Incidence Of Postoperative Bleeding Research Articles

Safety of Concomitant Laparoscopic Cholecystectomy and Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients: A Meta-Analysis

Abstract Background Laparoscopic sleeve gastrectomy is one of the most common bariatric procedure performed. The prevalence of cholelithiasis in morbidly obese individuals is 19–30 % and Gall stones are more symptomatic in obese patients than in non-obese patients. This study evaluates the safety of performing laparoscopic sleeve gastrectomy and laparoscopic cholecystectomy in the same session. Objective To evaluate the safety profile of performing laparoscopic cholecystectomy and sleeve gastrectomyin the same session in terms of : The incidence of biliary leakage. The incidence of gastric leakage. The incidence of intra operative bleeding from the sleeve gastrectomy and the cholecystectomy. The incidence of post-operative bleeding. The incidence of post-operative surgical site infection. Operation time. Length of hospital stay. Method Selected papers for the present meta-analysis included those that provided data from January 2010 to December 2020 on factors related to the patients who undergone laparoscopic sleeve gastrectomy with and without laparoscopic cholecystectomy. When institutions have published duplicate trials, only the most updated reports were included for qualitative appraisal. All publications were limited to human subjects and English language. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion Overall concomitant laparoscopic sleeve gastrectomy and laparoscopic cholecystectomy appears to be a safe procedure. The increase in surgical site infection and pneumonia may warrant prophylaxis against such infections with antibiotics. Another study is needed to determine the need and efficacy of such prophylaxis

Outcomes of Staple Line Reinforcement Following Robotic Assisted Sleeve Gastrectomy Based on MBSAQIP Database.

The objective of this study is to evaluate the outcomes for Staple Line Reinforcement (SLR) in RA-SG based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for 2019. We selected patients who underwent RA-SG in the MBSAQIP PUF (Public Utility File) for the year 2019 and grouped them based on their SLR status: Oversewing (OS), Buttressing (BR), both OS and BR and neither. Our primary outcomes were bleeding, organ space infection (OSI), and adverse events (AEs), and our secondary outcomes were operation length, hospital length of stay, readmissions, and conversion to open rates. We conducted separate chi square or one-way analysis of variance (ANOVA) as appropriate and multivariable direct logistic regression models for the categorical outcomes. We found 115,621 patients with complete data of which there were 16,494 who underwent RA-SG. Our results did not show a statistically significant decrease in incidence of postoperative bleeding for BR and OS (Adjusted OR = 0.782, p = 0.2291 and Adjusted OR of 0.482, p = 0.054 for BR and OS respectively). There was a statistically significant effect for SLR status on operation length, with OS patients having the highest operative times (log-transformed mean = 2.03), followed by both BR + OS patients (log-transformed mean = 1.99). BR patients had the shortest operation length. SLR did not result in any significant differences related to bleeding, OSI or AEs following RA-SG according to MBSAQIP for the year 2019. However, OS resulted in significantly longer operative time compared to BR alone.

Comparison of Various Regimens of Antithrombotic Therapy in Patients With Valvular Heart Disease and Coronary Artery Disease After Surgical and Interventional Interventions

