Intraoperative Hemorrhagic Complications Research Articles

Clinical experiences in precision treatment of giant plexiform neurofibromas of head, face, and neck

To summarize the treatment strategies and clinical experiences of 5 cases of giant plexiform neurofibromas (PNF) involving the head, face, and neck. Between April 2021 and May 2023, 5 patients with giant PNFs involving the head, face, and neck were treated, including 1 male and 4 females, aged 6-54 years (mean, 22.4 years). All tumors showed progressive enlargement, involving multiple regions such as the maxillofacial area, ear, and neck, significantly impacting facial appearance. Among them, 3 cases involved tumor infiltration into deep tissues, affecting development, while 4 cases were accompanied by hearing loss. Imaging studies revealed that all 5 tumors predominantly exhibited an invasive growth pattern, in which 2 and 1 also presenting superficial and displacing pattern, respectively. The surgical procedure followed a step-by-step precision treatment strategy based on aesthetic units, rather than simply aiming for maximal tumor resection in a single operation. Routine preoperative embolization of the tumor-feeding vessels was performed to reduce bleeding risk, followed by tumor resection combined with reconstructive surgery. All 5 patients underwent 1-3 preoperative embolization procedures, with no intraoperative hemorrhagic complications reported. Four patients required intraoperative blood transfusion. A total of 10 surgical procedures were performed across the 5 patients. One patient experienced early postoperative flap margin necrosis due to ligation for hemostasis; however, the incisions in the remaining patients healed without complications. All patients were followed up for a period ranging from 6 to 36 months, with a mean follow-up duration of 21.6 months. No significant tumor recurrence was observed during the follow-up period. For patients with giant PNF involving the head, face, and neck, precision treatment strategy can effectively control surgical risks and improve the standard of aesthetic reconstruction. This approach enhances overall treatment outcomes by minimizing complications and optimizing functional and cosmetic results.

Renal artery embolization in a case of renal cell carcinoma with intractable hematuria with acute myocardial infarction

Introduction: Renal artery embolization is a valuable treatment option for various renal tumors, both malignant and benign. The indications for this procedure include preoperative arterial embolization of large and vascular renal cell carcinoma to reduce intraoperative hemorrhagic complications, management of malignant renal tumors in patients who are not suitable candidates for surgery, treatment of symptomatic hematuria and palliative care for metastatic renal cancer. Case Report: In this case report, we present the case of a 56-year-old female with a known history of hypertension and cerebrovascular accident, who presented with complaints of hematuria and urinary retention. A diagnosis of left renal mass suggestive of renal cell carcinoma was made. The patient was planned for left radical nephrectomy and advised to discontinue aspirin for a week. However, on the morning of surgery, she experienced acute myocardial infarction and had to be hospitalized in intensive cardiac care. Aspirin was restarted, leading to recurrent severe hematuria. The patient underwent renal artery embolization, which successfully controlled the hematuria. Following cardiac stabilization, radical nephrectomy was performed three months later. The surgery and post-operative period were uneventful. Conclusion: This case study demonstrates the use of renal artery embolization as an effective modality for controlling hematuria, and temporizing management in a case of renal cell carcinoma where surgery was not immediately feasible due to a medical emergency.

Parent artery occlusion for ruptured aneurysms in moyamoya vessels or on collaterals.

Aneurysms in moyamoya vessels or on collaterals are difficult to treat. Parent artery occlusion (PAO) via endovascular treatment (EVT) is often the last resort, but the safety and efficacy of this approach need to be evaluated. A retrospective study was performed on patients admitted to our hospital who were diagnosed with unilateral or bilateral moyamoya disease (MMD) associated with ruptured aneurysms in moyamoya vessels or on collaterals. These aneurysms were treated with PAO, and the clinical outcome was recorded. Eleven patients were aged 54.7 ± 10.4 years, and six patients were male (54.5%, 6/11). The aneurysms in 11 patients were single and ruptured, and the average size was 2.7 ± 0.6 mm. Three (27.3%, 3/11) aneurysms were located at the distal anterior choroidal artery, 3 (27.3%, 3/11) were at the distal lenticulostriate artery, 3 (27.3%, 3/11) were at the P2-3 segment of the posterior cerebral artery, 1 (9.1%, 1/11) was at the P4-5 segment of the posterior cerebral artery, and 1 was at the transdural location of the middle meningeal artery. Among the 11 aneurysms, PAO by coiling was performed on 7 (63.6%, 7/11), and Onyx casting was performed on 4 (36.4%, 4/11). Of 11 patients, 2 (18.2%, 2/11) suffered intraoperative hemorrhagic complications. During follow-up, all patients had good outcomes with a modified Rankin scale score of 0-2. As a last resort, the application of PAO with coiling or casting Onyx for ruptured aneurysms in moyamoya vessels or on collaterals may be safe with an acceptable clinical outcome. However, patients with MMD may not always achieve expected health outcomes, and PAO for the aneurysm can bring only temporary relief.

