Intraoperative Bleeding Research Articles

Impact of enhanced chest CT with three-dimensional reconstruction combined with preoperative olive oil administration on the incidence of postoperative chylothorax: a retrospective study

BackgroundChylothorax is a rare but potentially life-threatening complication after esophageal cancer resection. This study aims to investigate the impact of a strategy combining preoperative three-dimensional (3D) reconstruction of contrast-enhanced chest CT with olive oil ingestion on the incidence of chylothorax following esophageal cancer resection.MethodsWe retrospectively analyzed the clinical data of 357 patients who underwent esophageal cancer resection in the Department of Thoracic Surgery at Gansu Provincial People’s Hospital from January 2019 to June 2024. Among them, 179 patients who underwent preoperative 3D reconstruction of contrast-enhanced chest CT combined with oral olive oil administration were assigned to the 3D reconstruction group, while 158 patients who did not receive these interventions served as the control group. The primary outcome measures included the incidence of chylous leakage and related perioperative outcomes.ResultsAll patients in both groups underwent surgeries successfully without any perioperative deaths. Compared to the control group, the 3D reconstruction group exhibited a significant decrease in the incidence of postoperative chylothorax (0% versus 8.2%, P < 0.001). The visualization rate of the thoracic duct during surgery was higher in the 3D reconstruction group compared to the control group (93.85% vs. 48.73%). Furthermore, patients in the 3D reconstruction group had less intraoperative bleeding (P = 0.003), shorter postoperative hospital stays (P = 0.003), and reduced chest drainage in the first three postoperative days (P < 0.001).ConclusionThis study reveals that preoperative three-dimensional reconstruction of chest using enhanced CT allows for the anticipation of thoracic duct anatomy. Additionally, the combination of preoperative oral olive oil administration significantly enhances the intraoperative visualization of the thoracic duct. This integrated strategy effectively reduces the incidence of postoperative chylothorax, demonstrating promising clinical application prospects.

Spheno-Orbital Aneurysmal Bone Cyst in Children: A Report of Three Cases and Literature Review.

Only 2% to 6% aneurysmal bone cyst (ABC) involve the cranial region, and even fewer show sphenoid and orbital involvement. The spheno-orbital ABC is prone to misdiagnosis and can result in intraoperative bleeding and residual lesions. The study was to summarize the clinical and therapeutic characteristics of patients with spheno-orbital ABC in children. We retrospectively analyzed three childhood-onset spheno-orbital ABC cases at our hospital. A literature review was conducted and the spheno-orbital ABC cases were retrieved. The characteristics of clinical manifestations, treatment outcomes, and follow-ups were analyzed. All three cases involved the sphenoid and orbital bones, and had a history of surgery or biopsy before being transferred to our hospital. Two of them were terminated due to severe bleeding. The surgeries were performed through frontotemporal craniotomy, where the masses and the surrounding suspected diseased bones were removed. The pathological diagnosis was ABC. All the patient's eye symptoms improved. A review of the literature reveals that ABC typically presents as bone destruction, with some lesions containing fluid levels. Tumors that significantly enhance on contrast-enhanced magnetic resonance imaging are often misdiagnosed. ABC is more prevalent in children. The ABC can lead to excessive intraoperative bleeding and residual lesions. Gross total resection is the treatment of choice. Spheno-orbital ABC should avoid transorbital approach in favor of craniotomy. It is imperative to remove as much of the affected bone as possible and to intensify subsequent monitoring. It is essential to prepare blood prior to surgery to manage potential severe bleeding.

Endoscopic paramaxillary ligation of the internal maxillary artery.

Endoscopic skull base surgery is increasingly utilized for managing skull base tumors. Complex techniques for resecting multicompartmental lesions can lead to higher intraoperative bleeding rates. While embolization can reduce blood flow, it may not always be feasible and can introduce additional risks. Endoscopic techniques allow for direct visualization and coagulation of parent arteries. This study discusses a subperiosteal transoral medial dissection technique, endoscopic paramaxillary corridor, to enable early vascular control prior to resection.

Presurgical Embolization of Meningiomas: Analysis of Safety and Efficacy in a Mexican National Center and Proposal for a Classification of Preoperative Embolization of Meningiomas Based on Embolic Agent Penetration.

