage, followed by over-the-scope clip closure. Results Complete resection and technical success were achieved in all four cases. One case of intraoperative bleeding was endoscopically managed. No postoperative complications occurred in any cases. The median maximum resected size was 27.5 mm. The median procedure time of the total operation, EFTR, and EFTC was 76, 37, and 35.5 minutes, respectively. The 1-month survival rate was 100 %. Conclusions This therapeutic strategy may lead to the establishment of exposed EFTR.

Initial Experience with Percutaneous Internal Ring Suturing for Indirect Inguinal Hernia in Pediatric Patients.

PurposeThe aim of this study is to review our experience in treating indirect inguinal hernia in pediatric patients.MethodsWe retrospectively studied a total of 43 patients who underwent percutaneous internal ring suturing (PIRS) for indirect inguinal hernia from January 2016 to September 2018. The participants included 29 boys and 14 girls. There were cases of bilateral internal inguinal hernia (n=12), right indirect inguinal hernia (n=16), and left indirect inguinal hernia (n=15). Their mean age was 3.8±2.9 years, and mean body weight was 16 kg. Clinical features and surgical outcomes were analyzed.ResultsMean operating time was 35 min for unilateral inguinal hernia and 40 min for bilateral inguinal hernia. There were five cases of intraoperative bleeding (12%) during needle insertion. In two cases, stress test resulted in escape of gas into the hernial sac and a second suture was inserted. The contralateral patent processus vaginalis was present in six (14% of cases) and closed. Follow-up was 6~30 months. Mean postoperative hospital stay was 1.2 days. No recurrence hernia and postoperative complications were reported.ConclusionAlthough this study investigated a small number of cases and the surgical experience was rather limited, the PIRS technique was shown to have advantages such as a short learning curve and its aid in detecting contralateral hernias. In this study, there were no reports of recurrence, metachronous inguinal hernias, and postoperative complications.

Endoscopic Third Ventriculostomy for Hydrocephalus in Infants: A Single-center Experience.

Introduction:Hydrocephalus remains one of the more common pathologies managed in pediatric neurosurgery. Endoscopic third ventriculostomy (ETV) has become the procedure of choice for the treatment of hydrocephalus due to aqueductal stenosis with high success rate. It has an advantage over ventriculoperitoneal (VP) shunting, as it enables patients to remain device free.Objective:The purpose of this study is to assess the role of ETV in the treatment of hydrocephalus in children under 1 year of age, including preterm low birth weight infants.Materials and Methods:A prospective study of 30 infants undergoing ETV in our institution between January 2014 and December 2018 was carried out. There were 25 cases of congenital hydrocephalus with aqueductal stenosis, two cases of Dandy–Walker cyst, two cases of cerebellopontine angle arachnoid cyst, and one case of posttubercular meningitis. ETV success score was calculated preoperatively to evaluate the percentage of success of ETV.Results:The overall success rate was 76.66% (23), with highest success rate of 84% in aqueductal stenosis. The mean age was 6.75 months (range: 1.5–12 months). Five infants were born preterm, four of them required a permanent VP shunt. There were two cases of intraoperative bleeding, four cases of cerebrospinal fluid leak from the wound, and one case of meningitis.Conclusion:ETV can be considered a safe and effective modality for the initial treatment of hydrocephalus in full-term normal birth weight infants, while the success of ETV in preterm low birth weight infants need further study of maturity at birth and birth weight as the determinant factors for the success of ETV in this special group.

2870 Flexible Endoscopic Diverticultomy: Development of a Community-Based Referral Program and Ways to Improve Efficiency and Outcomes