To evaluate the postoperative incidence of bleeding, incidence of thromboembolic complications, and all-cause mortality in patients with valvular heart disease and ischemic heart disease (IHD) associated with various regimens of the antithrombotic treatment during one year after surgery. This study included 271 patients with valvular heart disease and IHD after heart valve replacement and myocardial revascularization from 2009 through 2018. However, during the follow-up period (12 months), contact with 12 patients was lost, and therefore these patients were excluded from the study. Further analysis included 259 patients. Coronary artery bypass grafting (CABG) in combination with heart valve intervention was performed in 217 (83.8 %) patients, and percutaneous coronary interventions (PCIs) were performed in 42 (16.2 %) patients. There were 197 (72.7 %) male participants; median age was 64.0 [58.0; 67.5] years. The patients were divided into two groups. Group 1 consisted of 113 patients who received postoperative dual antithrombotic therapy (DAT) with acetylsalicylic acid (ASA)/clopidogrel+vitamin K antagonist (VKA). Group 2 included 146 patients receiving postoperative triple antithrombotic therapy (TAT) with ASA+clopidogrel+VKA. Follow-up duration was 12 months after surgery. Due to significant intergroup differences in major clinical anamnestic data, the data were adjusted using pseudo-randomization (Propensity Score Matching, PSM). In result, 109 patients were selected for each group. The incidence of adverse hemorrhagic outcomes was significantly higher in the group treated with TAT than with DAT. Minor bleedings were observed in 19 (17.4 %) vs. 8 (7.3 %) cases; moderate, clinically significant bleedings in 16 (14.7 %) vs. 6 (5.5 %) cases; and the total number of bleedings was 35 (32.1 %) vs. 14 (12.8 %; p=0.02, p=0.02, and р=0.001, respectively). Comparing the incidence of major bleedings did not show and significant intergroup differences (p=1.000). The incidence rate of any bleeding during the follow-up period was 32.1 % in patients treated with TAT (n=109) and 12.8 % in patients treated with DAT (n=109; p=0.005). The incidence of no bleeding during one year after surgery was 87 % in the DAT treatment group and 67 % in the TAT treatment group (p=0.005). The incidence of secondary endpoints, including ischemic stroke, myocardial infarction, prosthetic valve thrombosis, and death, was statistically non-significant. Administration of DAT vs. TAT after heart valve replacement and myocardial revascularization significantly decreases the incidence of any bleedings in the absence of significant differences in the incidence of thromboembolic events and mortality.

Cardiopulmonary bypass in neonates and infants: advantages of high flow high hematocrit bypass strategy-clinical practice review.

Cardiopulmonary bypass is an integral and indispensable part of surgical repair of congenital heart defects. While the complications and morbidity secondary to the use of cardiopulmonary bypass has decreased considerably, there remains a significant incidence of clinically relevant renal and neurological injury. To provide more physiological delivery of oxygenated blood to the end-organs, our center has been successfully using a high-flow, high hematocrit cardiopulmonary bypass strategy since 2006. The essential components of this strategy include maintaining high flows (typically 200 mL/kg/min in neonates, 150-175 mL/kg/min in older infants weighing <10 kg, and 2.6 L/min/m2 in older children) throughout the duration of cardiopulmonary bypass irrespective of patient temperature, as well as maintaining a hematocrit of at least 32% on cardiopulmonary bypass. The incidence of post-operative acute kidney injury (around 3%) and clinical acute neurological events (<1%) with this strategy is considerably less when compared to other contemporary publications using the conventional cardiopulmonary bypass strategy. In this review, we discuss the rationale behind our approach and present evidence to support the high-flow, high-hematocrit strategy. We also discuss the practical aspects of our strategy and describe the adjuncts we use to derive additional benefits. These adjuncts include the use of a hybrid pH/alpha stat strategy during cooling/rewarming, aggressive use of conventional ultrafiltration during cardiopulmonary bypass, a terminal hematocrit of 40-45%, and avoidance of milrinone and albumin in the early peri-operative period. This results in a very low incidence of post-operative bleeding, facilitates chest closure in the operating room even in most neonates, helps in reducing the need for post-operative blood product transfusion and helps in achieving a favorable post-operative fluid balance early after surgery.

Omentopexy versus non-omentopexy in laparoscopic sleeve gastrectomy

Background Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric operation nowadays all over the world. The most serious complications from this operation are postoperative bleeding and leakage. This study aimed to evaluate the effect of omentopexy in reducing the incidence of these complications. Patients and methods The current retrospective study included 82 patients who were eligible for sleeve gastrectomy and underwent one of the two procedures. Group A (n=41) underwent conventional sleeve gastrectomy without omentopexy and group B (n=41) underwent sleeve gastrectomy with omentopexy. Follow-up was designed for one month postoperatively for leakage or bleeding. Results The mean age of the eligible patients was 34.64±5.7 and 35. 32±5.42 years in group A and group B, respectively. No significant difference was reported as regards the sociodemographic data or patient comorbidities between the two groups. The mean operative time increased significantly in group B than in group A (P&lt;0.001). There was no significant difference between both groups as regards postoperative leakage and bleeding. Conclusion According to the current results: omentopexy has no additional benefit in reducing the incidence of postoperative bleeding or leakage. However, it results in an additional increase in the operative time.

