Postoperative Bleeding Episodes Research Articles

Improving the management of morbidly obese patients with postoperative bleeding undergoing Roux-en-Y gastric bypass.

Aim: To improve the management of morbidly obese patients who undergo gastric bypass surgery to reduce the number of postoperative complications, in particular, bleeding. Materials and Methods: From 2011 to 2022, a total of 348 patients with morbid obesity (MO) underwent laparoscopic gastric bypass treatment at the clinical base of the Department of General Surgery №2 of Bogomolets National Medical University. The retrospective group included 178 patients who received treatment between 2011 and 2019. 170 patients were enrolled in the prospective group for the period from 2019 to 2022. Results: Retrospective group had 8 episodes of postoperative bleeding, representing a rate of 4.49%, prospective group - 3 episodes of postoperative bleeding, representing a rate of 1.76% Four factor characteristics associated with the probability of bleeding were identified: "number of comorbid conditions", "arterial hypertension", "chronic liver diseases" and "chronic obstructive pulmonary disease". Conclusions: The factors responsible for the occurrence of postoperative bleeding in morbidly obese patients after laparoscopic gastric bypass surgery were the number of comorbid conditions, the presence of arterial hypertension, the presence of chronic liver diseases, and chronic obstructive pulmonary disease. A new strategy for the management of morbidly obese patients after laparoscopic gastric bypass was developed. This strategy involves changing cassettes to create gastroentero- and enteroenteroanastomoses, reducing the period of use of the nasogastric tube, drains, and urinary catheter from 3-4 days to 1 day, and resuming the drinking regimen 6 hours after extubation.

Risk factors of gastrointestinal bleeding after cardiopulmonary bypass in children: a retrospective study.

During cardiac surgery that involved cardiopulmonary bypass (CPB) procedure, gastrointestinal (GI) system was known to be vulnerable to complications such as GI bleeding. Our study aimed to determine the incidence and risk factors associated with GI bleeding in children who received CPB as part of cardiac surgery. This retrospective study enrolled patients aged <18 years who underwent cardiac surgery with CPB from 2013 to 2019 at Shanghai Children's Medical Center. The primary outcome was the incidence of postoperative GI bleeding in children, and the associated risk factors with postoperative GI bleeding episodes were evaluated. A total of 21,893 children who underwent cardiac surgery with CPB from 2013 to 2019 were included in this study. For age distribution, 636 (2.9%) were neonates, 10,984 (50.2%) were infants, and 10,273 (46.9%) were children. Among the 410 (1.9%) patients with GI bleeding, 345 (84.2%) survived to hospital discharge. Incidence of GI bleeding in neonates, infants and children were 22.6% (144/636), 2.0% (217/10,984) and 0.5% (49/10,273), respectively. The neonates (22.6%) group was associated with highest risk of GI bleeding. Patients with GI bleeding showed longer length of hospital stays (25.8 ± 15.9 vs. 12.5 ± 8.9, P < 0.001) and higher mortality (15.9% vs. 1.8%, P < 0.001). Multivariate logistic regression analysis showed that age, weight, complicated surgery, operation time, use of extracorporeal membrane oxygenation (ECMO), low cardiac output syndrome (LCOS), hepatic injury, artery lactate level, and postoperative platelet counts were significantly associated with increased risk of GI bleeding in children with congenital heart disease (CHD) pediatric patients that underwent CPB procedure during cardiac surgery. The study results suggest that young age, low weight, long operation time, complicated surgery, use of ECMO, LCOS, hepatic injury, high arterial lactate level, and low postoperative platelet counts are independently associated with GI bleeding after CPB in children.