Meningiomas are the most common primary central nervous system tumors, often requiring surgical resection. Presurgical embolization (PSE) is used to reduce intraoperative bleeding, although its effectiveness varies. This study evaluates the safety and efficacy of PSE using ethyl-vinyl alcohol (EVOH) in meningioma surgeries. This study included 48 patients with intracranial meningiomas treated between January 2022 and August 2024. Patients were divided into 2 groups: Group A (n= 24) underwent surgery without PSE, while Group B (n= 24) underwent surgery with PSE using EVOH. Outcomes assessed included anesthetic and surgical times, resection bleeding, total bleeding, and transfusion requirements. Meningioma size and bleeding per cm³ were also evaluated. PSE was classified into 4 grades based on liquid embolic penetrability, and its relationship with bleeding during resection was analyzed. PSE significantly reduced anesthetic (270 vs. 372minutes) and surgical times (222 vs. 348minutes). Group B exhibited less resection bleeding (450 vs. 1400ml) and total bleeding (650 vs. 1700ml) compared to Group A, with statistically significant differences (P < 0.01). Bleeding per cm³ was significantly lower in Group B (9.33ml/cm³) than in Group A (31.39ml/cm³). No complications related to PSE were observed. liquid embolic penetrability grades correlated with resection bleeding, where higher-grade embolizations led to reduced bleeding. PSE using EVOH significantly decreases surgical bleeding and time in meningioma resections without associated complications. The proposed PSE grading system (Preoperative Embolization of Meningiomas, Mexican Classification) may enhance the predictability of intraoperative bleeding control. While we acknowledge the relatively small sample size of 48 cases, we believe this study serves as a foundation to encourage the inclusion of more patients and collaboration with additional centers, aiming to further validate and standardize the classification.

Comparative analysis of the parapatellar and subpatellar approaches in reducing peripheral knee pain post-intramedullary tibial fracture surgery

IntroductionIntramedullary tibial nailing is a standard treatment for tibial shaft fractures. Postoperative knee pain significantly impacts functional recovery; however, studies on this issue are limited. This study evaluated the effect of the parapatellar approach for intramedullary nailing on postoperative knee pain.Materials and methodsA total of 29 patients with tibial shaft fractures treated with intramedullary nails from March 2019 to January 2022 were divided into two groups based on the surgical approach: the semi-extended lateral parapatellar approach and the conventional subpatellar ligament split approach. Recorded metrics included operation time, intraoperative fluoroscopy count, intraoperative bleeding volume, Visual Analog Scale (VAS) scores for knee pain at 24 h, 72 h, 1 week, and 1 month postoperatively, fracture healing time and Lysholm knee functional scores at 12 months.ResultsBoth groups completed the operation without significant differences in operation time, intraoperative bleeding, fracture healing time, or intraoperative fluoroscopy (P > 0.05). The parapatellar group showed significantly better VAS scores for knee pain at 24 h, 72 h, and 1 week postoperatively compared to the control group (P < 0.05), with no significant difference at 1 month. After 12 months, Lysholm scores indicated no significant differences in knee support, locking, and swelling (P > 0.05); however, the parapatellar group showed significant improvements in lameness, instability, stair climbing, squatting, and pain (P < 0.05). Overall, the parapatellar group outperformed the control group (P = 0.01). Additionally, long-term follow-up revealed potential advantages of the parapatellar approach in improving long-term functional outcomes.ConclusionsUsing the parapatellar approach for tibial intramedullary nailing avoids splitting the patellar ligament and entering the joint cavity, minimizing knee joint impact and effectively reducing postoperative knee pain, with potential benefits in long-term functional recovery.

Laparoscopic intracorporeal anastomosis vs open anastomosis for ileostomy reversal in Crohn's disease: A single center retrospective study.