Результаты применения усовершенствованного витреоретинального вмешательства при пролиферативной диабетической ретинопатии

Purpose. To improve the technology of combined vitreoretinal intervention, including preliminary intravitreal injection of angiogenesis inhibitors followed by vitrectomy and a differentiated approach to internal limiting membrane peeling in patients with proliferative diabetic retinopathy (PDR). Material and methods. The research based on analysis of morpho-functional parameters 134 patient's eyes with PDR during type II diabetes mellitus. The patients were divided into 2 groups. The first group consisted of 30 patients (30 eyes), who were determined optimal period for vitrectomy. That patients underwent fundus photography and optical coherence tomography during 1 month after intravitreal injection of ranibizumab. Vitrectomy was performed within 1-3 months (38.4 ± 5.6 days). The second group consisted of 104 patients (104 eyes) who underwent vitrectomy with a differentiated approach to internal limiting membrane peeling and tamponade of the vitreous cavity. Results. The optimal period for vitrectomy in patients with PDR is 10-14 days after preliminary ranibizumab injection, which is due to the maximal regression of neovascularization and minimal traction on the retina (the risk of developing local traction retinal detachment decreases by 36.6%). Carrying out vitrectomy in optimal period helped to reduce the risk of intraoperative hemorrhagic complications by 4.2 times, the frequency of using perfluorocarbons by 3.7 times. At postoperative period, in patients without internal limiting membrane peeling on the silicone oil tamponade, the risk of epiretinal fibrosis increased 2.7 times compared with the data before treatment, and 1.8 times on air-gas mixture tamponade. Conclusion. The optimal surgical tactic for patients with PDR is preliminary intravitreal injection of angiogenesis inhibitors before vitrectomy, internal limiting membrane peeling at silicone oil tamponade (frequency of epiretinal fibrosis 96%) and individual approach to surgical correction of macular area at gas-air mixture tamponade (frequency of epiretinal fibrosis 36%), which allows to achieve a progressive improvement in morphological and functional results. Key words: proliferative diabetic retinopathy, preliminary anti-VEGF therapy, vitrectomy, internal limiting membrane peeling.

Outcomes of an Overnight-Stay Unit for Urogynecologic Surgery: Feasibility and Risk Factors for Failure of Next-Day Discharge.

To evaluate outcomes of patients undergoing urogynecologic procedures with postoperative care in an overnight-stay unit at a tertiary care center. A retrospective cohort study of 1644 women admitted to an overnight-stay unit at a Canadian tertiary care center after urogynecologic surgery between 2014 and 2018 was completed. A multivariable logistic regression model was fit to identify risk factors for failed next-day discharge, defined as a delayed discharge of more than 24 hours, readmission within 30 days of surgery, or emergency room assessment within 7 days of surgery. One thousand five hundred seventy-eight patients (96%) were discharged within 24 hours of surgery. Mean patient age was 53.7 ± 15.1 years, with 21.2% 70 years or older. Surgical approaches included laparotomies (8.9%), major vaginal surgery (70.9%), and open retropubic procedures (2.1%). Hysterectomies were performed in 1120 patients (68.1%). One hundred one patients (6.1%) were assessed in the emergency department within 7 days of surgery, and 57 (3.5%) were readmitted to hospital within 30 days of their procedure. Multivariable regression identified the following as risk factors for failed next-day discharge: pulmonary disease (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.32-8.06; P = 0.010), longer operating time (OR, 1.40; 95% CI, 1.10-1.79; P = 0.006, per 60 minutes), and intraoperative hemorrhagic complications (OR, 22.64; 95% CI, 5.83-88.00, P < 0.001). Admission to an overnight-stay unit with next-day discharge is feasible for most patients undergoing urogynecologic surgery. Factors associated with requiring a longer hospital stay, presentation to an emergency department, or readmission to hospital within 7 days include pulmonary disease, longer operating times, and intraoperative hemorrhagic complications.

Risk Factors for Surgical Site Infection in Minor Dermatological Surgery: A Systematic Review.