The Impact of Blood Pressure Switching (from Controlled Hypotension to Late Elevated Blood Pressure) During Laparoscopic Sleeve Gastrectomy: Controlled Clinical Trial.

Laparoscopic sleeve gastrectomy (LSG) is the most done bariatric procedure. Bleeding and leak are the most common associated complications. Elevation of systolic blood pressure (SBP) leads to discovering the bleeding sites but results in a bloody field and increases the operative time. Controlled hypotension shortens the operative time, reduces tissue edema, and improves field vision. We aimed to test controlled hypotension during LSG. This was a randomized controlled trial that included 200 patients who were operated by LSG, randomly assigned to 2 equal groups: group 1, operated with controlled hypotensive anesthesia, and group 2, operated with elevated SBP to 140 mmHg. Of the patients, 162 (81%) were females, and 38 (19%) were male. The mean BMI was 45.7 kg/m2. The mean age was 41.7 years. The operative time was 36.43 ± 6.73 min in group 1 vs. 44.71 ± 5.47 min in group 2. The mean of total number of used gauzes and clips was 2.70 ± 3.49 in group 1 vs. 8.83 ± 3.15 in group 2. The mean amount of drain output was 37.65 ± 21.90 ml in group 1 vs. 74.00 ± 16.54 ml in group 2. The mean drop in the postoperative hematocrit was 0.08 in group 1 vs. 0.22 in group 2. The incidence of postoperative bleeding was 0% in group 1 vs. 1% in group 2. Controlled hypotensive anesthesia in LSG reduces the operative time, reduces the intraoperative bleeding, and improves the operative field.

Risk of bleeding in patients on single and dual antiplatelet therapy undergoing dental extractions

We assessed the impact of single and dual antiplatelet therapy on postoperative bleeding in dental extraction patients. The study involved 160 patients on antiplatelet medication and a control group of 105 healthy subjects undergoing extractions. Bleeding was considered an "event" if it persisted over 12 hours or met other specific criteria. A total of 115 teeth were extracted from control, 48 teeth were extracted from the dual drug group and 122 from the single drug group, with no significant difference in postoperative bleeding incidence (χ2 = 4.3, p = 0.11). Dental extractions for patients on single or dual antiplatelet therapy can be performed safely using local haemostatic measures without treatment interruption.

Analyzing the Effects of External Carotid Ligation and Preoperative Embolization of the Feeding Vessel to Prevent Postoperative Bleeding in Angiofibroma Excision

Objectives: This study evaluated the effectiveness of external carotid ligation and preoperative feeding vessel embolization to limit postoperative bleeding during angiofibroma excision. Methods: Eighty patients between 10 and 40 with angiofibroma excision at the Department of ENT, Hayatabad Medical Complex, Peshawar, between January 2020 and January 2022, were included in this Study. External carotid ligation (ECL) and preoperative feeding vascular embolization (EPV) were performed on these individuals. Following surgery, the patients were checked on at one week, one month, three months, six months, and one year. The patient's demographics, surgical conditions, side effects, and angiofibroma recurrence were recorded and examined. Results: The patient's average age was 21.3 ±7.6 years, and 100% were men. 79 of the 80 total cases were juvenile angiofibroma. The procedure lasted 65.2 minutes on average, while the average hospital stay was 1.3 days on average. There was a postoperative hemorrhage in 11 individuals (13.7%). It was found that there was no fatality rate. The incidence of postoperative bleeding in angiofibroma excision was shown to be significantly decreased (p=0.03) by preoperative Embolization with external carotid ligation. Conclusion: External carotid ligation and preoperative feeding vessel embolization may significantly decrease postoperative bleeding after angiofibroma excision. It was found that preoperative feeding vessel embolization before angiofibroma excision efficiently lowered the incidence of postoperative bleeding and should therefore be advised to patients for better treatment. Keywords: Angiofibroma excision, External carotid ligation, Preoperative Embolization, Postoperative bleeding.

Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies.

Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.