There is an increased maturation of laparoscopic intracorporeal anastomosis techniques. However, research on its application for small bowel stoma reversal in patients with Crohn's disease (CD) is limited. Therefore, in this study, we compared the perioperative outcomes between laparoscopic intracorporeal ileostomy reversal (LIIR) and open ileostomy reversal (OIR). To compare the safety, feasibility, bowel function recovery, and short- and long-term LIIR and OIR outcomes in patients with CD. This study included patients who underwent ileal reversal for CD between January 2021 and January 2023 at our institution. The baseline data, postoperative recovery, and complication indicators were retrospectively analyzed. Logistic regression analysis was conducted to explore factors that significantly influenced the development of enteral nutrition intolerance-related symptoms. Notably, 15 of the 45 patients in this study underwent OIR, and the remaining 30 received LIIR. Notably, no statistically significant differences were found between the two groups regarding clinical baseline characteristics, operation time, intraoperative hemorrhage, anastomotic site, enterolysis range, first postoperative flatus, postoperative complications, reoperation rate, or incidence of postoperative enteral nutrition intolerance. Compared with the OIR group, the LIIR group had a shorter postoperative hospital stay (P = 0.045), lower incidence of enteral nutrition intolerance symptoms (P = 0.019), and earlier postoperative total enteral nutrition initiation (P = 0.033); however, it incurred higher total hospital costs (P = 0.038). Furthermore, multivariate logistic regression analysis revealed that the duration of surgery and anastomotic technique were independent risk factors for postoperative symptoms of enteral nutrition intolerance (P < 0.05). Laparoscopic intracorporeal anastomosis for ileostomy reversal is safe and feasible. Patients who underwent this technique demonstrated improved tolerance to postoperative enteral nutrition and quicker resumption of total enteral nutrition.

Application of DynaCT biliary soft tissue reconstruction technology in diagnosis and treatment of hepatolithiasis.

Hepatobiliary stone disease involves an intrahepatic bile duct stone that occurs above the confluence of the right and left hepatic ducts. One-step percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) using the percutaneous transhepatic one-step biliary fistulation (PTOBF) technique enables the clearing of intrahepatic stones and the resolution of strictures. However, hepatolithiasis with associated strictures still has high residual and recurrence rates after one-step PTCSL. DynaCT can achieve synchronized acquisition with a flat-panel detector during C-arm rotation. The technical approach and application value of DynaCT biliary soft tissue reconstruction technology for the diagnosis and treatment of hepatolithiasis with bile duct stenosis were evaluated in this study. To explore the value of DynaCT biliary soft tissue reconstruction technology for the diagnosis and treatment of hepatolithiasis with bile duct stenosis, and to assess the feasibility and effectiveness of the PTOBF technique guided by DynaCT biliary soft tissue reconstruction technology. The clinical data of 140 patients with complex biliary stenosis disease combined with bile duct stenosis who received PTOBF and were admitted to the First Affiliated Hospital of Guangzhou Medical University from January 2020 to December 2024 were collected. The patients were divided into two groups: DynaCT-PTOBF group (70 patients) and conventional PTOBF group (70 patients). These groups were compared in terms of the preoperative bile duct stenosis, location of the liver segment where the stone was located, intraoperative operative time, immediate stone retrieval rate, successful stenosis dilatation rate, postoperative complication rate, postoperative reoperation rate, stone recurrence rate, and stenosis recurrence rate. DynaCT biliary soft tissue reconstruction technology was successfully performed in 70 patients. The DynaCT-PTOBF group had a higher detection rate of target bile ducts where bile duct stones and biliary strictures were located than the PTOBF group. Compared with the PTOBF group, the DynaCT-PTOBF group was characterized by a significantly greater immediate stone removal rate (68.6% vs 50.0%, P = 0.025), greater immediate stenosis dilatation success rate (72.9% vs 55.7%, P = 0.034), greater final stenosis release rate (91.4% vs 75.7%, P = 0.012), shorter duration of intraoperative hemorrhage (3.14 ± 2.00 vs 26.5 ± 52.1, P = 0.039), and lower incidence of distant cholangitis (2.9% vs 11.4%, P = 0.49). There were no significant differences between the two groups in terms of the final stone removal rate, reoperation rate, or long-term complication incidence rate. DynaCT biliary soft tissue reconstruction technology guiding the PTOBF technique in patients with hepatolithiasis with bile duct stenosis is feasible and accurate. It may be beneficial for optimizing the preoperative evaluation of the PTOBF technique.

