Complete Hemostasis Research Articles

MP31-07 FORVEIN TRIAL: EVALUATION OF THE HEMOSTATIC ROLE OF FIBRIN SEALANT ON RENAL VEIN ANASTOMOSIS DURING RENAL TRANSPLANT SURGERY: A PROSPECTIVE RANDOMISED CONTROLLED TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP31-07 FORVEIN TRIAL: EVALUATION OF THE HEMOSTATIC ROLE OF FIBRIN SEALANT ON RENAL VEIN ANASTOMOSIS DURING RENAL TRANSPLANT SURGERY: A PROSPECTIVE RANDOMISED CONTROLLED TRIAL Tejas Mistry, Mrinal Pahwa, and Vipin Tyagi Tejas MistryTejas Mistry More articles by this author , Mrinal PahwaMrinal Pahwa More articles by this author , and Vipin TyagiVipin Tyagi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intraoperative bleeding is one of the major complications associated with vascular anastomosis in kidney transplant. One of the novel measures for its prevention is the application of fibrin sealant over renal vein anastomotic site after completing the suturing. Till date, there is no study published to evaluate its role for this purpose. Hence, the current study was undertaken to evaluate the hemostatic role of fibrin sealant on renal vein anastomosis during renal transplant surgery. METHODS: This was a prospective randomised study (FORVEIN stands for Fibrin sealant On Renal VEIN anastomosis) done in our institute from April 2017 to March 2022. Approval of the study protocol was obtained from the Institutional review board. Total 307 renal allograft recipients (with age 18 to 60 years) who had undergone live related renal transplant at our center were included in the study as per the inclusion and exclusion criteria. Patients were randomised according to computer generated random numbers into test group in whom fibrin sealant was to be used and control group in whom saline was to be applied. Time to hemostasis was measured from removal of venous clamps to complete hemostasis at the site and was compared between both the groups. Data regarding age, sex, body mass index, number of vessels was recorded for subgroup analysis. Statistical analysis was done using t-test and MedCalc software (Version 20, Ostend, Belgium). RESULTS: Out of 307 cases, fibrin sealant was applied in 129 cases, whereas 178 cases received saline application. There was significant difference between mean time to hemostasis in fibrin sealant group (7.2min) and in control group (10.2min) (p<0.0001). On subgroup analysis, it was found that hemostasis time was significantly lower in fibrin sealant group for multiple vessels, obese and complex cases with multiple factors (p=0.02, p=0.005, p=0.04 respectively). No case of venous thrombosis was observed. CONCLUSIONS: Application of fibrin sealant over renal vein anastomosis during renal transplant surgery is safe and effective for achieving early hemostasis. Larger multi-centric randomised controlled studies would be needed for its generalized extrapolation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e432 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tejas Mistry More articles by this author Mrinal Pahwa More articles by this author Vipin Tyagi More articles by this author Expand All Advertisement PDF downloadLoading ...

Inframalleolar thrice distal puncture in a single endovascular treatment session for successful revascularization

BackgroundMost patients with chronic limb-threatening ischemia (CLTI) have infrapopliteal arterial disease, which are often challenging to treat. In endovascular treatment (EVT) for these complex lesions, establishing retrograde access is an essential option not only for guidewire crossing but also for device delivery. However, no EVT case has yet been reported requiring inframalleolar thrice distal puncture in a single EVT session so far.Case presentationA 60-year-old CLTI patient with grade 3 Wound, Ischemia and foot Infection (WIfI) classification underwent EVT for occluded dorsal artery and posterior tibial artery. First, we conducted successful balloon angioplasty of the posterior tibial artery by establishing a retrograde approach via the lateral plantar artery. To treat the occlusion of the dorsal artery, we punctured the first dorsal metatarsal artery, and retrogradely advanced a guidewire to the dorsal artery occlusion; however, the microcatheter could not follow the guidewire. Therefore, we punctured the occluded distal anterior tibial artery and introduced the retrograde guidewire into the puncture needle. After guidewire externalization, we pulled up the retrograde microcatheter into the occlusion of dorsal artery using the “balloon deployment using forcible manner” technique. Thereafter, we were able to advance the antegrade guidewire into the retrograde microcatheter. After guidewire externalization, an antegrade balloon catheter was delivered and inflated for the purpose of dorsal artery dilation and hemostasis at the “needle rendezvous” point. Consecutively, balloon dilation was performed for puncture site hemostasis of the first dorsal metatarsal artery and complete hemostasis was achieved. Finally, we confirmed good vascular patency and favorable blood flow. After revascularization, transmetatarsal amputation was performed and the wound healed favorably.ConclusionsWe can markedly increase the success rate of revascularization by effectively utilizing the retrograde approach in EVT for complex chronic total occlusions in infrapopliteal arterial diseases.