Impact of continued clopidogrel use on outcomes of patients undergoing carotid endarterectomy

ObjectiveThe aim of this study was to evaluate the use of clopidogrel at the time of carotid endarterectomy (CEA) and its association with postoperative complications. MethodsSingle-institution, retrospective review of a prospective database. ResultsFrom 2010 to 2017, CEA was performed in 1066 consecutive patients (median age, 73 years; 66% men). The indications for operation included ≥70% asymptomatic stenosis (458; 43%), prior stroke (314; 29%), and transient cerebral or retinal ischemia (294; 28%). At the time of operation, 509 (48%) patients were taking aspirin alone, 441 (41%) were taking clopidogrel (374 in combination with aspirin, 67 as sole therapy), 83 (8%) were on no documented antiplatelet medication, and 33 (3%) were taking warfarin (with therapeutic international normalized ratio). The likelihood of clopidogrel use at the time of operation was higher for patients with a history of symptomatic carotid disease (P = .002). Over the study period, clopidogrel use increased from 31.9% in 2010 to 56.8% in 2017, which corresponds to an 11% (95% confidence interval, 6%-15%) increase annually. Postoperative strokes occurred in 15 patients (overall incidence, 1.4%), the majority of which were minor (12/15; 80%). Six strokes occurred in patients taking aspirin alone (6/509; 1.2%), two in patients on clopidogrel and aspirin (2/441; 0.5%), two in patients taking clopidogrel alone (2/67; 2.9%), three in patients on no documented antiplatelet medication (3/83; 3.6%), and two in those taking warfarin (one of which was secondary to a fatal intracranial hemorrhage within 30 days of discharge [2/33; 6.1%]). The 30-day mortality rate was 0.03% (3/1066); the risk for the combined endpoint of any stroke, death, or myocardial infarction (MI) was 2.3% (25/1066), and the risk for major stroke, death, or MI was 1.2%. There was no apparent association between clopidogrel use and the incidence of postoperative bleeding (P = .59) or any other postoperative complication (stroke, death, MI, cranial nerve injury; P = .15). ConclusionsClopidogrel use in our CEA practice has increased over time and has not been associated with an increased risk of postoperative complications, including bleeding. These data suggest that clopidogrel should not be discontinued prior to CEA and should be considered as part of ‘optimal medical therapy’ in patients undergoing CEA.

Methylprednisolone is related to lower incidence of postoperative bleeding after flow diverter treatment for unruptured intracranial aneurysm.

Regarding the anti-inflammatory effect, methylprednisolone is a candidate to prevent patients with unruptured intracranial aneurysms (UIAs) from postoperative bleeding (PB) after flow diverter (FD) treatment. This study aimed to investigate whether methylprednisolone is related to a lower incidence of PB after FD treatment for UIAs. This study retrospectively reviewed UIA patients receiving FD treatment between October 2015 and July 2021. All patients were observed until 72 h after FD treatment. The patients receiving methylprednisolone (80 mg, bid, for at least 24 h) were considered as standard methylprednisolone treatment (SMT) users, otherwise as non-SMT users. The primary endpoint indicated the occurrence of PB, including subarachnoid hemorrhage, intracerebral hemorrhage, and ventricular bleeding, within 72 h after FD treatment. This study compared the incidence of PB between SMT users and non-SMT users and investigated the protective effect of SMT on PB after FD treatment using the Cox regression model. Finally, after controlling the potential factors related to PB, we performed subgroup analysis to further confirm the protective effect of SMT on PB. This study finally included 262 UIA patients receiving FD treatment. PB occurred in 11 patients (4.2%), and 116 patients (44.3%) received SMT postoperatively. The median time from the end of surgery to PB was 12.3 h (range: 0.5-48.0 h). SMT users had a lower incidence of PB comparing with non-SMT users (1/116, 0.9% vs. 10/146, 6.8%, respectively; p = 0.017). The multivariate Cox analysis demonstrated that SMT users (HR, 0.12 [95%CI, 0.02-0.94], p = 0.044) had a lower risk of PB postoperatively. After controlling the potential factors related to PB (i.e., gender, irregular shape, surgical methods [FD and FD + coil] and UIA sizes), the patients receiving SMT still had a lower cumulative incidence of PB, comparing with patients receiving non-SMT (all p < 0.05). SMT was correlated with the lower incidence of PB for patients receiving FD treatment and may be a potential method to prevent PB after the FD treatment.

Diagnosis and treatment of postoperative bleeding in patients after gastrectomy: a retrospective case series study.