Abstract B010: Interim report of Phase I study of window-of-opportunity fractionated stereotactic radiotherapy combined with checkpoint blockade prior to surgical resection for newly diagnosed glioblastoma

Abstract Background: Preclinical studies with transplanted GL261 glioma in mouse brain treated with radiosurgery and checkpoint blockade showed dramatic improvement of tumor cure and prolonged survival, associated with activated macrophage infiltration in the tumor site. We perform phase I study in patients with glioblastoma to assess safety and local tumor response by combined radiosurgery and checkpoint inhibitor given during window-of-opportunity prior to surgical resection, and progression-free survival and overall survival. Method and Procedure: Biopsy-proven WHO grade 4 glioblastoma patients were enrolled to the study (NCT05423210). Patients were treated with two doses of intravenous Atezolizumab at the beginning and at the end of the two-week period, concomitantly with fractionated radiosurgery (8 Gy x 4 to the grossly enhancing tumor) over 4 days during the course of 2 weeks. Maximal safe surgical resection was subsequently performed within 2 weeks from completion of radiosurgery. Adjuvant radiation 50 Gy over 5 weeks and Temozolomide were given as per standard treatment of GBM along with continuation of Atezolizumab until unacceptable toxicity or tumor progression. The initial biopsy specimen and surgical specimen were collected for laboratory examination of immune profiles. Results: The study plans to enroll total 12 histologically confirmed CNS WHO Grade 4 GBM patients also planned for surgical resection. Six patients were enrolled after consenting so far. There was no grade 3 or 4 toxicity from the window-of-opportunity combination treatment, all 6 patients successfully completing the treatment. Three patients reported fatigue and two patients had skin rash. There was one patient experiencing metallic taste. At present, five patients survive progression-free at 25, 18, 16 and 6 months since the treatment. An unanticipated finding is that there was significantly less intraoperative bleeding in the surgical field than usual brain tumor surgery. Conclusion: Preoperative fractionated radiosurgery and Atezolizumab was well tolerated so far, and appear to improve tumor control. We continue enroll the patients. Lab study of immune cell profile is underway. Citation Format: Samuel Ryu, Alexander Stessin, Charles Mikell, Agnieszka Kowalska, Roberta Seidman, Steven West, Kartik Mani. Interim report of Phase I study of window-of-opportunity fractionated stereotactic radiotherapy combined with checkpoint blockade prior to surgical resection for newly diagnosed glioblastoma. [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Translating Targeted Therapies in Combination with Radiotherapy; 2025 Jan 26-29; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(2_Suppl):Abstract nr B010.

10-year experience with single-site laparoscopic-assisted Soave operation for Hirschsprung disease

Background The aim of this study was to investigate the clinical outcomes after a transumbilical single-site laparoscopic-assisted Soave operation (TSLSO) for Hirschsprung disease (HD) in children, with a 10-year follow‑up results assessment. Methods We retrospectively analyzed the clinical data of 165 children with HD from January 2013 to January 2023. The operation method was a TSLSO. The operation time, intraoperative bleeding, postoperative abdominal drainage time, postoperative hospitalization time, and postoperative complications were analyzed. Results All 165 cases were successfully completed using the TSLSO. The median operative time was 160 (120–210) minutes, and the median volume of bleeding was 9 mL (3–15 mL). The median length of the resected intestine was 25 cm (20–32 cm), and the median postoperative peritoneal drainage time was 4.2 days (3–6 days). Postoperative defecation function generally recovered well, there was no recurrence of constipation. There were three cases of anal stenosis, 12 cases of perianal dermatitis, two cases of adhesive intestinal obstruction, 14 cases of soiling, and 18 cases of enterocolitis. Conclusion The TSLSO is a safe and feasible surgical method for the treatment of HD in children. It has the advantages of little bleeding, a good cosmetic effect, and fast postoperative recovery. However, it does require skilled laparoscopic technique by the surgeon.

