Intraoperative Salvage Research Articles

Perioperative extracorporeal membrane oxygenation in liver transplantation—bridge to transplantation, intraoperative salvage, and postoperative support: outcomes and predictors for survival in a large-volume liver transplant center

Data on perioperative extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) are scarce. ECMO has been used preoperatively, intraoperatively, and postoperatively for a variety of indications at our center. This retrospective, single-center study of ECMO use peri-LT aimed to describe predictors for successful outcome in this highly select cohort of patients. Demographics, support method, and indication for LT were compared between survivors and nonsurvivors. Twenty-nine patients received venovenous (V-V; n = 20), venoarterial (V-A; n = 8), and venoarteriovenous (n = 1) ECMO. Twelve (41.4%) patients were bridged to emergency LT for acute liver failure, and emergency redo LT. Four (13.3%) patients required intraoperative V-A ECMO salvage, 2 necessitating extracorporeal cardiopulmonary resuscitation. Thirteen (43.3%) patients required ECMO support after LT: V-V ECMO (n = 9); V-A ECMO (n = 1); and extracorporeal cardiopulmonary resuscitation (n = 3) between postoperative days 2 to 30. Overall, 19 patients (65.5%) were successfully weaned off ECMO; 15 (51.7%) survived to intensive care unit discharge. All patients who underwent intraoperative salvage ECMO and all who were bridged to emergency redo LT died. Peri-LT ECMO is feasible. Post-LT ECMO outcomes are encouraging, in particular for V-V ECMO. Intraoperative ECMO salvage, uncontrolled sepsis, and graft failure are associated with poor outcomes.

Successful Intraoperative Salvage of a Venous Congested Deep Inferior Epigastric Perforator Flap Using a Cross-thoracic Saphenous Vein Graft.

For autologous breast reconstruction using the deep inferior epigastric perforator flap, the internal mammary vessels are a common choice for recipient vessels. However, if these vessels are discovered to be inadequate, this may require the utilization of alternative vessels for successful salvage. Here, we demonstrate the use of a venous conduit for flap salvage in a patient undergoing bilateral deep inferior epigastric perforator flap breast reconstruction. Intraoperative venous congestion was identified on the left side. A contributing factor was an unresolvable size discrepancy between the deep inferior epigastric and the internal mammary venae comitantes. A saphenous vein graft can be used to drain the donor inferior epigastric vein to the contralateral internal mammary venae comitantes. In this discussion, adequate venous drainage was obtained with this approach, and the flap remained viable with good Doppler signals without further complications over a year postoperatively.

100 What Are We Transfusing? A Prospective Trial Evaluating the Quality of Intraoperatively Salvaged Red Blood Cells in Spinal Deformity Surgery

INTRODUCTION: Intraoperative RBC salvage (aka Cell Saver) is widely employed in spinal deformity surgery. Unlike other surgical subspecialities wherein blood is immediately salvaged (with low potential RBC injury), modern approaches to spine surgery inherently result in collection of blood exposed to high-heat electrocautery, prolonged stasis, and abrasive pharmaceuticals, potentially resulting in RBC injury. However, this has not been studied in a scientific manner. METHODS: Patients undergoing spinal deformity surgery with Cell Saver were prospectively enrolled (N = 86). Comparison blood samples include baseline (arterial-line), allogenic (blood bank), and salvage (Cell Saver transfusate). Qualitative laboratory measures of RBC health and hemolysis were collected. Morphological assessment utilized Stimulated Raman Histology (SRH) and artificial intelligence based machine-learning algorithm. Functional RBC evaluation was measured via ektacytometry. RESULTS: Salvage blood differed significantly from baseline and allogenic blood, including an unpredictable range of RBC density (2.11-9.52 x 1000/uL), and significantly lower MCV (smaller RBCs) vs. baseline and allogenic samples (p = 0.015 and 4.05E-8, respectively). SRH revealed a high proportion (30.7%) of often irreversibly injured acanthocytes (shrunken and irregularly spiculated RBCs). Ektacytometry revealed that salvaged RBCs were poorly deformable and had impaired relaxation kinetics. Salvage blood samples had significantly higher intracellular components indicating active lysis: potassium (p = 0.019 and 8.2E-16), LDH (p = 3.3E-11 and 1.66E-6), and free-hemoglobin (p = 4.87E-7 and 0.001). The salvage blood mean hemolysis index (HI) was significantly higher than baseline (155x, p = 1.1E-10) and allogenic blood (7.23x, p = 2.29E-5). CONCLUSIONS: Intraoperative salvaged blood is composed of high proportions of irreversibly injured RBCs with HI even exceeding levels suitable for transfusion by US FDA and Council of Europe standards, properties that may decrease the suitability of salvaged RBCs as a blood replacement. Collection of postoperative laboratory data and perioperative outcomes are currently underway.