There are significant differences in terms of the pathophysiology and clinical manifestations between intra- and extra-luminal bleeding, and it is also difficult to determine the reasonable management of the bleeding. This study is to analyze the clinical characteristics of postoperative bleeding in gastric cancer, and to explore the management of postoperative intra-intestinal and extra-intestinal bleeding. We collected the clinical data of 2,978 patients with gastric cancer from the Department of Surgery, Fujian Cancer Hospital, from May 2014 to September 2019. A total gastrectomy or a distal or proximal subtotal gastrectomy with regional lymph node dissection (D1+ or D2) was included. The clinic data and management of both early (postoperative days ≤6 d) and delayed (postoperative days ≥7 d) post-operative hemorrhage were explored. This retrospective study is to compare the clinical characteristics and treatment of intra-intestinal and extra-intestinal hemorrhage. The incidence of postoperative bleeding in gastric cancer was 2.85% (n=85), and the bleeding-related mortality was 4.7% (4/85). There were 67 men and 18 women, and four patients died, with a bleeding-related mortality rate of 4.7%. There were 46 cases of intra-intestinal hemorrhage and 39 cases of extra-intestinal hemorrhage. The reoperation rate in the extraneous bleeding group was higher than that in the intra-intestinal bleeding group (66.67% vs. 19.57%, P<0.001), and the incidence of delayed bleeding in the extra-intestinal bleeding group was higher than that in the intra-intestinal bleeding group (46.15% vs. 8.70%, P<0.001). In the delayed phase, 11 patients underwent reoperation to stop the bleeding, and three patients died due to bleeding-related complications. Hemostasis was successfully achieved in four patients by transcatheter arterial embolization (TAE). In the reoperation group, 72.73% (8/11) suffered hemodynamic instability and 63.64% (7/11) had an abdominal infection, while in the TAE group, 25% (1/4) had hemodynamic instability and 50% (2/4) had an abdominal infection. A greater number of gastric cancer patients with intra-intestinal hemorrhage are treated conservatively, while more patients with extra-intestinal hemorrhage are treated by reoperation. External bleeding is more likely to occur in the delayed period of bleeding. TAE is a safe and effective means of hemostasis if the hemodynamics is stable.

A retrospective comparative study of postoperative bleeding after coblation tonsillectomy versus noncoblation tonsillectomy in North Indian population

Background: This study was done to look at the difference in incidence of postoperative bleeding after tonsillectomy using coblation or noncoblation. Methods: A review of all the cases of tonsillectomy done at NIMS Medical college from January 2019 to September 2022 was done to ascertain type of tonsillectomy performed and the presence of postoperative bleeding. Statistical analysis was done by chi-square test to determine a statistical difference between the postoperative bleeding rate of coblation and noncoblation method. The Cochraine-Armitage test of linear trend was done to measure change in the postoperative bleeds. The tested term was divided into two-month durations, and the coblation postoperative bleeds were checked for every 2-month period. Results: 238 tonsillectomies were performed. The postoperative bleed rate for noncoblation tonsillectomy was 3.4% (8/238) and 5/238 (2.1%) in coblation tonsillectomy. No statistical difference (p=0.93) was found between bleed rates for coblation versus noncoblation techniques. There was no difference seen in the need for operative intervention to control postoperative bleeding: 8 (5.4% of only non coblated patients and 3.4% of all tonsillectomy patients) for noncoblation procedure and 5 (5.6% of only coblated patients and 2.1% of all tonsillectomy patients) for coblation procedures (p=0.25). Postoperative bleed rates in coblation patients for the 2-month periods did not reveal an increasing or decreasing trend in the bleed rate (p=0.49). Conclusions: Coblation tonsillectomy is a safe method for performing tonsillar surgery with no significant difference in postoperative bleeding from previous techniques and no increased need for operative intervention to control postoperative bleeding.