Predictive nomogram for postoperative lower-limb deep vein thrombosis in patients undergoing endoscopic endonasal surgery during hospitalization: a retrospective cohort study

Deep vein thrombosis (DVT) in patients undergoing endoscopic endonasal surgery remains underexplored, despite its potential impact on postoperative recovery. This study aimed to develop and validate a predictive nomogram for assessing the risk of lower-limb DVT in such patients without chemoprophylaxis. A retrospective analysis was conducted on 935 patients with postoperative lower-limb vein ultrasonography. Clinical data, including potential risk factors, were used to construct a predictive model via multivariate logistic regression analysis. The resulting nomogram was validated using an independent cohort and evaluated through concordance index (C-index), calibration plots, and decision curve analysis. The incidence of postoperative DVT was 28.9%, with most cases being distal (27.2%). Significant predictors included older age, intraoperative bleeding, female gender, prolonged surgery duration, elevated postoperative APTT and D-dimer levels, and disturbance of consciousness. The nomogram demonstrated good predictive performance, with C-index values of 0.81 in the training cohort and 0.75 in the validation cohort. Calibration and decision curve analyses confirmed the model’s clinical applicability. This nomogram offers a practical tool for individualized DVT risk assessment in patients undergoing endoscopic endonasal surgery, facilitating more targeted prophylactic measures.

Comparative Analysis of the Efficacy of Four Different Surgical Modalities in the Treatment of Cesarean Scar Pregnancy: A Multicenter Retrospective Study.

This study explored the effects of four different surgical methods in the treatment of cesarean scar pregnancy (CSP). In this multicenter retrospective analysis of 359 patients, the surgical indices, the time taken for the serum human chorionic gonadotropin level to return to normal, the recovery time of menstruation, and the incidence of postoperative adverse reactions were comparatively analyzed. The clinical efficacies of various preoperative treatment methods to block the blood supply to CSP tissues and those of four different surgical methods to treat CSP, namely, curettage, hysteroscopic surgery, laparoscopic surgery, and vaginal surgery, were evaluated in this study. Hysteroscopic pregnancy tissue removal in patients with typeI CSP was found to be associated with low cost, rapid postoperative recovery, and a low incidence of postsurgical complications. Among patients with typeII-III CSP, the operation success rate (96.97% for typeII and 88.46% for typeIII) in those who underwent uterine artery embolization + curettage was lower than that in patients from the other groups (all 100%). Among patients with typeIII CSP who underwent transvaginal ligation of the descending uterine artery + hysteroscopic removal of the pregnancy tissues, three patients (12.5%) underwent hysteroscopic surgery under transumbilical single-port laparoscopic surveillance so as to avoid uterine perforation considering that the pregnancy tissue was only 1mm away from the uterine plasma membrane layer. Hysteroscopic surgery without pretreatment can be adopted for patients with typeI CSP. In contrast, patients with typeII and III CSP should be initially pretreated with vascular ligation to prevent intraoperative bleeding, followed by laparoscopic or vaginal surgery. Clinical Trial Registry Number ChiCTR2000040357.

The effectiveness of ERCP in managing preoperative complications of choledochal cysts in children and its role in facilitating early surgical intervention

IntroductionCurrently, there is no established guideline for the application of ERCP in children with choledochal cyst. This study aimed to investigate the safety and effectiveness of ERCP in managing preoperative complications of choledochal cyst in children, as well as the timing for definitive surgery following ERCP.MethodsWe conducted a retrospective review of medical records for 68 pediatric patients who presented with complications of choledochal cyst, including pancreatitis and biliary obstruction combined with cholangitis. All patients underwent ERCP treatment followed by definitive surgery. The primary outcomes assessed included treatment efficacy, post-ERCP complication, and the impact of ERCP on definitive surgical procedures.ResultsAmong the 68 patients studied, 41 presented with pancreatitis, while the remaining patients had biliary obstruction and cholangitis. Sixty-five patients successfully completed their treatments, with 64 experiencing alleviation of symptoms. Significant improvements were observed in serum amylase levels and liver function tests following ERCP. Post-ERCP complications occurred in three cases, including one case of pancreatitis and two cases of infection. The median interval between ERCP and surgery was 11 days. There was no significant difference in primary outcomes, such as surgical duration, rate of minimally invasive surgery, conversion to open surgery, intraoperative bleeding volume, intraoperative blood transfusion, postoperative complications, or average length of hospital stay, between the early surgery group (≤2 weeks) and the late surgery group (&amp;gt;2 weeks).ConclusionsERCP was proved to be a safe and effective intervention for alleviating preoperative complications in pediatric patients with choledochal cyst. Early definitive surgery following ERCP did not significantly impact the perioperative outcomes of pediatric patients.