Safety and Effectiveness of a Sequential Suture and Plug Vascular Closure Devices Technique for Large-Bore Access Closure after Percutaneous Endovascular Aneurysm Repair

PurposeTo evaluate the safety and effectiveness of sequential sutures and plugged vascular closure devices (VCDs) for large-bore access closure during percutaneous access endovascular aneurysm repair (PEVAR). Materials and MethodsData on 16 patients who underwent PEVAR at the authors’ center from January 2022 to May 2022 were retrospectively reviewed. The median age was 72 years (interquartile range [IQR], 59–75 years), with a male-to-female ratio of 3:1. All patients received sequential suture and plug VCDs using dual Exoseal after 1 Proglide for access closure. Success was defined as the ability to achieve complete hemostasis and was confirmed by ultrasonography. The patients were followed up for access-related adverse events at 30 and 90 days after the procedure, and the severity was graded according to the Society of Interventional Radiology (SIR) classification. ResultsOverall, 24 access sites were included. The median sheath size was 21 F (IQR, 18–23 F). The median hemostasis time was 11.0 minutes (IQR, 9.3–13.0 minutes), the median procedural time was 133.5 minutes (IQR, 102.5–151.0 minutes), and the median length of stay was 5 days (IQR, 4.0–6.8 days). The success rate was 95.8%, and a pseudoaneurysm (SIR Grade 2) developed in 1 patient, which was treated by a percutaneous injection of thrombin. No other access-related adverse events occurred, and the total adverse event rate was 4.2%. ConclusionsPlacement of sequential suture and plug VCDs using 1 Proglide and dual Exoseal is a safe and effective method and may be an option for access closure during PEVAR.

Short-term efficacy of cholecystectomy plus bile duct T-tube drainage or choledochojejunostomy in the treatment of gallbladder cancer and its effects on median survival time and postoperative complications.

To explore the short-term efficacy of cholecystectomy plus bile duct T-tube drainage or choledochojejunostomy (CJ) in the treatment of gallbladder cancer (GC) and its effects on the median survival time and postoperative complications. The clinical data of 121 patients who underwent laparoscopic cholecystectomy (LC) in department of hepatobiliary surgery of the hospital from January 2018 to December 2018 were retrospectively analyzed. According to the adjuvant treatment methods, the patients were divided into 2 groups: the control group (n = 61, LC + bile duct T-tube drainage) and experimental group (n = 60, LC + CJ). The perioperative indicators, short-term efficacy, median survival time, postoperative complications and immune stress response were compared between the 2 groups of patients before and after propensity score matching. The surgical time, postoperative anal first exhaust time, and intraoperative blood loss in the experimental group were no different from those in the control group (P > .05), but the hospital stay was shorter than that in the control group (P < .05). There was no difference in the effective rate of treatment and median survival time between the 2 groups (P > .05). The total incidence rate of complications in the experimental group at 14 days after surgery was lower than that in the control group (P < .05). Day 3 after surgery, the levels of immunoglobulin M (IgM) and immunoglobulin G (IgG) of the experimental group were higher than those of the control group (P < .05), while the level of C-reactive protein (CRP) was lower than that of the control group (P < .05). Compared with bile duct T-tube drainage, LC + CJ in the treatment of GC can better shorten the postoperative hospital stay and reduce the postoperative complications and immune stress response, but and the median survival time of the 2 is similar, which can be promoted in clinical practice.

Efficacy and safety of transarterial embolization in patients with intraabdominal hemorrhage: Experience from two centers