Risk of bleeding in anticoagulated patients undergoing dental extraction treated with topical tranexamic acid compared to collagen-gelatin sponge: Randomized clinical trial

This two-arm, parallel-group, double-blind, randomized clinical trial design evaluated the risk of postoperative bleeding in anticoagulated patients undergoing dental extraction treated with topical TXA in comparison to collagen-gelatin sponge. Forty patients were randomly included in one of the study groups: (1) topical use of 4.8% TXA solution; and (2) resorbable hydrolyzed collagen-gelatin sponge applied to the surgical alveolus. Primary outcomes were postoperative bleeding episodes and secondary outcomes were thromboembolic events and postoperative INR values. The relative risk (RR), the absolute risk reduction (RAR) and the number needed to treat (NNT) were used as effect estimates and calculated from the counting of bleeding episodes observed during the first postoperative week. The bleeding rate under the TXA treatment was 22.2%, while in the collagen-gelatin sponge group it was 45.7%, resulting in a RR of 0.49 (95% CI 0.24–099; p = 0.046), RAR 23.5% and NNT 4.3. TXA was more effective in reducing bleeding in surgical sites located in the mandible (RR = 0.10; 95% CI 0.01–0.71; p = 0.021) and the posterior region (RR = 0.39; 95% CI 0.18–0.84; p = 0.016). Within the limitations of the study it seems that topical TXA is more effective in controlling bleeding after tooth extractions in anticoagulated patients than collagen-gelatin sponge. Clinical trial registrationRBR-83qw93.

Ultrasonic scissors decrease postoperative bleeding complications in mastectomy: A retrospective multicenter cohort study on 728 patients.

The aim of this study was to evaluate the rate of postoperative bleeding complications (primary outcome) and any other surgical complications (secondary outcome) in mastectomy between two surgical instruments, ultrasonic SonoSurg® scissors (US) and traditional electrocautery (EC). In total 728 patients undergoing mastectomy in two adjacent university hospitals were retrospectively evaluated in terms of postoperative bleeding episodes, surgical site infections, skin flap necrosis, and any reoperations for 30 postoperative days. A propensity score matching was performed to acquire balanced groups. Patients consuming medications affecting hemostasis were excluded from the study. A multivariable logistic regression analysis was conducted to define the odds ratio (OR) for each complication separately. A cost analysis was performed. The rate of postoperative bleeding complications was significantly lower in patients operated with US (0.3% vs 11.5%, OR 0.020, 95% CI 0.034-0.14) when compared to EC. The rate of surgical site infections (OR 0.65, 95% CI 0.35-1.23) was similar with both instruments, but there were less skin flap necroses (OR 0.35, 95% CI 0.13-0.98) in US group. For any reoperation, the OR for US was 0.13 (95% CI 0.046-0.39), mainly due to the lower number of acute bleeding complications. Even though the US instrument is more expensive than EC, the total cost of the treatment is lower in patients operated with US (3419 vs. 3475 euro). US seems to be associated with a lower risk of bleeding complications in mastectomy.

Hemorrhagic complications in individuals with liver disease submitted to minor oral surgery.

Individuals with chronic liver disease (CLD) have an increased risk of bleeding from thrombocytopenia and changes in hemostasis. The aim of this study was to evaluate the frequency of and the factors associated with the occurrence of bleeding in CLD patients who underwent dental surgical procedures. This was a retrospective study whose data were collected in a hospital dentistry service between 2010 and 2016. The patients were referred from the gastroenterology and liver transplantation services of a university hospital for dental treatment. The study followed the STROBE guidelines. Among the 71 surgical procedures performed, there were 17 (24%) perioperative and postoperative bleeding episodes, 14 of which were in pretransplant patients and 11 received blood transfusion before dental surgery. Individuals with a previous history of bleeding (PR = 2.67, CI = 1.07-6.67, P = 0.035) and those with a platelet count before surgery 50 × 10 9 /l or less (PR = 7.48, CI = 1.70-32.86, P = 0.008) had a higher prevalence of perioperative and postoperative bleeding episodes than their peers without a previous history of bleeding, and those with platelet count greater than 50 × 10 9 /l. The approach to individuals with CLD is complex and represents a challenge to the clinician. A careful anamnesis combined with laboratory screening of coagulation disorders appears to be useful to identify individuals at a major risk of bleeding. Studies identifying the predisposing factors of bleeding in CLD patients support well tolerated protocols for oral surgery in this group.