Chemoprophylaxis Timing Is Not Associated With Postoperative Bleeding After Spinal Trauma Surgery

BackgroundLittle is known regarding appropriate timing for chemical venous thromboembolism (VTE) prophylaxis initiation in operative traumatic spinal injuries. We hypothesized that the incidence of post-operative bleeding leading to neurological decline or re-operation would not increase in patients who received early VTE prophylaxis (≤2 days post-surgery) as compared to those who received late VTE prophylaxis (≥ 3 days post-surgery). MethodsThis is a retrospective cohort study. Spine trauma patients who underwent spinal surgery, defined as anterior cervical discectomy and fusion, posterior cervical spinal fusion, anterior or posterior thoracic/lumbar spinal fusion, or vertebral percutaneous fixation from July 2015 to July 2020 were included. Demographics, pre-injury anti-thrombotics, operative characteristics, pre- and post-operative VTE prophylaxis, and post-operative complications, including spinal bleeding, and VTE were collected. Univariate analysis was performed, comparing baseline characteristics, VTE prophylaxis timing, and complications between the early and late groups. ResultsTwo-hundred-eighty-two patients were included; 189 were in the early group (1.7 ± 0.5 days), and 93 were in the late (4.4 ± 2.1 days) group. The late group received enoxaparin more often than patients in the early group (41.9 % vs. 19 %, p < 0.001). Baseline characteristics, hospital course, and surgical management were similar between the groups. The rate of post-operative complications, including hematoma and VTE was similar between the groups. None of the patients in the early group had post-operative bleeding. ConclusionIn this retrospective cohort study, VTE prophylaxis timing was not associated with clinically significant post-operative spinal bleeding and VTE in trauma patients.

The importance of compression time in stapled hemorrhoidopexy: is patience a virtue?

The aim of this study was to evaluate whether longer compression time before firing the stapler reduced the postoperative complications related to staple line formation in stapled hemorrhoidopexy. This retrospective case-control study was conducted at a colorectal-anal specialty hospital. Consecutive patients with grades III and IV hemorrhoids who underwent stapled hemorrhoidopexy between January 2016 and November 2019 were included. According to the compression time, patients were assigned to the long compression time group (2 minutes) or the typical compression time group (30 seconds). The primary outcome measure was incidence of staple line complications such as dehiscence, bleeding, and stenosis. A total of 348 patients treated with stapled hemorrhoidopexy were evaluated. Seventy-three and 275 patients were included in the long compression time group and the typical compression time group, respectively. No significant differences were observed in patient characteristics between the groups. However, additional procedures were performed more frequently in the typical compression time group (78.1% vs. 92.0%, P=0.001). Bleeding occurred more frequently in the typical compression time group (1.4% vs. 8.4%, P=0.030). The rates of dehiscence and stenosis were not significantly different between the groups. Fecal urgency developed more frequently in the typical compression time group (0% vs. 5.1%, P=0.040). In logistic regression analysis, typical compression time (30 seconds) was the only risk factor for bleeding (odds ratio, 8.496; P=0.040). Longer compression time was associated with a decreased incidence of postoperative bleeding after stapled hemorrhoidopexy.

Intermittent Pringle maneuver combined with controlled low Central venous pressure prolongs hepatic hilum occlusion time in patients with hepatocellular carcinoma complicated by post hepatitis B cirrhosis: a randomized controlled trial

Background: The optimal occlusion and reperfusion time to balance blood loss and ischemia–reperfusion injury to the remnant liver remains unclear. The aim was to explore the clinical impact of prolonging the hepatic hilum occlusion time from 15 to 20 min using the intermittent Pringle maneuver (IPM) combined with controlled low central venous pressure (CLCVP). Methods: A total of 151 patients were included and divided into an experimental group (Group 20,75 cases) and a control group (Group 15,76 cases). In both groups, the hepatic hilum was blocked by the IPM combined with CLCVP to control intraoperative hepatic cross-sectional bleeding. The preoperative, intraoperative and postoperative parameters and safety were compared between the two groups. Results: There were no significant differences between the two groups in the postoperative aminotransferase serum levels (p > 0.05). However, the operation time in Group 20 was significantly lower than that in Group 15 (222.4 ± 87.8 vs. 250.7 ± 94.5 min, p < 0.05). The procalcitonin at 1 day after operation in Group 20 was lower than that at 1 day after operation in Group 15 (0.78 ± 0.66 vs. 1.45 ± 1.33 ng/mL, p < 0.05). There was no significant difference in the incidence of postoperative bleeding, postoperative bile leakage and postoperative infection between the two groups (p > 0.05). Conclusions: For patients with hepatocellular carcinoma after hepatitis B cirrhosis, it is feasible and safe to prolong the hepatic hilum occlusion time from 15 to 20 min using the IPM combined with CLCVP.