Objective: To evaluate the safety, efficacy, and clinical outcomes of transarterial embolization (TAE) in patients with intraabdominal hemorrhage. Materials and methods: Eighty-one patients who underwent intraabdominal TAE between January 2020 and March 2023 were evaluated retrospectively. Patients who underwent transarterial chemoembolization (n=15), mass embolization (n=12), and venous embolization (n=4) were excluded. Patient characteristics, hemorrhage etiology, embolized arteries, embolizing agents used, technical and clinical success, and rebleeding and mortality rates were recorded. Results: A total of 50 patients (37 males, 74%) were included in the study. The mean age of patients was 53.4±21.1 years. The most common pathology causing hemorrhage was upper gastrointestinal bleeding due to peptic ulcers (n=21, 42%), followed by tumors (n=8, 16%), iatrogenic causes (n=8, 16%), and trauma (n=6, 12%). The most commonly used embolizing agents were isolated coil (n=26, 52%) and a combination of coil and polyvinyl alcohol (n=12, 24%). The rate of technical success was 98% (n=49/50), and catheterization could not be performed in only one of the patients due to advanced vasospasm in the first procedure. After the first angiography, rebleeding occurred in 8% (n=4) cases, of which three were due to peptic ulcers and one was related to gastric cancer. One of these patients died in hospital, while the remaining three were discharged. The rate of in-hospital mortality was 16% (n=8) in all patients, and the clinical success rate was 84% (n=42). Conclusion: TAE provides high rates of immediate and complete hemostasis with low complication rates. It is an effective method, especially for solid organ injuries and in the management of bleeding complications after surgery or intervention.

Multifactorial Intraoperative Uterine Scar Dehiscence: A Case Report

Now-a-days, the number of Caesarean section (c-section) has increased, also the complications of c-section has increased. Obstetricians often encounter uterine scar dehiscence during delivery by c-section. However, it is rare to find a uterine scar dehiscence which is extending over one-third of the anterior uterine wall and it is yet to build the best surgical approach for repairing this rare complication of c-section or a torn anterior wall during delivery. Herein, a 23-year-old female who is Rhesus factor (Rh) negative G2P1L1 with seven months of amenorrhea came with chief complaints of pain in the abdomen since morning. On ultrasonography, severe oligohydramnios was diagnosed as Amniotic Fluid Index (AFI) was &gt;5 cm. Hence, the patient was taken for emergency Lower Segment Caesarean Section (LSCS), Lower Uterine Section (LUS) was papery thin, uterovaginal fold of peritoneum was opened and the bladder was pushed down. One-third of the anterior uterine wall was involved. LUS was sutured using vicryl No. 1 and complete haemostasis was achieved. As uterine scar dehiscence is not preventable, efforts should be made to manage it efficiently and repair the myometrium safely.

Harmonic Scalpel versus Electrocautery and its Outcome in Laparoscopic Cholecystectomy: A Prospective Interventional Study

Introduction: Laparoscopic cholecystectomy can now be performed safely and effectively due to various surgical tools that have significantly reduced intraoperative and postoperative problems. The Harmonic® Scalpel (HS) is a superior option to more conventional Electrocautery (EC) because it reduces temperatures, smoke, and lateral tissue damage. The Harmonic® Scalpel also lowers the risk of injury due to minimal heat dispersion. Due to less trauma, there is a decrease in both moderate and severe bleeding. It is hypothesised that the HS might be a more cost-effective alternative to employing a variety of disposable tools, such as scissors, a clipper, an EC hook, and a grasper. Aim: To compare the effectiveness and safety of the HS compared to traditional EC in achieving complete dissection and haemostasis during laparoscopic cholecystectomies. Materials and Methods: A prospective interventional study was conducted with 300 patients diagnosed with chronic calculous cholecystitis, admitted to a tertiary care hospital under Department of General Surgery, from November 2020 to October 2022. Patients were allocated to two groups, and the outcomes of laparoscopic cholecystectomy were compared between the usage of a HS and EC in Calot’s triangle dissection and Gallbladder (GB) dissection from the GB fossa. Descriptive data were represented through frequencies and percentages. The means of the two groups were compared using t-test, and categorical variables were compared using chi-square test. Results: The mean age was 46.53±13.740 years in the HS group, while it was 45.3±13.961 years in the EC group. The average duration of dissection with a HS was 52.84±6.167 minutes and 56.79±5.582 minutes in the EC group (p-value 0.001). A total of 67 (44.7%) patients in the HS group had minimal or no bleeding, while it was 23 (15.3%) patients in the EC group. GB perforation occurred in 13 (8.7%) patients in the HS group and in 26 (17.3%) patients in the EC group. Liver injury occurred in 2 (1.3%) patients in the HS group and in 6 (4%) patients in the EC group. Postoperative nausea and vomiting were reported in 20 (13.3%) and 72 (48%) patients in the HS and EC groups, respectively, in the first 48 hours. All these associations were found to be statistically significant (p-value 0.001). Conclusion: The present study found that the HS offers a hassle-free dissection without much incidence of intraoperative bleeding or surrounding tissue damage.