The learning curve of totalrobotic jejunojejunostomy duringcholedochal cystexcision in pediatrics: a retrospective study.

We conducted this retrospective study to investigate the characteristics of the learning curve of totalrobotic jejunojejunostomy duringcholedochal cystexcision in pediatrics. The study analyzed a database of medical records from the first 54 consecutive patients who underwent total robotic jejunojejunostomy during choledochal cyst excision by a single surgeon. Baseline information and postoperative outcomes were collected, and learning curves were assessed using the cumulative sum (CUSUM) method. Patients were then divided into two groups (A and B) based on the learning curve's cut-off points, and the intraoperative characteristics and postoperative outcomes were compared between the two groups. CUSUM plots revealed that the cut-off point of the learning curve was 17 cases. The operative time of jejunojejunostomy in group A was (61.71 ± 13.47min), which was longer than that of group B (42.43 ± 2.97min) (p < 0.0001). No statistically significant differences were found in terms of the intraoperative bleeding, time to start diet after surgery, hospital stay, and total complications between the two groups (p > 0.05). The learning curve for total robotic jejunojejunostomy during choledochal cyst excision in pediatrics is 17 cases, which can serve as the basis for performance guidance during future training.

Comparison of the Pfannensteil and Lower Midline Incisions in Simple Open Prostatectomy

Background and Objective: Benign prostate hyperplasia is the most common benign tumor in males. An open prostatectomy procedure can be performed to treat this problem. This procedure can be performed using Pfannenstiel or lower midline incisions. The purpose of this study was to investigate the effect of each of these incisions on the operation time, postoperative pain, intraoperative bleeding, and postoperative scar. Materials and Methods: This study was conducted using a randomized clinical trial method on 62 patients who had been referred to Shahid Beheshti Hospital in Hamadan, Iran in 2022 for prostatectomy. Patients were randomly divided into two groups of L (lower midline incision) and P (Pfannenstiel incision). The required data was collected through relevant tools, and the collected data were analyzed using an independent t-test in SPSS software (version 23). Results: The results showed that there was no significant difference between the L and P groups before studying individual characteristics and the two groups were homogeneous. Based on statistical tests, there was a significant difference between group P and group L regarding the amount of bleeding in the enucleating stage, the amount of pain 24 h after the operation, and the scar score (P&lt;0.05). Conclusion: The Pfannenstiel incision was considered preferable during the open simple prostatectomy and had less bleeding during the operation, less postoperative pain, and better aesthetic results than the lower midline incision.

Effect of tranexamic acid dissolved in warm, cold, and room-temperature irrigation fluid on complications during and after TURP surgery: a double-blind, randomized clinical trial

BackgroundTransurethral resection of the prostate (TURP) surgery, as a common surgical technique for cases of benign prostatic hyperplasia, can often lead to various complications during and after the procedure. Among these, intraoperative bleeding and postoperative shivering are highly prevalent. Accordingly, the present study aimed to compare three combinations of tranexamic acid (TXA) dissolved in warm, cold, and room-temperature irrigation fluids to determine their greater effectiveness in reducing bleeding and postoperative complications, such as shivering, following TURP.MethodsThis prospective, double-blind clinical trial was conducted from April to November 2023 at Imam Khomeini Hospital in Alashtar, Iran. 100 patients scheduled for TURP were selected via convenience sampling and randomly assigned into four groups using a four-block and permutation design. The groups were as follows: Intervention Group A (TXA dissolved in cold irrigation fluid), Intervention Group B (TXA dissolved in room-temperature irrigation fluid), Intervention Group C (TXA dissolved in warm irrigation fluid), and the Control Group (room-temperature irrigation without TXA). Intraoperative bleeding was measured using a photometer, hemoglobin levels were assessed with the Cell-Dyn3200 hematology analyzer, and postoperative shivering was evaluated using the Crossley and Mahajan scale.ResultsPostoperative bleeding was significantly lower in Intervention Group A compared to the other groups (P < 0.05). Hemoglobin levels decreased significantly over time (P < 0.05), but no significant inter-group differences in hemoglobin changes were observed (P > 0.05). Postoperative shivering was lowest in Intervention Group C and highest in Intervention Group A (P < 0.05).ConclusionsCombining TXA in a cold irrigation fluid potentially reduces intraoperative bleeding, but is associated with a higher incidence of postoperative shivering than the other groups.