Impact of SMS Text-Messaging on Patient-Provider Communication, Protocol Adherence, and Clinical Outcomes in Adult Patients with Bleeding Disorders Undergoing Surgery or Procedures: A Real-World Feasibility Study

Background: Adult patients with bleeding disorders (PWBD), such as hemophilia or von Willebrand Disease (VWD), frequently require surgeries and procedures. In order to achieve and maintain hemostasis throughout the peri-operative period, clotting factor concentrates (CFCs) are prescribed. Patients then adhere to a detailed CFC treatment plan (TP), which outlines exact doses to take, when to take them, and for how long. However, despite following the TP, non-adherence sometimes occurs. Importantly, if inadequate amounts of CFC are prescribed or taken, and under-treatment leads to bleeding complications, even simple procedures could result in death. As a result, the ability to evaluate clinical effectiveness in real-time is urgently needed. However, most post-procedure-related recovery happens outside of the hospital or clinic setting. Therefore, little is known about clinical outcomes post-procedurally. A baseline study at our institution showed only 51% of PWBD answered their phone when clinic staff called to assess the effectiveness of and adherence to the TP. A better understanding of CFC adherence and bleeding rates may improve cost-effectiveness of and patient satisfaction with CFC use peri-procedurally. Our aims were to assess feasibility of 2-way SMS text messaging (TM) between our clinic and PWBD, establish peri-operative CFC adherence rates, evaluate for post-operative bleeding, and to determine patient-preferred methods of communication during peri-operative management. Design/Methods: The Utah Center for Bleeding & Clotting Disorders at the University of Utah follows approximately 500 PWBD, all of whom were eligible for participation. Patients were consented using Adobe Sign software. Webtext.com served as the TM platform. Mobile devices were provided to patients free-of-charge using grant funding. HIPAA-compliant, templated TMs were sent by clinic staff to participants each day CFCs were prescribed to assess adherence to the TP, and incidence and severity of post-procedural bleeding. A patient satisfaction survey was emailed on the final day of CFC therapy. Study data, captured using REDCap, included baseline demographics, bleeding disorder type and severity, procedure type, factor therapy prescribed, and TM responses. Descriptive analyses were used for all study endpoints. The primary endpoint was to compare the ability to reach patients using TMs vs. phone call (feasibility). Secondary endpoints included: doses taken vs. prescribed, incidence of post-operative bleeding, overall patient satisfaction with TM, and average total cost of CFC therapy. Results: To date, 50 PWBD consented. Average age: 37 years (range: 18 - 81); 28 PWBD had hemophilia (19 HA, 9 HB), 20 had VWD, and 2 had unconfirmed bleeding disorders; 50% were women. Eleven PWBD lived ≥ 50 miles from the HTC. Ten were taking CFC prophylaxis. Of the 50 PWBD, 10 have undergone surgery (Table 1). The remaining PWBD have yet to undergo their planned procedure. The average cost of CFC procured per PWBD per procedure exceeded $100,000. In total, PWBDs responded to 121/142 (85%) of TMs sent. All PWBD (n=10; 100%) responded to at least one text message sent. Daily communication (time from first text sent to time when last response received) lasted roughly 8 minutes. Protocol adherence: In total, 87% (55/63) of CFC doses prescribed were taken (Table 1). Post-op bleeding occurred in 3 PWBD (30%). Patient satisfaction survey results showed 70% (7/10) of PWBD preferred TM to communication via chart messaging, 90% (9/10) chose to use TM again for their care, and no PWBD was dissatisfied with TM communication. Conclusion: This is the first study to assess the impact and feasibility of using TM to determine protocol adherence and clinical outcomes in adult PWBD undergoing surgery or procedures in a real-world setting. Compared to phone calls, the response rate to TM was 34% higher. This study identified both PWBD that were non-adherent to the TP, and those who experienced post-operative bleeding at home. Most PWBD (90%) elected to continue using TM to communicate with clinic staff. These data may help improve the cost-effective management of future procedures for PWBD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Utility of Preoperative Laboratory Testing for Ambulatory Endoscopic Sinonasal Surgery in Low-Risk Patients.