A self-gelling starch-based sponge for hemostasis.

Uncontrolled bleeding remains one of the direct causes of high mortality. There is an urgent need for developing emergency hemostats capable of coping with uncontrolled bleeding. The commercial starch-based hemostatic powder (PerClot®) requires compression during application, which limits its application in hemostasis of irregular and non-compressed wounds. Herein, a boronic acid-modified thiol starch sponge (St-SP sponge) with self-gelling properties was developed for hemorrhage control. The results show that the St-SP sponge could quickly absorb blood, self-gel and self-heal to seal the bleeding sites. In addition, the St-SP sponge can rapidly initiate the coagulation cascade and promote the adhesion and aggregation of erythrocytes and platelets. The St-SP sponge exhibited significantly improved in vitro and in vivo hemostatic abilities as compared with PerClot. Notably, the St-SP sponge attained complete hemostasis without any compression in 61.5 s and made a great difference compared to PerClot (169 s) for the irregular wound constructed on the rabbit liver. In addition, the St-SP sponge had good hemocompatibility and cytocompatibility. It turns out that the newly developed St-SP sponge is a promising material for first-aid hemostasis of irregular and non-compressed wounds.

Impact of radial compression protocols on radial artery occlusion and hemostasis time in coronary angiography

Protocols for hemostasis after trans-radial approach (TRA) vary depending on the institute as there is no established evidence-based protocol. This study aimed to investigate the clinical implications of radial compression protocols. Consecutive patients who underwent outpatient invasive catheter angiography before and after April 2018 were treated with traditional and new protocols, respectively. Using the same hemostasis band, in the conventional protocol, fixed amount of air was removed soon after the procedure, 2 h later, and 3 h later, whereas the air was removed as much as possible every 30 min in the new protocol. A total of 1842 patients (71 ± 10 years old, 77% male) were included. Compared with the traditional protocol group (n = 1001), the new protocol group (n = 841) had a significantly lower rate of dual antiplatelet therapy (35% and 24% in the traditional and new groups, respectively, p < 0.001). The time required for complete hemostasis was approximately one-third with the new protocol (190 ± 16 and 66 ± 32 min, p < 0.001) with no clinically relevant bleeding. The incidence of radial artery occlusion (RAO) was 9.8% and 0.9% in the traditional and new protocol groups, respectively (p < 0.001). After adjusting for covariates, the new protocol was associated with a reduced risk of RAO (odds ratio 0.10, p < 0.001) and a shorter hemostasis time (odds ratio 0.01, p < 0.001). The new protocol for hemostasis after TRA was strongly associated with a shorter hemostasis time and a lower rate of RAO.

Drain-Less Submandibular Gland Excision With Preserved Facial Artery.

To describe our experience in excision of the submandibular gland (SMG) without drain insertion and with preservation of the facial artery as a day case surgery as well as evaluation of the surgical outcomes of this procedure. Prospective case series study of 42 cases of chronic calcular submandibular sialadenitis that underwent SMG excision by the same surgical team during the period from 2017 to 2021. The initial surgical plan in all cases was to excise the SMG with preservation of the facial artery and without drain insertion. SMG excision without drain insertion was successfully achieved in 28 patients who were discharged on the same day. In the remaining 14 patients, the surgical dissection was difficult and a suction drain was inserted at the end of the surgery; consequently, they were discharged on the next day. In all cases, facial vessels were preserved, and complete gland excision was achieved. Among the 28 patients who had no drain insertion, 1 patient had a postoperative seroma and no patient had wound related complications. Among the 14 patients who had drain insertion, 2 patients had postoperative seroma and 3 patients had wound related complications in the form of obvious scar formation. There were no other significant complications in all patients. Submandibular gland (SMG) excision with facial artery preservation and without drain insertion as a day case surgery could be safely done in cases of chronic calcular inflammation provided that meticulous surgical dissection and complete hemostasis were achieved.