76. Robot-assisted Vaginoplasty: A Multidisciplinary Technique for Gender Affirmation

Background: Gender affirming trans female bottom surgery is critical in treating gender dysphoria but can result in complications such as stricture/stenosis development, neovaginal prolapse, and rectal injury. The authors describe a multidisciplinary robot-assisted technique incorporating a free peritoneal graft to alleviate these complications. Methods: Patients who met the World Professional Association for Transgender Health (WPATH) criteria for bottom surgery, underwent robotic-assisted penile inversion vaginoplasty with senior author (J.D.K), and had at least three months of follow-up were included in the study. Patients undergoing zero-depth vaginoplasty or revision vaginoplasty were excluded. The free peritoneal graft is harvested robotically and used as a strip of mucosal-like tissue for a more anatomic neovagina and sutured to scrotal skin grafts over a vaginal conformer. The construct is sutured to the remaining penile shaft skin and then then inverted and passed through the perineal body into the robotically-created space. The apex of the neovaginal lining created by the skin graft-peritoneal graft construct is then sutured to the peritoneal reflection with barbed suture in two layers intra-corporally via the robot. Results: Thirty-eight patients were included in our study. Average age at the time of initial consult was 31 years. All patients were on hormone therapy and 42% of patients had previously undergone top surgery. The average length of follow-up was 230 days. The most common complication was stricture/stenosis secondary to non-compliance with post-operative dilation protocol. Eight patients (21%) experienced stricture, four of which were managed with aggressive dilation. Three patients required surgical revision and one patient did not require any intervention. Seven patients (18%) experienced wound dehiscence with four patients requiring operative repair. Four patients (11%) developed labial banding/webbing that required revision. Other complications included one hematoma, one infection, and two episodes of post-operative bleeding. Eleven patients (29%) developed symptomatic granulation tissue during the healing process that was treated with silver nitrate application and resolved with time. Lastly, two patients (5%) had labial asymmetry that did not interfere with function, but who desired revision for cosmesis. Eighty-four percent of patients used Soul Source vaginal dilators (Sour Source Therapeutic, North Hollywood, CA) post-operatively and of those patients 53% could dilate with the orange dilator (the largest, 1 1/2 inch diameter), 13% with teal (1 3/8 inch diameter), 16% with blue (1 ¼ inch diameter) and 19% with purple (1 1/8 inch diameter). All dilators are 9 inches in length. Patients are cleared for sexual intercourse three months after surgery. Many patients had return of sensation to light touch of the neo-clitoris and were able to achieve organism through direct neo-clitoral stimulation. Conclusion: With experience and an interdisciplinary team, robotic-assisted vaginoplasty with free peritoneal grafting is safe and effective with a low complication rate and high neo-vaginal patency rate. Many patients report successful penetrative intercourse and the ability to achieve orgasm post-operatively.

Intraoperative use of tranexamic acid eliminates bleeding complications in thyroid and parathyroid surgery

Abstract Introduction Postoperative neck bleeding is a rare but life-threatening complication in thyroid and parathyroid surgery. It requires an emergency treatment algorithm to prevent asphyxia and severe brain injury. Tranexamic acid is an antifibrinolytic medication which treats or prevents excessive blood loss in a variety of clinical situations such as, major trauma, postpartum bleeding, and heavy menstruation. We studied the use of tranexamic acid to eliminate the incidence of postoperative neck hematoma. Methods All thyroid and parathyroid patients operated from the same surgical team were evaluated. The patients were divided in two groups: Group A before and Group B after the use of tranexamic acid. The medication was used intravenously to all Group B patients during the hemostasis control and prior the neck wound closure. Results A total of 1457 consecutive patients were studied from 01-01-2001 to 06-06-2021. Group A included 669 patients (620 thyroid and 49 parathyroid patients) from 01-01-2001 until 27-06-2018. Group B included 788 patients (705 thyroid and 83 parathyroid patients) from 27-06-2018 until 06-06-2021. Group A had 15 (2,24% incidence) postoperative neck hematomas and 6 of them (0,89%) required emergency surgical drainage. Group B had no postoperative bleeding episodes with the intraoperative use of tranexamic acid. Conclusion The use of tranexamic acid eliminates postoperative bleeding episodes in thyroid and parathyroid surgery.