INTRODUCTION: Until recently Flexible endoscopic diverticulotomy (FED) has not gained momentum among GI endoscopists in USA due to a variety of reasons including new skill set, referral patterns, procedural risks and complexity. Thus far it has been limited to select university hospitals, restricting its availability. We present a case series of FED performed in our community hospital system. METHODS: Retrospective review was performed from the start of the FED program over 3 months in 2018. We established a new multi-disciplinary Advanced GERD &amp; Esophageal Services (PAGES) program through which patients were reviewed and selected. All were performed by a single interventional ESD (endoscopic submucosal dissection) trained endoscopist. RESULTS: Mean age 69yrs; mean Eckardt score (EDS) 5. Prominent symptoms were dysphagia and weight loss. Diagnosis was established by imaging or EGD. ESD knives were used. Clips were placed on the diverticular base. The thickness and length of the cricopharyngeal bar varied from 0.7- 3 cm (mean: 1.8) and 3- 5 cm (mean: 3.6) respectively. Total operative time depended on the length of the septum, thickness, the type of knife used and varied from 25-168 min (mean:62). The transition from other ESD knives to scissor type knives reduced our operative time by 50% (168 down to 40min) (Table 1). Patients were discharged home 6 hrs post-procedure. A routine predischarge esophagogram was obtained to document complete excision of cricopharyngeal bar. One case of intraoperative bleeding was controlled using a coagrasper. No blood transfusions or second endoscopic procedures were required to control bleeding. One patient was readmitted within 24 hrs of discharge for control of N/V. The success of the procedure was measured using 4 week post-operative EDS. Three of five patients achieved complete symptom resolution at week 1. Two patients had occasional dysphagia (EDS:1) and regurgitation (EDS:1) respectively. All were symptom free at the end of week 4 (EDS: 0 -1) (Table 2). CONCLUSION: Transoral FED gives the gastroenterologists the opportunity to be the forerunners in managing ZD. The vast majority of these patients present to GI physicians with a complaint of dysphagia. The development of the multi-disciplinary program to identify and triage patients, scissor type ESD knife, and a fellowship trained advanced endoscopist are the recipe to success for a tertiary community program.

Splenectomy for people with thalassaemia major or intermedia.

Thalassaemia is a genetic disorder of the haemoglobin protein in red blood cells. It has been historically classified into thalassaemia minor, intermedia and major, depending on the genetic defect and severity of the disease. The clinical presentation of β-thalassaemia varies widely from a mild asymptomatic form in thalassaemia minor, to a severe disease in thalassaemia major where individuals are dependant on life-long blood transfusions. The hallmark of thalassaemia syndromes is the production of defective red blood cells that are removed by the spleen resulting in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. To assess the efficacy and safety of splenectomy in people with β-thalassaemia major or intermedia. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched online trial registries and the reference lists of relevant articles and reviews (27 July 2018).Date of the most recent search of the Group's trials register: 02 August 2019. We included randomised controlled and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. The quality of the evidence was assessed using GRADE. One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. This study assessed the feasibility of splenectomy using a laparoscopic approach versus open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio (RR) 0.50 (95% confidence interval (CI) 0.05 to 4.90) or for bleeding, RR 5.00 (95% CI 0.26 to 95.61) (very low-quality evidence). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, RR 7.00 (95% CI 0.39 to 124.14) (very low-quality evidence). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.

Management of intraoperative bleeding in the video-assisted thoracoscopic surgeries

Minimally invasive approach using video-assisted thoracoscopic (VATS) to lung and esophageal cancer resection offers enormous benefits over open surgery. Yet, the intraoperative bleeding is still a primary cause of conversion to open surgery as well as a major risk for VATS surgery. We present two cases of intraoperative bleeding during thoracoscopic lobectomy and esophagectomy. Ethical approval was obtained from the institutional ethics board. Thoracoscopic management of intraoperative bleeding was demonstrated in different operations. Calm maintenance of a clear thoracoscopic view and prompt establishment of bleeding control, may allow for suture repair of injured vessels. Despite intraoperative bleeding remains the most challenging risk factor, proper management renders minimal invasive approach safe and effective for vasculature repair.

Early complications of tracheostomy: a study on 100 patients at a single tertiary care centre

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tracheostomy is a life saving procedure, which when performed correctly greatly impacts the final outcome of the patient. Although uncommon, fatal complications have been known to occur. The present study was conducted to observe the incidence of early complications of tracheostomy in a tertiary care centre.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 100 consecutive patients subjected to tracheostomy were enrolled, and data pertaining to the indication, and intraoperative and early postoperative complications was collected. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The overall incidence of complications was 77%, with 53% cases of intraoperative bleeding and 13% tube obstruction. A higher incidence of complications was noted in emergency procedures and pediatric tracheostomies. No mortality was seen in the present series.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Serious complications may be associated with tracheostomies, many of which can be avoided by meticulous surgical technique and postoperative care.&lt;/p&gt;

Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction.