The “Pro-Seal” Large-Bore Arterial Access Closure Technique: Making the Best of What Is Available

The number of patients undergoing transcatheter aortic valve replacement (TAVR) and other percutaneous procedures for structural heart disease has risen in recent years and will likely continue to increase. Despite iterative improvements in delivery systems resulting in smaller sizes and entry profiles, large-bore vascular access will continue to be needed. Cardiovascular interventionalists are tasked with performing TAVR procedures as safely as possible while maintaining a low incidence of bleeding and ischemic access site complications—all while using commercially available vascular closure equipment.Multiple large-bore vascular closure devices are currently used in clinical practice; one of the most commonly employed is the suture-based Perclose ProGlide system (Abbott Vascular, Inc). Even though its versatility and effectiveness are acceptable, the Perclose ProGlide device does occasionally fail. How best to achieve complete hemostasis when a failure occurs remains to be determined.In this issue of the Journal, Cakal et al1 report their experience using an ANGIOSEAL device (Terumo Medical Corporation) in patients for whom Perclose ProGlide device deployment did not result in complete hemostasis. The authors performed a retrospective review of 185 patients who underwent TAVR in their center. In all individuals, vascular closure was performed using 2 Perclose ProGlide devices; in 46 of these patients, an 8F ANGIO-SEAL device was added as a “bailout” when the Per-close ProGlide device failed and persistent vascular bleeding was noted. The auxiliary ANGIO-SEAL device was deemed successful in all cases. No statistically significant differences in vascular complications were noted, although a higher incidence of hematoma formation was found in the ANGIO-SEAL bailout group.The findings from Cakal et al1 support the safety and feasibility of using an ANGIO-SEAL device as bailout when use of 2 Perclose ProGlide devices fails to achieve hemostasis in large-bore arterial closure—an approach that has come to be referred to as the “Pro-Seal” technique. These are welcome data because they inform current practice and broaden the operators' options in complex patients. Nonetheless, it is worth noting a particular limitation of this study and its proposed approach (beyond its limited number of patients and retrospective nature). Deciding when hemostasis is suboptimal remains a significantly subjective endeavor. It is unclear whether manual compression after Perclose ProGlide closure might have successfully controlled bleeding in some of these patients, thereby avoiding the use of an additional device that could cause further complications. Clarifying this point is especially important because the operators suggest a Perclose ProGlide failure rate exceeding 20%, which is significantly higher than expected. Fortunately, given the authors' experience, the downside of adding an ANGIO-SEAL device appears to be minimal.Even though a surgeon with experience in open vascular repair may be profoundly dissatisfied with the macroscopic and microscopic appearance of 2 Perclose ProGlide devices and 1 ANGIO-SEAL device in the arteriotomy site, the Pro-Seal technique appears to be an acceptable solution for completing the procedure safely and efficiently. This strategy is effective not only as bailout in case of bleeding but also as a planned strategy from the outset, as demonstrated in a large retrospective study.2 As expected, additional data confirming the utility, safety, and effectiveness of the Pro-Seal approach are needed, as is the development of newer and better closure devices designed from inception to be used specifically for large-bore access closure.

Urethral pseudoaneurysm life-threatening bleeding: a case report and literature review of etiological and treatment options

BackgroundPseudoaneurysm (PA) of pudendal artery’s distal branches is an extremely rare clinical scenario. We report a case of life-threatening urethrorrhagia due to PA of the internal pudendal artery (IPA).Case presentationA 35-year-old man presented with massive urethral bleeding after traumatic urethral catheterization. Failed attempts of conservative management necessitate an emergency intervention with angiography which shows an active extravasation from the left IPA, which was embolized with gel foam, and complete hemostasis was achieved.ConclusionPA of the pudendal artery’s distal branches is serious, and majority of cases need an emergency intervention. CT angiography is the best diagnostic imaging, and angioembolization of the bleeding site is considered the first-line treatment. Other treatment options such as US-guided compression, endoscopic coagulation, and open surgery are alternative treatments.

S2645 Remnant Stomach Bleeding in Roux-en-Y Gastric Bypass Anatomy Managed by Transgastric Endoscopic Ultrasound-Guided Stenting and Hemostasis