Is Antifibrinolytic Therapy Effective for Preventing Hemorrhage in Patients with Hemophilia Undergoing Dental Extractions? A Systematic Review and Meta-Analysis

ObjectivesThis systematic review aims to analyze the systemic administration of antifibrinolytics (tranexamic acid and aminocaproic acid) to prevent postoperative bleeding in patients with hemophilia.MethodsThis systematic review was conducted adhering to PRISMA guidelines. Only randomized controlled trials that assessed human subjects of any age or gender with any severity of hemophilia undergoing dental extractions, and systemically administered antifibrinolytic therapy compared to placebo were included. Post-operative bleeding episodes and adverse events were presented. PubMed, Cochrane, Embase, CINAHL, Web of Science, and Scopus were searched through April 15, 2022. The risk ratio (RR) and odds ratio (OR) applying 95% confidence intervals (CI) were computed using RevMan 5.4.1 (Cochrane).ResultsTwo randomized, placebo-controlled trials pooling in a total of 59 patients were pooled in this analysis. Among patients administered antifibrinolytic therapy, 84% reduced risk of post-operative bleeding was reported (RR = 0.16, 95% CI = 0.05–0.47, P = 0.0009). The chances of post-operative bleeding were reduced by 95% among the antifibrotics group (OR = 0.05, 95% CI = 0.01–0.22, P < 0.0001).ConclusionThis review finds favorable outcomes for the routine use of antifibrinolytic therapy for dental extractions in hemophiliacs. Further trials are required to rationalize existing evidence.

Surgery-Associated Bleeding Risk in Patients with Platelet Function Disorders - a Cross Sectional Study with the American Thrombosis and Hemostasis Network Dataset (ATHNdataset)

▪Introduction: Platelet function disorders (PFDs) are a group of heterogenous bleeding disorders with varying bleeding phenotype. Intraoperative and post-operative bleeding are serious complications among patients with PFDs undergoing surgery. There are very few studies in literature that have specifically investigated surgery associated bleeding complications in PFDs. The aim of this study was to utilize a large national dataset to describe surgeries performed in patients with PFD, characterize the bleeding associated with these surgical procedures and outline the therapeutic approaches adopted.Methods: In this retrospective study, the ATHNdataset was queried for demographic data, PFD diagnosis, surgeries among patients with PFD, intraoperative and post-operative bleeding episodes and treatment. Descriptive statistics were used. The ATHNdataset captures information from patients with bleeding and clotting disorders from over 140 federally funded hemophilia and thrombosis treatment centers (HTCs) in the US. Patients authorize inclusion of their demographic and clinical information in this de-identified Health Insurance Portability and Accountability Act (HIPAA)-compliant data set.Results: From January 2010 to March 2020, the ATHNdataset captured 2767 patients with PFDs, of which 1769 (63.93%) were female and 998 (36.1%) were male, with 1393 patients between 0-18 years (50%) and 1374 (50%) adults >18 years. PFDs identified include 32 patients with Bernard Soulier syndrome (1.16%), 131 patients with Glanzmann thrombasthenia (4.7%), 4 patients with Gray platelet syndrome (0.14%), 29 patients with Hermansky Pudlak syndrome (1%), 1548 patients with storage pool deficiency (55.9%), and 1023 patients diagnosed as PFD (36.9%). A total of 3252 procedures were reported between 2010 and 2020; 1271 patients (46%) patients with at least one documented procedure. Figure 1 shows common procedures among patients with PFDs.Surgery-associated bleeding episodes (includes intraoperative and post-operative bleeds) were reported with 69 procedures (2.1%), which included intraoperative bleeds reported for 18 procedures (0.5%) and post-operative bleeds reported for 51 procedures (1.6%). Of the 60 procedures in patients with Glanzmann thrombasthenia, surgery-associated bleeding episodes were reported after 9 dental procedures (41%), 1 circumcision (25%) and 11 other surgeries/procedures (18.3%). Of the 6 procedures in patients with Bernard Soulier syndrome, no intraoperative or post-operative bleeding episodes were reported. Of 1688 procedures in patients with storage pool deficiency, surgery-associated bleeding episodes were reported after 26 dental procedures (1.5%) and 62 other surgeries/procedures (3.67%). No intraoperative or post-operative mortality was reported among these patients.Of 1272 patients who underwent at least 1 procedure, 646 patients (50.7%) received some form of treatment before/during/after a procedure. Among these 646 patients, 2794 exposure days of hemostasis medications were used before/during/after procedures. Among these, 49% were prior to the procedure, 0.7 % during the procedure and 49.5% after the procedure. Treatments used are shown in figure 2.Conclusion: Our study shows that patients with PFDs have a substantial risk of bleeding associated with surgery. Identifying the risk of bleeding by type and providing appropriate pre-surgical prophylaxis can decrease rates of surgery-associated bleeding in PFDs. [Display omitted] DisclosuresSidonio: Sanofi, Takeda, Octapharma, Bayer, Biomain, Grifols, Kedrion, Genentech. Catalyst, Guardian Therapeutics, Novo Nordisk, Hema Biologics, Uniqure.: Consultancy, Honoraria. Ahuja: Genentech: Membership on an entity's Board of Directors or advisory committees; Takeda: Other: DSMB member ; XaTek, Inc: Patents & Royalties; Sanofi: Membership on an entity's Board of Directors or advisory committees.