To identify patient- and procedure-related risk factors for surgical site infection following minor dermatological surgery. The MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Informit, and Scopus databases were searched for relevant literature on patient populations receiving minor surgery, where risk factors for surgical site infection were explicitly stated. Studies involving major dermatological surgery were excluded. The preliminary search yielded 820 studies after removing duplicates; 210 abstracts were screened, and 42 full texts were assessed for eligibility. A total of 13 articles were included. Studies were appraised using the Newcastle-Ottawa Quality Assessment Scale. An electronic data collection tool was constructed to extract information from the eligible studies, and this information was distributed to participating authors. Risk factors identified included age, sex, diabetes mellitus, chronic obstructive pulmonary disease, use of antihypertensive or corticosteroid medications, smoking, surgery on the lower or upper extremities, excision of nonmelanocytic skin cancers, large skin excisions, and complex surgical techniques. No more than two studies agreed on any given risk factor, and there were insufficient studies for meta-analysis. Re-excision of skin cancer, below-knee excisions, and intraoperative hemorrhagic complications were predictive for infection in more than one study. More high-quality studies are required to accurately identify risk factors so they can be reliably used in clinical guidelines.

Laparoscopic distal pancreatectomy with preservation of splenic vessels. Lateral to medial aproach

Background: Distal pancreatectomy with preservation of splenic vessels is a technique described by Kimura in 1996. It is indicated for the treatment of benign or potentially malignant lesions confined to the body or tail of pancreas. Like the Warshaw technique, it allows preservation of the spleen in cases of left pancreatectomy, but the incidence of vascular complications (splenic infarction) is lower with the Kimura technique, specially in the surgery of elderly patients. Methods: We present in the video the case of a 72-year-old female patient with an intraductal mucinous secondary branch neoplasia, which had increased size and associated cytology with atypia. Results: The patient was placed in the right lateral semidecubitus position and the intervention was performed using four trocars. The very caudal location of the lesion, as well as its size, allowed the easy identification of the splenic vein in its extrapancreatic segment next to the splenic hilum, reason why the pancreatic dissection was developed in lateral to medial sense. The parenchyma section was performed by applying an Echelon stapler ® with jaws protected with Seamguard ®. Surgical time was 180', with minimal blood loss. The patient was discharged 48 hours after the procedure. He did not present any postoperative complication. Conclusion: Kimura's technique is appropriate for the treatment of distal pancreatic lesions. In such cases a lateral to medial approach may be helpful in order to minimize the risk of intraoperative hemorrhagic complications.

Damage to vessels and retroperitoneal organs during lumbar spine surgery through the posterior approach

The study objective is to summarize the existing literature and own experience related to damage to vessels, retroperitoneal organs, and abdominal organs during lumbar spine surgery through the posterior approach, as well as to identify risk factors associated with this damage and to describe measures for their elimination and prevention.Materials and methods. In addition to analyzing the research literature, we also described 9 cases (3 males and 6 females; mean age 52 ± 9 years) of intraoperative damage to vessels and adjacent organs during lumbar spine surgery for some degenerative disease, including herniated disc (n = 7), anterolisthesis (n = 1), and vertebral-motor segment instability (n = 1). The surgery was performed at the L4–L5 level (n = 7) and L5–S1 level (n = 2). Results. The damages observed in the cohort analyzed were caused by a conchotome (n = 6), transpedicular screw (n = 1), Volkmann spoon (n = 1), and a tip of the SpineJet Hydrodiscectomy System (n = 1). The following structures were damaged; left common iliac vein (n = 2), left common iliac artery (n = 2), left common iliac vein and root of the small-bowel mesentery (n = 1), sigmoid colon (n = 1), aorta (n = 1), inferior vena cava (n = 1), and aortocaval anastomosis (n = 1). Five patients had intraoperative hemorrhagic complications. Four patients were found to have damage to vessels or abdominal organs later (1 h, 2 h, 3 days, and 4 months postoperatively). Four patients were discharged without consequences; 2 patients became disabled; 3 patients died.Conclusion. Damage to vessels, retroperitoneal organs, and abdominal organs during lumbar spine surgery through the posterior approach is a rare, but mortally dangerous complication. Spine surgery should be performed in multi-unit hospitals that have a surgery unit, a vascular surgery unit, an intensive care unit, and a sufficient supply of blood for transfusion.