Introduction: Upper GI bleeding identification and treatment is challenging in patients with Roux-en-Y gastric bypass (RYGB) due to their complex anatomy. Remnant stomach and duodenal bleeding in particular can be very challenging to reach and manage endoscopically due to the long length of the Roux and biliary limb. Case Description/Methods: A 58-year-old female patient, who underwent gastric bypass in 2004, was diagnosed with fibular fracture and placed on NSAIDs 2 weeks before presenting to the hospital with melena and anemia. In addition to medical management of hypovolemic shock, the patient underwent upper endoscopy (EGD), colonoscopy, small bowel enteroscopy, and angiography followed by left gastric artery embolization all of which failed to localize or stop her bleeding. The patient’s hemoglobin dropped to a nadir of 5.7, and she was referred for upper endoscopic ultrasound which demonstrated a very large clot burden within the excluded stomach ( Figurea), and an ultrasound-guided gastrogastric lumen apposing metal stent (LAMS) was placed from the gastric pouch into the excluded stomach. The stent was successfully dilated and fixed with stay sutures (Figure1b). A large burden of clot was subsequently removed from the excluded stomach and duodenum. A deep ulcer with active bleeding was localized to the posterior wall of the duodenum. Bipolar cautery and epinephrine injection were used initially but failed to achieve hemostasis. Over-the-scope clip was considered but given the lack of having a mature gastrogastric fistula tract it was instead elected to use hemostatic powder application ( Figurec). With this, complete hemostasis was achieved, and the LAMS stent was left in place for subsequent intervention(s) as needed. The patient continued to pass melena for 3 days post procedure with stable Hb readings and follow up EGD showed no signs of active bleeding in the excluded stomach or duodenum. At 6 weeks, the LAMS was removed and the gastrogastric fistula tract was closed with argon plasma resurfacing and suture. Discussion: Identification the source of UGIB in RYGB patients can be challenging. Accessing the excluded stomach should be considered early in the evaluation if the EGD shows no obvious source of bleeding or if other evaluation (such as angiogram) suggests a remnant stomach or duodenal source.Figure 1.: (1a) Endosonographic photo showing blood in the remnant stomach, (1b) Fluoroscopy showing proper placement and dilatation of the gastrogastric LAMS , (1c) Endoscopic photo showing complete hemostasis after hemostatic powder application.

S2631 The Unusual Suspect: Gastrointestinal Bleeding From an Ampullary Dieulafoy Lesion

Introduction: Dieulafoy lesions (DLs) are an unusual but important cause of acute upper gastrointestinal bleeding (UGIBs), and can be difficult to diagnose. Three fourths are found in the stomach close to the gastroesophageal junction, but have also been reported in small bowel and colon. There are only a few reported cases of ampullary DLs. We present a rare case of a recurrent UGIB from an ampullary Dieulafoy lesion and its management. Case Description/Methods: A 65-year-old male presented for type B aortic dissection requiring endovascular repair, which was complicated by type 1 endoleak. His hospital course was complex owing to sepsis, respiratory failure, and cardiac arrest. Gastroenterology was consulted on day 16 for multiple tarry bowel movements. Esophagogastroduodenoscopy (EGD) showed healing ulcers in lower esophagus. and non-bleeding ulcers in the duodenal bulb. The culprit lesion was an oozing Dieulafoy at the major papilla. Hemostasis was achieved with epinephrine injection and thermal therapy. Rebleeding occurred 5 days after the initial EGD leading to shock and cardiac arrest. Once the patient was hemodynamically stabilized, he underwent another EGD that showed copious fresh blood in stomach body as well as the second and third portions of duodenum. Active arterial spurting was noted from the superior aspect of major papilla. Given the severe hemodynamic compromise from this bleeding, we elected to clip the lesion this time, accepting the risk of pancreatitis and/or biliary obstruction. One endoclip was placed across the dorsal aspect of major papilla and closed. Persistent oozing was noted from under the clip which was arrested by applying a hot snare to the already placed endoclip and delivering thermal energy to the area pinched by the endoclip. Complete hemostasis was then achieved [Figure 1]. Liver function tests and lipase were monitored for a week and the patient did not develop pancreatitis or biliary obstruction despite placement of endoclip across the major papilla. Discussion: Ampullary DLs are extremely rare and can present a unique diagnostic and therapeutic challenge due to their anatomical location. There is currently no consensus on how to best treat ampullary DLs. Verification of the diagnosis and definitive treatment might require repeated examinations. Early and aggressive endoscopic treatment should be adopted when an ampullary DL is suspected, and patients should be closely followed up given therapeutic interventions can potentially impair biliary drainage.Figure 1.: Endoscopic images of bleeding from ampullary Dieulafoy lesion before and after endoscopic intervention.