Endoscopic evacuation of supratentorial hematoma: A hemostatic strategy for surgeons.

Endoscopic hematoma evacuation has become well received for its high evacuation rate in patients with intracerebral hematoma. Effective hemostatic procedure is the key to the success of the procedure. Any single method cannot solve all kinds of intraoperative bleeding, The key to hemostasis is to identify the type of bleeding and take the best hemostasis method during endoscopic surgery. In our study, sixty-two intracerebral hemorrhage patients who underwent endoscopic hematoma evacuations were analyzed. Intraoperative bleeding was graded as Grades 0, 1, 2, and 3 based on characteristics of bleeding. A hemostatic strategy was created from the grading system. The efficiency was evaluated by operation time, evacuation rate, and re-bleeding rate after surgery. Procedure safety was evaluated by mortality rate and postoperative complications. We found that endoscopic removal of putamen hematoma was more prone to intraoperative bleeding (P = .00). Active bleeding occurred in early operative stage and errhysis happen in later stage (P = .00). Average evacuation rate was 95.61% and the mortality rate was 3.23%. The mean Glasgow outcome scale (GOS) score at 6-month follow-up was 3.77 ± 1.12. No patient experienced postoperative re-bleeding. These findings indicated that most patients will experience different degrees of intraoperative bleeding during endoscopic hematoma evacuation. A hemostatic strategy based on intraoperative bleeding grade resulted in efficiency and safety.

Proposal of a Machine Learning Based Prognostic Score for Ruptured Microsurgically Treated Anterior Communicating Artery Aneurysms.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) carries significant mortality and disability rates, with rebleeding posing a grave risk, particularly in anterior communicating artery (AcoA) aneurysms. This retrospective study aims to analyze preoperative and intraoperative variables of patients with ruptured AcoA aneurysms, evaluating the association of these variables with patient outcomes using machine learning techniques, proposing a prognostic score. Materials and Methods: A retrospective study was conducted on 50 patients who underwent microsurgical clipping for a ruptured AcoA aneurysm at San Giovanni Bosco Hospital, Turin, Italy. The clinical and aneurysmal data-including clinical evaluations, risk factors, aneurysmal characteristics, and intra- and postoperative details-were examined. The study population was analyzed using machine learning techniques such as the MRMR algorithm for feature selection, and the LASSO method was employed to construct linear predictive models based on these features. Results: The study cohort had a mean age of 54 years, with 26 female and 24 male patients. Temporary clipping of main vessels was performed in 96% of procedures, with a mean duration of 3.74 min. Postoperatively, the mean Intensive Care Unit (ICU) stay was 7.28 days, with 14% mortality at 30 days and 4% within the first week. At the six-month follow-up, 63% of discharged patients had a Glasgow outcome scale (GOS) of 5, with radiological confirmation of complete aneurysm exclusion in 98% of cases. Machine learning techniques identified the significant predictors of patient outcomes, with LASSO algorithms generating linear models to predict the GOS at discharge and at 6 months follow-up. Conclusions: Preoperative factors like the BNI score, Vasograde, and preoperative cerebral edema demonstrate significant correlations with patient outcomes post-clipping. Notably, intraoperative bleeding and extended temporary clipping durations (over 3 min) emerge as pivotal intraoperative considerations. Moreover, the AcoA prognostic score shows promise in predicting patient outcomes, discharge plans, and ICU duration.

A Successful Control of the Intraoperative Bleeding from McConnell's Artery during Fully Endoscopic Resection of Planum Sphenoidale Meningioma Using Bone Chip and Bioglue : A Case Report.