Congenital hemophilia A diagnosed with postoperative hemorrhage after thyroidectomy for papillary thyroid carcinoma: a case report

BackgroundPostoperative bleeding in thyroid surgery is a serious complication with fatal outcomes. Risk factors for postoperative hemorrhage have been reported as old age, male sex, Graves' disease, use of anticoagulants, and hematological disorders. Among the hematological diseases, congenital hemophilia is an inherited bleeding disorder characterized by absence or reduced levels of clotting factors VIII or IX. Most patients with hemophilia display bleeding symptoms during infancy or childhood, but diagnosis could be delayed in mild cases. We report a case of congenital hemophilia A that was diagnosed after three episodes of postoperative bleeding after thyroid surgery.Case presentationA 46-year-old man developed repeated postoperative hemorrhage after thyroid surgery for thyroid cancer. In this case, several irregularities were seen in the postoperative course, such as a relatively long interval between surgery and bleeding, the lack of an obvious bleeding point, fresh red blood dripping from the drain insertion site on the second postoperative day, and repeated bleeding three times. We therefore considered that the cause of postoperative hemorrhage might be other than the surgical operations. After a thorough examination, hemophilia A was diagnosed.ConclusionsHemophilia is a risk factor for postoperative bleeding in thyroid surgery. However, mild hemophilia shows normal prothrombin time and activated partial thromboplastin time. We encountered a case of papillary thyroid carcinoma associated with congenital hemophilia A, which was diagnosed after repeated bleeding.

A novel electrosurgical divider: performance in a self-controlled tonsillectomy study

PurposeTonsillectomies are among the most common surgeries in otorhinolaryngology. A novel electrosurgical temperature-controlled instrument (device) promises rapid tonsillectomies and might reduce postoperative pain, but comparative studies to assess performance are warranted.MethodsThis randomized self-controlled clinical trial was conducted from October 2019 to October 2020 at the Department of Otorhinolaryngology, Head and Neck Surgery of the Medical University of Vienna. Forty-eight patients underwent a tonsillectomy with the device on one side and using cold-steel with localized bipolar cauterization on the other side (control). Main outcomes were the time for tonsil removal (per side) and the time to stop bleeding (per side). Secondary measurements were postoperative pain, assessed once on day 0 and five times on days 1, 3, 5, 7, and 10. Postoperative bleeding episodes and consequences were recorded.ResultsDevice tonsillectomies were performed significantly faster than controls; the mean surgical time difference was 209 s (p < 0.001, 95% CI 129; 288). Intraoperative blood loss was significantly lower on the device side (all p < 0.05). Postoperative measurements of pain and bleeding were similar for both sides. Two return-to-theatre secondary bleeding events were recorded for the control side.ConclusionThe novel electrosurgical temperature-controlled divider reduced the tonsillectomy surgical time and intraoperative blood loss, with no apparent negative effects on postoperative pain or bleeding, compared to a cold-steel tonsillectomy with localized bipolar cauterization. In time-restricted settings, the device could be beneficial, particularly after familiarization with device handling.Trial registrationClinicalTrials.gov Identifier: NCT03793816.