Розрив рудиментарного рогу матки під час вагітності: опис клінічного випадку

в статті описано клінічний випадок розриву рудиментарного рогу матки під час вагітності. Труднощі своєчасної діагностики вагітності в рудиментарному розі матки можуть обумовлювати ургентне оперативне втручання з приводу розриву рогу матки та антенатальної загибелі плода, збільшення частоти акушерських кровотеч, геморагічного шоку та збільшення частоти гемотрансфузій. Метою даного дослідження було продемонструвати варіант розвитку повторної вагітності при однорогій матці з контралатеральним рудиментарним рогом. Матеріалами дослідження слугували дані медичної карти стаціонарної хворої, що включали анамнестичні дані, результати лабораторних та інструментальних досліджень, протокол операцій та епікриз. Вагітна в терміні 16 тижні поступила до приймального відділення міського пологового будинку у 2020 році у вкрай важкому стані з ознаками гострої внутрішньочеревної кровотечі. Враховуючи тяжкий стан пацієнтки, була виконана ургентна нижньосерединна лапаротомія з ревізією черевної порожнини. Під час операції була виявлена аномалія розвитку матки - однорога матка з контралатеральним рудиментарним рогом, не з’єднаним з порожниною матки та з ознаками перерваної вагітності внаслідок розриву рогу. Тактика оперативного лікування включала відсічення рудиментарного рогу, повний гемостаз, санацією та дренування черевної порожнини. Паралельно проводилась інтенсивна терапія: трансфузія свіжозамороженої плазми та еритроцитарної маси. Аналіз літературних джерел щодо питань вроджених аномалій матки показав наявність високого ризику розвитку вагітності саме у рудиментарному розі матки та велику частоту ускладнень даної вагітності у вигляді розриву рогу переважно в ІІ триместрі. Систематизація підходів до вирішення проблеми розриву рудиментарного рогу під час вагітності свідчить про надання вищого пріоритету тактиці збереження нормально розвиненого рогу з паралельною інфузійною терапією у веденні пацієнток з розривом рудиментарного рогу матки та відносно нестабільною гемодинамікою. Разом з тим демонструється обговорення успішних випадків планового видалення рудиментарного рогу з плодом та нормальної повторної вагітності за своєчасного виявлення вродженої аномалії матки. Результати опису даного клінічного випадку можуть бути корисними для акушер-гінекологів, загальних хірургів та лікарів ультразвукової діагностики для удосконалення виявлення рідкісних аномалій розвитку жіночої репродуктивної системи в контексті диференційної діагностики причин "гострого живота" у жінок та оптимізації хірургічної тактики лікування ускладнень вагітності у рудиментарному розі матки.

Bleeding Lesion from Roux-en-Y Hepaticojejunostomy: A Successful Combined Hemostasis with Dual Emission Laser 1.9/1.5 μm.

A 28-year-old woman, with a history of liver transplantation with Roux-en-Y hepaticjejunostomy, was admitted for melena and severe anemia. Bidirectional endoscopy was normal. Capsule endoscopy demonstrated fresh blood in the efferent limb downstream of the jejuno-jejunostomy. Anterograde double-balloon enteroscopy (DBE) showed an adherent clot with a visible vessel oozing next to the hepaticojejunostomy. Bleeding was treated firstly with argon plasma coagulation and endoclips and further treated with dual emission laser, achieving complete hemostasis. At the 3 months follow-up, hemoglobin was stable without evidence of re-bleeding.

Novel Hemostatic Technique During Laparoscopic Liver Parenchymal Transection: Saline-Linked Electrocautery Combined With Wet Oxidized Cellulose (SLiC-WOC) Method.

Introduction: Although laparoscopic hepatectomy has the potential advantage of reducing intraoperative blood loss, it is more difficult to control bleeding laparoscopically compared to an open approach. We introduced a novel hemostatic technique, the saline-linked electrocautery combined with wet oxidized cellulose (SLiC-WOC) method, during laparoscopic hepatectomy where a combination of saline-linked electrocautery (SLiC) and wet oxidized cellulose (WOC) is used. This study aimed to investigate the feasibility of employing the SLiC-WOC method for laparoscopic hepatectomy.Methods: Thirteen patients who underwent laparoscopic liver resection with the SLiC-WOC method between 2019 and 2020 were included in this study. The number of bleeding episodes in which the SLiC-WOC method was applied was counted, and the time required to achieve complete hemostasis was measured.Results: Among the bleeding events that were difficult to achieve hemostasis by SLiC alone, 94% were safely and efficiently controlled. Additionally, 69% of hemostasis was achieved within 60 seconds and 91% within 120 seconds. Postoperatively, most patients experienced no complications and no operative mortality was observed.Conclusions: The SLiC-WOC method can provide safe and time-efficient hemostasis during laparoscopic hepatectomy. This is especially crucial for bleeding, which is difficult to control using electrocautery alone.