Multidisciplinary conference for complex surgery leads to improved quality and safety.

Complex surgery for adult spinal deformity has high rates of complications, reoperations, and readmissions. Preoperative discussions of high-risk operative spine patients at a multidisciplinary conference may contribute to decreased rates of these adverse outcomes through appropriate patient selection and surgical plan optimization. With this goal, we implemented a high-risk case conference involving orthopedic and neurosurgery spine, anesthesia, intraoperative monitoring neurology, and neurological intensive care. Included in this retrospective review were patients ≥ 18years old meeting one of the following high-risk criteria: 8 + levels fused, osteoporosis with 4 + levels fused, three column osteotomy, anterior revision of the same lumbar level, or planned significant correction for severe myelopathy, scoliosis (> 75˚), or kyphosis (> 75˚). Patients were categorized as Before Conference (BC): surgery before 2/19/2019 or After Conference (AC): surgery after 2/19/2019. Outcome measures include intraoperative and postoperative complications, readmissions, and reoperations. 263 patients were included (96 AC, 167 BC). AC was older than BC (60.0 vs 54.6, p = 0.025) and had lower BMI (27.1 vs 28.9, p = 0.047), but had similar CCI (3.2 vs 2.9 p = 0.312), and ASA Classification (2.5 vs 2.5, p = 0.790). Surgical characteristics, including levels fused (10.6 vs 10.7, p = 0.839), levels decompressed (1.29 vs 1.25, p = 0.863), 3 column osteotomies (10.4% vs 18.6%, p = 0.080), anterior column release (9.4% vs 12.6%, p = 0.432), and revision cases (53.1% vs 52.4%, p = 0.911) were similar between AC and BC. AC had lower EBL (1.1 vs 1.9L, p < 0.001) and fewer total intraoperative complications (16.7% vs 34.1%, p = 0.002), including fewer dural tears (4.2% vs 12.6%, p = 0.025), delayed extubations (8.3% vs 22.8%%, p = 0.003), and massive blood loss (4.2% vs 13.2%, p = 0.018). Length of stay (LOS) was similar between groups (7.2 vs 8.2days, 0.251). AC had a lower incidence of deep surgical site infections (SSI, 1.0% vs 6.6%, p = 0.038), but a higher rate of hypotension requiring vasopressor therapy (18.8% vs 4.8%, p < 0.001). Other postoperative complications were similar between groups. AC had lower rates of reoperation at 30 (2.1% vs 8.4%, p = 0.040) and 90days (3.1 vs 12.0%, p = 0.014) and lower readmission rates at 30 (3.1% vs 10.2%, p = 0.038) and 90days (6.3 vs 15.0%, p = 0.035). On logistic regression, AC patients had higher odds of hypotension requiring vasopressor therapy and lower odds of delayed extubation, intraoperative RBC, and intraoperative salvage blood. Following implementation of a multidisciplinary high-risk case conference, 30- and 90-day reoperation and readmission rates, intraoperative complications, and postoperative deep SSIs decreased. Hypotensive events requiring vasopressors increased, but did not result in longer LOS or greater readmissions. These associations suggest a multidisciplinary conference may help improve quality and safety for high-risk spine patients. particularly through minimizing complications and optimizing outcomes in complex spine surgery.

First dorsal metacarpal arterialized venous (FDMAV) flap: intraoperative salvage of an ischemic FDMA flap by arteriovenous supercharging—a case report in thumb reconstruction

First dorsal metacarpal arterialized venous (FDMAV) flap: intraoperative salvage of an ischemic FDMA flap by arteriovenous supercharging—a case report in thumb reconstruction

Intraoperative salvaging of failure to harvest the bi-paddle anterolateral thigh flap: a case series.