RISK FACTORS FOR BLEEDING IN LIVER DISEASE INDIVIDUALS UNDERGOING DENTAL SURGERY

Objective The aim of the study was to investigate factors associated with bleeding outcomes in liver disease individuals. Study Design A retrospective study of the information of liver disease individuals who had undergone dental surgery at a hospital-based dental service between 2010 and 2016 was conducted. Sociodemographic and clinical data, including perioperative and postoperative bleeding episodes were surveyed. The association between the outcome variable (bleeding) and the independent variables was evaluated by means of bivariate analyses and Poisson regression analysis. Level of significance was set at .05. Results A total of 71 procedures were carried out in 47 individuals. Seventeen cases (24%) of bleeding complications were recorded. Individuals who had already been submitted to blood transfusion (P = .014) and those who had reported previous hemorrhage (P = .006) presented higher occurrence of bleeding complications. Poisson regression revealed that previous blood transfusion (P = .044) and the indication of liver transplantation (P = .025) significantly increased the occurrence of perioperative and postoperative bleeding. Conclusions Bleeding outcomes in liver disease patients were associated with those procedures that required previous blood transfusion usually with basal platelet count

Coblation vs. dissection tonsillectomy: a prospective randomized study comparing surgical and clinical outcomes

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of this study is to compare operative time, intraoperative bleeding, postoperative pain between coblation and dissection tonsillectomy.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 62 patients who met the inclusion criteria were divided into two groups according to the surgical procedure they went through. Surgical time intraoperative blood loss, postoperative pain, postoperative regaining of activity and any episode of postoperative bleeding were noted in both the groups and compared. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Coblation tonsillectomy fared better than dissection tonsillectomy in terms of having less intraoperative blood loss, less postoperative pain. Patients who underwent coblation assisted tonsillectomy also had earlier return to normal activities. Though the time required for coblation tonsillectomy was more than dissection tonsillectomy there were no episodes of postoperative bleeding in subjects who underwent coblation tonsillectomy.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Coblation assisted tonsillectomy is a promising new technique for tonsillectomy as patients had less postoperative morbidity mainly pain. The surgical time required could be reduced further with experience.&lt;/p&gt;

Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions.

Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences.Date of last search: 04 January 2018. Randomised and quasi-randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified.Three randomised trials and one quasi-randomised trial (follow-up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically.The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of -0.25 (95% confidence interval (CI) -0.36 to -0.14) (128 participants) (moderate-quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI -0.07 to 0.11) (125 participants) (moderate-quality evidence). The combined RD of all included trials was -0.13 (95% CI -0.30 to 0.05) (moderate-quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate-quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics.Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population.We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs.