Preoperative laboratory tests (PLTs) are often obtained prior to outpatient surgical procedures. The objective of this study is to examine the current practice of routine PLT in low-risk patients undergoing ambulatory endoscopic sinonasal surgery (ESS) and to assess whether such testing impacts surgical outcomes. Patients undergoing ambulatory ESS were identified from the 2011 to 2018 NSQIP database. Low-risk patients were defined as American Society of Anesthesiologist class 1 or 2. PLTs were grouped into hematologic, chemistry, coagulation, and liver function tests. Chi-square analyses and independent samples t-tests were conducted to compare categoric and continuous variables, respectively. A total of 664 cases met the inclusion criteria, of which 419 (62.1%) underwent at least one PLT. Of these, the most frequent PLT obtained was a complete blood cell count (92.4%). Major complications occurred in 1.5% of patients. There were no statistically significant differences in overall postoperative complications between those with and without PLT (P = .264). Specifically, no significant difference was seen in the incidence of postoperative bleeding (P = .184), urinary tract infection (P = .444), pulmonary embolism (P = .444), or wound infection (P = .701). On multivariable analyses, PLT status was not significantly associated with any complication (P = .097) or unplanned readmission (P = .898). Our analysis did not reveal an association between the use of PLT and postoperative morbidity or unplanned readmission in low-risk patients undergoing outpatient ESS.

Laparoscopic mesh placement during inguinal hernia repair: a meta-analysis of two methods of repair.

There are several modifications in the technique for the placement of mesh during laparoscopic inguinal hernia repair. One of these is a slit on the mesh to surround the cord structures which proponents of it suggest that it decreases the recurrence rate due to better anchoring of the mesh and lower risk of displacement. There is only low-level evidence in current literature examining the two methods. The present study aimed to provide stronger evidence in establishing whether the slit mesh technique is superior to the non-slit mesh technique. The reporting of this systematic review was guided by the standards of the preferred reporting items for systematic review and meta-analysis statement and registered with PROSPERO (ID: CRD42022300629). Eligible studies had to compare the two methods of mesh placement slit Vs nonslit in laparoscopic Inguinal hernia repair and also report on at least one outcome. The outcomes were expressed in odd ratios with their 95% confidence intervals. Where significant heterogeneity existed a random effects model was used otherwise a fixed effects model was used. Five studies met the criteria for inclusion in quantitative analysis. Overall, there were 10 (1.5%) recurrences in the slit group compared to 12 (2.5%) in the non-slit group OR 0.62, 95% CI (0.27-1.41). There was no difference in the incidence of post-operative bleeding (OR 1.21, 95%CI 0.4-3.66), seroma formation (OR1.5, 95% CI 0.81-2.76), or post-operative neuralgia (OR 0.98, 95%CI 0.11-8.92) between the two groups. There was no difference between the two methods.

Invasive Coronary Angiography in Patients with Native or Prosthetic Aortic Valve Endocarditis.

Invasive coronary angiography (ICA) is essential to detect significant coronary artery disease (CAD) but is generally not recommended in patients with infective aortic valve endocarditis. This study aimed to evaluate the risks and benefits of preoperative ICA in patients before aortic valve replacement. Between March 2008 and September 2020, 232 patients were surgically treated for infectious endocarditis of the aortic valve. Sixty-seven (29%) of them underwent preoperative diagnostic ICA and were compared with the patients without preoperative ICA. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the ICA data. The intraoperative data and clinical outcomes after ICA and after surgery were evaluated. ICA revealed a CAD in the majority of our patients (n = 36; 54%): One-vessel disease n = 19 (28%), two-vessel disease n = 6 (9%), and three-vessel disease n = 11 (16%). We observed no adverse events following preoperative diagnostic ICA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischemia were detected. During surgical aortic valve replacement, concomitant coronary artery bypass grafting was performed in 20 patients (30%). In patients with preoperative ICA, postoperative in-hospital mortality was significantly lower (n = 8 [12%] vs. n = 30 [18%]; p < 0.001), while the incidence of postoperative bleeding was higher (n = 18 [27%] vs. n = 22 [13%]; p = 0.022). The new-onset stroke incidence was 5% in each group. Taking a multidisciplinary team approach, ICA is safe in selected patients with aortic valve infectious endocarditis with no adverse clinical outcomes, but significant clinical implications.