The endoscopic transsphenoidal approach is a common approach used in skull base neurosurgery to reach the sellar region. One of the intraoperative risks of this approach is intraoperative bleeding out of the carotid artery. Gentle drilling can prevent carotid artery injury. However, injury to smaller branches, such as the McConnell's capsular artery, which is located within the surgical corridor, is more difficult to prevent. If such an injury is within the junction to the main trunk of the carotid artery, there will be a small circular defect in this area. This can result in massive blood loss and should be closed surgically immediately. We describe a clinical case of intraoperative bleeding from the McConnell's artery originating from the carotid arterial segment (C4) in a 78-year-old female patient operated on for planum sphenoidale meningioma via endoscopic transsphenoidal approach, as well as provide a technical note on a possible technique for bleeding control in such cases. Pinpoint carotid bleeding as a result of intraoperative injury can be stopped by wedging a bone fragment in the carotid canal and fixing it in that position with histoacryl glue at the defect site.

The "CUPCAKE" technique (coiled underlying pseudoaneurysm contained by a woven endobridge device) for treating intracranial aneurysms with atypical morphology.

Intrasaccular flow diversion using the woven endobridge device (WEB; MicroVention, Aliso Viejo, CA, USA) for the treatment of intracranial aneurysms has demonstrated large scale safety and efficacy. However, limitations arise from its structural configuration, restricting its application to specific aneurysm sizes and shapes. We introduce the CUPCAKE technique, a combination of conventional coiling followed by WEB intrasaccular flow disruption in select cases of atypical aneurysms with technically challenging morphology not typically treatable by WEB alone. A retrospective analysis of a prospectively-maintained dataset from three Australian neurovascular tertiary referral centers, identifying patients treated with the CUPCAKE technique between April 2018 and September 2023. Evaluation of patient and aneurysm characteristics, procedure parameters, complications, radiological and clinical outcomes at follow-up was performed. The CUPCAKE technique was used for the treatment of 22 intracranial aneurysms of total 169 treated with WEB. Overall successful immediate flow stagnation was observed in 95.5% (n = 21) of aneurysms with no cases of perforation or intraoperative hemorrhage. Imaging confirmed thromboembolic complications occurred in two patients, one patient had persistent flow requiring re-treatment during initial admission. Follow-up imaging demonstrated 88.2% complete aneurysm conclusion with no delayed aneurysm expansion or rupture. Synergistic use of conventional coiling with WEB intrasaccular flow disruption presents a viable solution for technically difficult aneurysm treatment. In our series, 13% of all patients treated with WEB received CUPCAKE treatment, resulting in high technical success and no increase in thromboembolic complications with the union of two methods.

Safety Analysis of Visual Percutaneous Tracheostomy in Neurocritical Care Patients with Anticoagulation and Antithrombosis.

This study aims to evaluate the safety of visual percutaneous tracheostomy (vPDT) in neurologic intensive care unit (NICU) patients who are under anticoagulant and antithrombotic therapy. A retrospective cohort study was conducted on 54 NICU patients who underwent vPDT at Tai'an Central Hospital from September 2022 to September 2023. The cohort included 36 men and 18 women aged 36-90years (mean age 62.24 ± 12.24years). Patients were divided into two groups based on their treatment: an anticoagulant and antithrombotic group (22 patients) and a non-anticoagulant and non-antithrombotic group (32 patients). Clinical data, including demographic information, comorbidities, Glasgow Coma Scale (GCS) score before vPDT, time from NICU admission to vPDT, laboratory indicators, and vPDT complications, were analyzed. The incidence of vPDT complications in the anticoagulant and antithrombotic group was 18.2%, involving three cases of minor intraoperative bleeding and one case of posterior airway wall injury. The non-anticoagulant and non-antithrombotic group had an 18.8% complication rate, including four cases of minor intraoperative bleeding, one case of subcutaneous emphysema with local infection, and one unrelated death. No significant difference in vPDT complications was observed between the two groups (P > 0.05). However, the anticoagulant and antithrombotic group had a higher average age, higher GCS scores, and longer time intervals from NICU admission to vPDT and from intubation to vPDT (all P < 0.05). vPDT appears to be a safe and feasible procedure for NICU patients receiving anticoagulant and antithrombotic therapy, with no significant increase in complications compared to those not on such therapies.