Laparoscopic Versus Finger-Assisted Open Donor Nephrectomy Techniques

Background Advances in minimally invasive surgery for live kidney donor nephrectomy have led to the use of the laparoscopic and robotic technique as the standard of care. The aim of the study was to compare an open finger-assisted open donor nephrectomy (FAODN) versus standard laparoscopic donor nephrectomy (LDN). Methods Retrospective demographic and surgical data were analyzed using the electronic medical records at the University of Virginia and Imperial College Hospital. The analysis included 95 consecutive donors in each center undergoing donor nephrectomy. LDN and FAODN were compared using Fishers Exact Test and Likelihood Ratio Chi-Square. Results Overall, donor demographics and clinical characteristics were similar between groups. The FAODN group had less females donors (70.5% vs. 29.5%, p=0.003) with similar median body mass index (BMI) (28 vs. 26, p=0.032). The LDN group had longer operative duration (3.5 vs. 1.2 hours, p<0.001), longer combined length of incision (6 vs. 5 cm. p=0.001), with shorter median hospital length of stay (LOS) (3 vs. 4 days, p<0.001). Left nephrectomy was preferred in both groups. Minor postoperative complications occurred less often in the FAODN group (14.7% vs. 31.6%, p=0.0094) while rates of hernia, operative blood transfusions and postoperative bleeding episodes were similar between groups. Recipients of LDN donors demonstrated a higher creatinine (1.1 vs. 0.9 mg/dl, p<0.001), and lower recipient GFR at 1 year (60 vs. 89 ml/min/1.73m2, p<0.001) post-donation. Conclusions Our study demonstrates that FAODN is a successful alternative to LDN. It appears to provide kidney donors with favorable outcomes in terms of complications and outcomes, and recipients with excellent renal function at 1 year post-donation.

Oral surgery in patients under antithrombotic therapy: perioperative bleeding as a significant risk factor for postoperative hemorrhage.

: To investigate perioperative and postoperative bleeding, complications in patients under therapy with anticoagulant or antiplatelet drugs submitted to oral surgery. To evaluate the risk of bleeding and safety for dental surgery, a retrospective chart review was performed. Medical and dental records of patients taking oral antithrombotic drugs undergoing dental surgery between 2010 and 2015 were reviewed. Results were statistically analyzed using Fisher's exact test, t test or the χ test. One hundred and seventy-nine patients underwent 293 surgical procedures. A total of eight cases of perioperative and 12 episodes of postoperative bleeding were documented. The complications were generally managed with local measures and did not require hospitalization. We found significant association of postoperative hemorrhage with increased perioperative bleeding (P = 0.043) and combination of anticoagulant and antiplatelet therapy (P < 0.001). The chance of postoperative hemorrhage for procedures with increased perioperative bleeding is 8.8 times bigger than procedures without perioperative bleeding. Dental surgery in patients under antithrombotic therapy might be carried out without altering the regimen because of low risk of perioperative and postoperative bleeding. However, patients with increased perioperative bleeding should be closely followed up because of postoperative complications risk.

Perception of Chemical Venous Thromboprophylaxis for Oncologic Lung Resections among Thoracic Surgeons

Controversies on chemical venous thromboembolic (VTE) prophylaxis in patients undergoing lung resection for malignancy exist. The available guidelines on VTE do not specifically address its prophylaxis in patients undergoing oncologic lung resections. The goal of this survey was to evaluate the perception of VTE prophylaxis among thoracic surgeons performing these operations. A self-reported online survey was distributed to 267 active members of the General Thoracic Surgical Club between July and September 2015. The survey consisted of 22 questions related to the use of chemical venous thromboprophylaxis in patients undergoing oncologic lung resection and their impact on outcomes. Fifty-six thoracic surgeons replied to the survey. The majority of these surgeons (57%) perform both open and thoracoscopic surgery for lung cancer. All respondents stated that treatment modality and extent of surgical resection have no influence on their decision to use chemical VTE prophylaxis. Twenty-two (39%) respondents do not use chemical VTE prophylaxis prior to their oncologic lung resections, while the remaining 34 (61%) reported use of anticoagulants prior to them. None of the respondents prescribe extended 30-day VTE prophylaxis to these patients. Forty-nine (87%) respondents believe that chemical VTE prophylaxis is not related to major postoperative bleeding episodes. Forty-five (81%) respondents reported that none of their reoperations for bleeding were secondary to VTE prophylaxis or if it was, that isolated event could be successfully managed nonoperatively. The majority of thoracic surgeons surveyed believe that chemical VTE prophylaxis is safe and should be used regardless of the magnitude of oncologic lung resections whenever possible. Extended 30-day VTE prophylaxis is not yet used by the survey respondents.

Surgical management of driveline infections in patients with left ventricular assist devices.