LOCAL AND SYSTEMIC VEGF-А PRODUCTION IN COMPLICATED PROLIFERATIVE DIABETIC RETINOPATHY

VEGF-A contents was studied in blood serum, lacrimal fluid, and vitreous body of patients with different clinical forms of complicated proliferative diabetic retinopathy (PDR). The study included 50 patients with diabetes mellitus (type I, II), twelve patients with rhegmatogenous retinal detachment and fifteen healthy individuals. Complicated PDR was shown to be associated with higher levels of VEGF-A in blood serum and lacrimal fluid of these patients as compared to the cases of stable PDR and healthy individuals, as well as increased VEGF-A concentrations in vitreous humor. Concentrations of this cytokine in vitreous body proved to be significantly exceeded those in rhegmatogenous retinal detachment. Most severe clinical manifestations in complicated PDR and intraoperative hemorrhagic complications were associated with sharp VEGF-A increase in blood serum and vitreous humor, thus reflecting certain disturbances at local and systemic levels.

Maintenance of Warfarin Anticoagulation for Patients Undergoing Vitreoretinal Surgery

To evaluate the risk of hemorrhagic complications associated with vitreoretinal surgery in patients whose warfarin sodium therapy was continued throughout the surgical period. A review of 1737 records of patients undergoing pars plana vitrectomy was conducted. Inclusion criteria included patients receiving warfarin therapy whose international normalized ratios (INRs) were elevated above normal values on the day of surgery. Intraoperative and postoperative hemorrhagic complications were documented. Fifty-four patients underwent 57 vitreoretinal surgical procedures with warfarin therapy and were divided into groups as follows: group S with INRs of 1.20 to 1.49, values considered subtherapeutic; group B with INRs of 1.50 to 1.99, values considered borderline therapeutic; group T with INRs of 2.00 to 2.49, values considered therapeutic; and group HT with INRs of 2.50 or greater, values considered highly therapeutic. No patients experienced anesthesia-related or intraoperative hemorrhagic complications. Two (7.7%) of 26 eyes in group S and 2 (16.7%) of 12 eyes in group HT experienced postoperative hemorrhages. All of the patients with vitreous hemorrhages had spontaneous clearing without additional treatment. Many patients may safely undergo vitreoretinal surgery while maintaining therapeutic levels of warfarin anticoagulation. We experienced no intraoperative hemorrhagic complications; the 4 postoperative complications resolved spontaneously without persistent visual sequelae or the need for supplemental surgery.

Vaginal paravaginal repair: One-year outcomes

Objective: This study was carried out to determine the efficacy and safety of the vaginal approach to paravaginal repair of symptomatic paravaginal defect cystocele. Methods: This study is an observational case series of 100 consecutive women, referred from December 1996 to August 2000, with symptomatic grade II to IV paravaginal defect cystocele. Preoperative and postoperative pelvic evaluations were performed with the Baden-Walker halfway system. The same surgeon performed all repairs. Fourteen patients had prior anterior repairs, and 530 concomitant procedures were performed. The vaginal approach consisted of a thorough entry from the vesicovaginal space under the inferior pubic ramus into the retropubic space, widely exposing the area of the arcus tendineus. A repair was done bilaterally in 95 patients and unilaterally in 5. Between 1 and 6 Gore-tex CV-0 sutures (W. L. Gore and Associates, Inc, Elkton, Md) were placed widely around the arcus tendineus on either side and fixed to appropriate locations on the bladder fascia and anterior vaginal walls. Tying these sutures resulted in dramatic elevation of the lateral superior sulci. Patients were followed up for 1 to 36 months, with a mean of 10.6 months. Criteria for objective cure were defined as the lateral sulci of the anterior vaginal walls being at grade 0 and firmly apposed to the lateral pelvic sidewalls. Results: Of the 100 patients, 34 had grade II, 54 had grade III, and 12 had grade IV paravaginal defect cystocele. Patients were followed up postoperatively for 1 to 36 months: 84 for more than 6 weeks and 55 for 1 year or longer. Our objective cure rate was 98%. Two asymptomatic patients had a unilateral grade I or a bilateral grade II paravaginal defect cystocele. A recurrent midline cystocele occurred in 22 patients between 3 and 11 months after the operation. Twenty-one patients were asymptomatic and one was symptomatic. Twenty-one patients had grade I-II cystocele and one had grade III cystocele. There were 3 major intraoperative hemorrhagic complications; one of the operations was converted to an anterior colporrhaphy. There were a total of 21 major and 14 minor inpatient complications. Twenty-five subsequent complications included various urinary symptoms in 14 patients, long-term lower extremity neuropathy in 2, bloody discharge from intravaginal sutures in 3, absent coital sensation in 1, and recurrent pelvic organ prolapse in 5, all of which included grade III enterocele between 3 and 25 months. Conclusions: The vaginal approach to the correction of paravaginal defect cystocele is highly effective in our population at a mean of 11 months after the operation. Frequent complications do occur but are largely manageable. (Am J Obstet Gynecol 2001;185:1360–7.)