A dacryocystorhinostomy (DCR) procedure aims to restore drainage of tears by bypassing a blockage in the nasolacrimal duct, through the creation of a bony ostium that allows communication between the lacrimal sac and the nasal cavity. It can be performed using endonasal or external approaches. The comparative success rates of these two approaches have not yet been established and this review aims to evaluate the relevant up-to-date research. The primary aim of this review is to compare the success rates of endonasal DCR with that of external DCR. The secondary aim is to compare the complication rates between the two procedures. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2016, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to 22 August 2016), Embase (January 1980 to 22 August 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to 22 August 2016), Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to 22 August 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 22 August 2016. We requested or examined relevant conference proceedings for appropriate trials. We included all randomised controlled trials (RCTs) comparing endonasal and external DCRs. Two review authors independently assessed studies for eligibility and extracted data on reported outcomes. We attempted to contact investigators to clarify the methodological quality of the studies. We graded the certainty of the evidence using GRADE. We included two trials in this review. One trial from Finland compared laser-assisted endonasal DCR with external DCR, and one trial from India compared mechanical endonasal DCR (using punch forceps) with external DCR. The trials were poorly reported and it was difficult to judge the extent to which bias had been avoided.Anatomic success was defined as the demonstration of a patent lacrimal passage on syringing, or endoscopic visualisation of fluorescein dye at the nasal opening of the anastomoses after a period of at least six months following surgery. Subjective success was defined as the resolution of symptoms of watering following surgery after a period of at least six months. Both included trials used anatomic patency demonstrated by irrigation as a measure of anatomic success. Different effects were seen in these two trials (I2 = 76%). People receiving laser-assisted endonasal DCR were less likely to have a successful operation compared with external DCR (63% versus 91%; risk ratio (RR) 0.69, 95% confidence intervals (CI) 0.52 to 0.92; 64 participants). There was little or no difference in success comparing mechanical endonasal DCR and external DCR (90% in both groups; RR 1.00, CI 0.81 to 1.23; 40 participants). We judged this evidence on success to be very low-certainty, downgrading for risk of bias, imprecision and inconsistency. The trial from Finland also assessed subjective improvement in symptoms following surgery. Resolution of symptoms of watering in outdoor conditions was reported by 84% of the participants in the external DCR group and 59% of those in the laser-assisted endonasal DCR group (RR 0.70, CI 0.51 to 0.97; 64 participants, low-certainty evidence).There were no cases of intraoperative bleeding in any participant in the trial that compared laser-assisted endonasal DCR to external DCR. This was in contrast to the trial comparing mechanical endonasal DCR to external DCR in which 45% of participants in both groups experienced intraoperative bleeding (RR 1.00, 95% CI 0.50 to 1.98; 40 participants). We judged this evidence on intraoperative bleeding to be very low-certainty, downgrading for risk of bias, imprecision and inconsistency.There were only two cases of postoperative bleeding, both in the external DCR group (RR 0.33, 95% CI 0.04 to 3.10; participants = 104; studies = 2). There were only two cases of wound infection/gaping, again both in the external DCR group (RR 0.20, CI 0.01 to 3.92; participants = 40; studies = 1). We judged this evidence on complications to be very low-certainty, downgrading one level for risk of bias and two levels for imprecision due to the very low number of cases. There is uncertainty as to the relative effects of endonasal and external DCR. Differences in effect seen in the two trials included in this review may be due to variations in the endonasal technique, but may also be due to other differences between the trials. Future larger RCTs are required to further assess the success and complication rates of endonasal and external DCR. Different techniques of endonasal DCR should also be assessed, as the choice of endonasal technique can influence the outcome. Strict outcome criteria should be adopted to assess functional and anatomical outcomes with a minimal follow-up of six months.

Splenectomy for people with thalassaemia major or intermedia.