Driveline infections in patients with implantable left ventricular assist devices (VAD) carry increasing risk for pump infection, thromboembolic events, decreased quality of life, and increased hospitalization. We report our experience with a surgical technique for refractory driveline infections without mediastinitis consisting of translocation and wrapping of the driveline with greater omentum tissue. We retrospectively reviewed data of VAD patients who underwent surgical treatment by translocation and wrapping with omentum for severe chronic driveline infection. Thirteen patients were treated between January 2010 and October 2015; 12 (92%) were male, and the mean age was 56 ± 14 years. Ten patients (77%) were managed with driveline sheathing with omentum and repositioning with a new exit site, and three (23%), suffering from driveline fistula, with driveline covering with omentum maintaining the previous exit site. Three episodes of postoperative bleeding (23%) required surgical revision. Twelve patients (92%) were discharged from the hospital and one (8%) died. Nine patients (69%) were free from infection at the time of discharge, and three (23%) had recurrence of infection within the first postoperative year. Only four patients (31%) required admission to the intensive care unit; overall median hospital stay was 23 days (range 7-205 days). Driveline relocation with use of omentum is a feasible and effective procedure in selected cases of chronic severe driveline infection. The risk for perioperative bleeding should be taken into consideration and carefully monitored.

Dental and oral surgical treatment of medication-induced bleeding patients: Audit of the national guideline in Hungary

In 2015 a new Hungarian guideline was published regarding dental treatment and management of anticoagulated patients in agreement of the Hungarian Association of Oral and Maxillofacial Surgeons and the Dental Implantology Association of Hungarian Dentists. The aim of the authors was to evaluate the efficiency and safety of local hemostatic measures recommended by the guideline in anticoagulated patients. In these patients, postoperative bleeding episodes were examined after dental and oral surgical treatments, retrospectively. Overall 263 bleeding risk cases were treated; 138 patients with vitamin K antagonists, 97 patients with antiplatelet therapy and 6 patients with novel oral anticoagulants. Six patients (2.3%) had minor postoperative bleeding after the "one hour control", while one patient needed a night duty support (0.5%). In contrast, 86 patients who were treated in rural practices neglecting the guideline attended the night duty with postoperative bleeding (3 patients treated with vitamin K antagonists, 24 patients taking low molecular weight heparin, 30 patients receiving antiplatelet therapy and one patient on novel oral anticoagulant therapy. The Hungarian guideline can be applied safely, without increasing the risk of postoperative bleeding, however, rural dental practices are frequently unprepared for these treatments. Orv. hetil., 2016, 157(43), 1722-1728.

Bleeding risk of endoscopic ultrasound-guided fine-needle aspiration in patients undergoing antithrombotic therapy.

Bleeding events related to endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are rare. However, for patients treated with antithrombotic agents, the bleeding risk of EUS-FNA is uncertain. Hence, the aim of this study was to assess the bleeding event rate associated with EUS-FNA in patients receiving antithrombotic treatment. A retrospective study was conducted in 742 consecutive patients who underwent EUS-FNA for solid lesions between 2008 and 2015. We compared the bleeding event rates among patients who were not administered antithrombotic agents, those whose agent use was discontinued, those who continued treatment with aspirin or cilostazol, and those who were administered heparin as a replacement. There were 131 patients (17.7%) treated with antithrombotic agents. Seven experienced bleeding events, and the overall bleeding event rate was 0.9% (7/742). All bleeding events were intraoperative; there were no postoperative bleeding episodes. Subgroup analysis by antithrombotic agent revealed bleeding event rates of 1.0% (6/611), 0% (0/62), 1.6% (1/61), and 0% (0/8) for the non-administration, discontinuation of agents, continuation of aspirin or cilostazol, and heparin replacement groups, respectively. Only one severe bleeding event necessitated hemostatic treatment (1/742; 0.1%); this occurred in a patient in the non-administration group, and there were no severe bleeding events in patients receiving antithrombotic treatment. The present study found a low incidence of EUS-FNA-related bleeding in patients receiving antithrombotic treatment. The bleeding event rate was low even in patients who underwent EUS-FNA while continuing aspirin or cilostazol.