Diagnosis and Management of Traumatic Hemipelvectomy.

Traumatic hemipelvectomy (THP) is a catastrophic injury associated with high-energy trauma and high mortality. THP has been defined as a complete dislocation of the hemipelvis, often with disruption through the symphysis pubis and sacroiliac joint with concurrent traumatic rupture of the iliac vessels. Despite recent advances in prehospital resuscitative techniques, the true incidence of THP is difficult to ascertain because many patients die before hospital arrival. The leading causes of death associated with THP include blood loss, infection, and multiple system organ failure. Recognition and immediate intervention for these injuries is imperative for survival. The initial assessment includes a thorough physical examination assessing for signs of arterial damage and other associated injuries. Hemorrhage control and vigorous resuscitation should be prioritized to combat impending exsanguination. Emergent amputation has been found to be a lifesaving operation in these patients. The basis of this approach is rooted in achieving complete hemostasis while reducing complication rates. Understanding the nature of these massive pelvic injuries, the role of early amputation, and the importance of subspecialty communication can improve survivability and optimize patient outcomes.

A rare case of cervical ectopic pregnancy

Cervical ectopic pregnancy is the implantation of conceptus in the cervical glands and fibrous cervical wall below the level of internal os. It is a rare and potentially life threatening condition associated with a high rate of maternal morbidity and accounts for less than 1% of all ectopic gestation. It may turn into an obstetric emergency, if not detected and treated early due to risk of severe hemorrhage. This entity can be diagnosed at early gestational age with help of ultrasonography and conservative approach of management help to preserve fertility. A 32- year female treated for secondary infertility via in-vitro fertilization(IVF) and embryo transfer(ET) with previous three dilation and curettage following previous missed conceptions presented with vaginal bleeding and Transvaginal ultrasonography revealed a cervical ectopic pregnancy of 5 weeks and 3 days with cardiac activity present. She was managed successfully by PGF2 alpha analogue administration preceding dilation and curettage of endocervical canal and cervical packing with hemocoagulase soaked gauze. Complete hemostasis was achieved and discharged after an uneventful hospital stay. Endocervical curettage is one of the minimally invasive management strategy in cervical ectopic pregnancy with cardiac activity and sufficient for full recovery with preservation of reproductive capacity. Our case demonstrates a new strategy combining systemic intramuscular prostaglandin and curettage for treatment of cervical ectopic pregnancy which may provide an efficient and safe alternative to embryocides at early gestational age.

Iliofemoral Tortuosity Increases the Risk of Access-Site-Related Complications After Aortic Valve Implantation and Plug-Based Access-Site Closure

BackgroundAccess-site-related complications are often related to high-risk anatomy and technical pitfalls and impair the outcomes of transfemoral aortic valve implantations (TAVIs). Calcification and tortuosity are widely recognized risk factors, and their impact on procedural planning is left to the implanting experts’ discretion. To facilitate decision-making, we introduced a quantitative measure for iliofemoral tortuosity and assessed its predictive value for access-site-related vascular and bleeding complications. MethodsWe performed a single-centre prospective cohort study of consecutive, percutaneous transfemoral TAVI performed between April 2019 and March 2020. Medical history and all-cause mortality were extracted from the electronic patient files. Arterial anatomy and calcifications were evaluated using 3mensio Structural Heart software. The primary outcome was access-site-related vascular or bleeding complications. ResultsIn this elderly, intermediate-risk population, we registered the primary outcome in 43 patients (39%), and major access-site complications in 10 patients (9.2%). Complete hemostasis was achieved in 77 patients (70.6%), by the application of the MANTA plug alone. In the group with access-site-related adverse events, compared with the group without, the tortuosity index was higher median (26% interquartile range [IQR 18%-33%] vs median 19% [IQR 13%-29%], respectively; P = 0.012), as was maximal angulation median (50° [IQR 40°-59°] vs median 43° [IQR 36°-51°], respectively; P = 0.026) were higher. Both variables had a significant effect on our primary outcome, with odds ratios (OR) of 3.1 (tortuosity, P = 0.005) and 2.6 (angulation, P = 0.020). The degree of angulation was a predictor of major complications too (odds ratio 7 [1.4-34.8]; P = 0.017). ConclusionsSteeper angles and greater arterial elongation increase the risk of vascular and bleeding complications after femoral TAVI with the utilization of a plug-based closure device.