Thalassaemia is a genetic disease of the haemoglobin protein in red blood cells. It is classified into thalassaemia minor, intermedia and major, depending on the severity of the disease and the genetic defect. Thalassaemia major and intermedia require frequent blood transfusions to compensate for the lack of well-functioning red blood cells, although this need is significantly less in thalassaemia intermedia.Damaged or defective red blood cells are normally eliminated in the spleen. In people with thalassaemia there is a large quantity of defective red blood cells which results in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. To assess the efficacy and safety of splenectomy in people with beta-thalassaemia major or intermedia. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the most recent search: 25 April 2016. We included randomised controlled studies and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. The study assessed the feasibility of splenectomy using laparoscopy in comparison to open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio 0.50 (95% confidence interval 0.05 to 4.90) or for bleeding, risk ratio 5.00 (95% confidence interval 0.26 to 95.61). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, risk ratio 7.00 (95% confidence interval 0.39 to 124.14). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.

Supine pediatric percutaneous nephrolithotomy (PCNL)

Many authors reported their experience with supine PCNL in adult population comparing the outcome with prone PCNL and they found that the stone free rate and the operative time were in favor of prone PCNL with a lower patient morbidity among patients with supine PCNL. This encouraged us to perform supine PCNL in pediatric population. In this study we evaluated the safety and efficacy of supine PCNL in pediatric population. Between April 2011 and February 2014 a total of 27 children (6 girls and 21 boys) presented with renal calculi. The stones were single pelvic stone in 14 cases, pelvic stone with lower calyceal stones in 7 cases and pelvic stone with upper calyceal stones in 6 cases. The mean stone size was 32 mm (range 20-47 mm). All patients were managed with supine PCNL performed by a single surgeon. Marking the posterior axillary line in standing position before the operation is a mandatory initial step. The patients were placed in supine position with elevation of the ipsilateral shoulder and hip by means of two bags one underneath the shoulder and the other underneath the hip to widen the operative field. The technique was performed using a sheathless 19 fr. Richard wolf rigid nephroscope after acute tract dilation by amplatz dilators. Complications (intraoperative and postoperative) and stone free rate rates were reported. A single lower calyceal access was used in all cases through which we could successfully remove even the upper calyceal stones. Kinking of the guide wire during tract dilatation were encountered in 4 cases and the guide wire was successfully exchanged using a small Teflon dilator in 2 cases while ultrasonographic guided lower calyceal repuncture was done in 2 cases. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was (41 ± 15) min. The operation was successfully completed as planned in all cases with two cases of intraoperative complications (one case of pelvicalyceal system perforation and another case of intraoperative bleeding and blood transfusion). The initial stone free rate was (92.5%). Postoperative complications was reported in the form of 2 cases of fever that respond to medical treatment for 72 h. The main advantages of supine pediatric PCNL is that it is comfortable for the surgeon, the anesthetist and the child. The main disadvantages of supine pediatric PCNL is that it is not familiar for most urologists and small field of operation. The short outcome of our study is the small number of cases and the lack of comparative study with prone pediatric PCNL. Pediatric supine PCNL is a safe and effective method for management of pediatric renal stones. It carries the advantages of easily upper calyx access through the lower calyceal tract, low incidence of fluid absorption or hypothermia and easy anesthesia monitoring. However a larger number of cases are needed to be evaluated.

Intraoperative Bleeding in Stereotactic Biopsies and Its Implication on Postoperative Management: Can We Predict CT Findings?

Background: Stereotactic biopsies are procedures with a high diagnostic yield and a low but serious risk of hemorrhage. Postoperative management remains controversial. Objectives: To evaluate the predictive value of intraoperative bleeding and its implication on postoperative management. Methods: Cases of intraoperative bleeding were prospectively documented in a consecutive series comprising 303 patients. Categories were as follows: no bleeding, single drop, ≤10 drops and >10 drops. Incidence, size of hemorrhage and neurological deterioration were noted. Hemorrhage on routine postoperative CT scans was correlated with intraoperative findings, sample size, location and pathology. Results: A total of 93 patients (30.7%) showed intraoperative bleeding and 68 (22.4%) showed blood on postoperative CT. In 13 patients (4.3%) the diameter was >1 cm; 19 patients (6.3%) experienced neurological worsening, 9 (3.0%) having postoperative hemorrhage and 3 (1.0%) permanent neurological deficits. Bleeding was associated with postoperative hemorrhage (p < 0.0001). The negative predictive values to rule out any postoperative hemorrhage or hemorrhages >1 cm were 92 and 100%, respectively. Number of samples, location and pathology had no significant influence on postoperative hemorrhage. Conclusion: Stereotactic biopsies have a low risk of symptomatic hemorrhages. Intraoperative bleeding is a surveillance parameter of hemorrhage on CT. Therefore, routine postoperative CT may be restricted to patients who show intraoperative bleeding.

PTH-034 Achieving Nice Standards for Endoscopic Submucosal Dissection: First Uk Practice Study

IntroductionEndoscopic submucosal dissection (ESD) is an advanced technique that aims to resect appropriately selected gastrointestinal intraepithelial neoplasias en bloc, allowing precise histological diagnosis for staging and resection margin analysis. No...

The endovascular treatment of ruptured anterior communicating artery aneurysms

Objective To summarize the experience of endovascular treatment of ruptured anterior communicating artery aneurysms and discuss the technical points of procedure. Methods Retrospective analysis of the stent - assisted or dual microcatheter endovascular treatment for 38 patients of ruptured anterior communicating artery aneurysms in our hospital,the clinical data of anterior communicating artery aneurysm embolism process and treatment outcomes were evaluated.Results Densely packing 33 cases of 38 patients,most of the filling three cases,the residual aneurysm neck one cases of intraoperative bleeding,1 patient died.12 cases of patients on admission DSA review the no aneurysm recurrence.Conclusion Rupture of the anterior communicating artery aneurysm treatment,endovascular treatment can achieve a good therapeutic purpose,but also need to accumulate a lot of clinical experience,and continuously improve the level of endovascular treatment. Key words: Anterior communicating artery aneurysm; Stent-assisted; Dual microcatheter; Endovascular treatment

Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children

Background/Purpose There has been great interest in natural orifice transluminal endoscopic surgery in recent years. We report another new approach for pediatric inguinal hernia repair: transumbilical endoscopic surgery (TUES). Compared with the natural orifice transluminal endoscopic surgery technique, TUES can obtain similar scarless results on the abdomen. Methods In our hospital, 2-trocar TUES was the standard procedure used to repair pediatric inguinal hernias. Through 2 intraumbilical incisions, two 5-mm trocars were inserted into the abdomen under laparoscopic guidance. With the use of a needle-holding forceps, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The orifice of the hernial sac was closed extraperitoneally with a purse-string suture around the internal inguinal ring, and intraperitoneal knot-tying was performed. Results A total of 76 inguinal repairs were performed in 64 children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls). All operations were completed successfully by TUES, with the exception of one case of intraoperative bleeding because the inferior epigastric vein was punctured. The mean operating time was 20 minutes (range, 15-30 minutes). No postoperative bleeding, hydrocele, or scrotal edema in this group of patients was found, and there were no known cases of postoperative testicular atrophy or hypotrophy nor hernia recurrence on the symptomatic side. Conclusions Our preliminary experience shows satisfactory outcomes with TUES for completely enclosing inguinal hernias in children. This technique appears to be safe, effective, and reliable. The cosmetic result is excellent.

Analysis of 40 Cases of Intraoral Verticosagittal Ramus Osteotomies to Treat Dentofacial Deformities

The aim of the present study was to report the experience of 40 patients who had undergone intraoral verticosagittal ramus osteotomy (IVSRO) to treat dentofacial deformities. The charts of 40 consecutive patients who had undergone IVSRO were analyzed regarding the diagnosis, amount of mandibular movement, and complications. Eighty IVSROs were performed in 40 patients. The mean follow-up was 18 months. Mandibular protrusion in both genders was the main preoperative diagnosis (25 patients), and the treatment was 2-jaw surgery in 36 patients. The mean amount of movement was 2 mm for the mandible setback and advancement, 3 mm for mandible counterclockwise rotations, and 2 mm for mandible clockwise rotations. The mean period of maxillomandibular fixation was 15 days, followed by a period of heavy elastics. The rate of complications was 2%, including 2 bad splits, and 2 cases of intraoperative bleeding. No nerve injury was observed in the 40 patients studied. The IVSRO is efficient and versatile, with low morbidity, and is an option for the oral and maxillofacial surgeon to treat patients with mandibular dentoskeletal discrepancies.