BackgroundThe size and versatility of anterolateral thigh (ALT) flap enables a bi-paddle flap to cover complex and extensive defects optimally. However, it is characterized by variations in the sources of blood vessels and in the number of perforators, which increases the chances of failure of harvesting a bi-paddle flap. We present our method to overcome such failure. This is the first study exploring the optimal salvaging algorithm to overcome harvesting failure with the bi-paddle ALT flap.MethodsFrom January 2014 to December 2020, in 9 patients to be treated with bi-paddle ALT flap for soft-tissue defects (range, 48–288 cm2), there was failure of flap harvest because of perforator variations. We redesigned and converted the flaps to other forms for harvest intraoperatively, based on the characteristics of the defect, and the number and sources of perforators.ResultsSalvage of flap harvest was successfully performed in all 9 cases. In 4 cases the flap with a single perforator was converted to widened-single-perforator flaps; in 2 cases, a single perforator was converted to a de-epithelialized flap; in 2 cases of 2 perforators from different main branches, conversion was to sequential chimeric flaps; in the remaining case of 2 perforators from the descending branch and transverse branch, conversion was to a combined transverse-and-descending branches flap. Venous compromise occurred in only 1 case, and the patient survived after revised surgery. Local infection in the receiving area occurred in 3 cases, and was cured by wound dressing. All flaps survived (follow-up 5–24 months).ConclusionsDespite preoperative preparation, anatomic variations resulted in failure of bi-paddle ALT flap harvesting. As shown by our results, it is feasible to redesign and convert the bi-paddle flap to other forms based on the defect characteristics, and the number and sources of perforators.

Salvage Fixation With a Single Nitinol Compression Staple for a Lateralized Fibular Tunnel in Posterolateral Corner Reconstruction of the Knee

Recognition and treatment of injuries to the posterolateral (PLC) corner of the knee have increased in recent decades. Despite advancements in surgical technique, complications can occur in up to 20% of PLC reconstructions. Lateralization of the fibular tunnel during drilling is a common intraoperative pitfall and can lead to cortical breach or fibular head fracture after graft tensioning. Compression staples have been increasingly used for fracture fixation in the hand, foot, and ankle. Because of its pseudo-elastic properties, insertion of a low-profile, compressive Nitinol staple could serve as an intraoperative salvage technique to reinforce and prevent failure through a thin lateral cortex of the fibular head. The purpose of this Technical Note is to describe a reproducible technique for the implementation of a Nitinol staple for reinforcement of a lateralized fibular tunnel in posterolateral corner reconstruction.

Effects of transfusion load and suction pressure on renal function in intraoperative salvage autotransfusion.

Although some investigations have been performed to determine the effects of transfusion load and suction pressure on renal function during intraoperative salvage autotransfusion, the precise threshold is still undetermined. A total of 625 patients undergoing surgery with the Continuous AutoTransfusion System (CATSplus) were enrolled and divided into groups according to the utilized suction pressure and transfusion volume. Plasma free hemoglobin (FHB) and creatinine clearance (CCr) were assayed to indicate the renal function. Both 0.03 MPa suction (≥4-unit load) and >5 units transfusion changed the levels of FHB and CCr significantly when measured 24 h post-operation compared to pre-operation. Under 0.02 MPa suction (≥4-unit load), the alteration of FHB and CCr returned to normal after 24 h. Under 3 units transfusion, the levels of FHB and CCr at 6 and 12 h post-operation changed significantly compared to pre-operation (P<0.05 or P<0.01, respectively), and this alteration could be restored to normal at 72 h post-operation. After an exhaustive investigation, less than 4 units transfusion and less than 0.03 MPa suction pressure are recommended for intraoperative salvage autotransfusion.

Dabigatran reversal with idarucizumab prior to lung transplantation.

When the transplant candidates are receiving oral anticoagulation therapy before transplantation, it is crucial to have an urgent reversal strategy to prevent hemorrhagic complications perioperatively. The aim of this study was to present the experience with idarucizumab to reverse the anticoagulant activity of dabigatran prior to lung transplantation. A single-center retrospective study was performed to analyze the clinical outcomes of idarucizumab use before lung transplantation. Between July 2016 and June 2019, six patients were on dabigatran at the time of transplantation. Out of the six patients, four patients received idarucizumab. These four recipients received a median of 3 units (range 0-4 units) of packed red blood cells (pRBCs) and 450ml (range 250-1500ml) of intraoperative salvage of shed blood (cell saver blood) during the lung transplant. The two patients who were not administered idarucizumab received 5 units and 13 units of pRBCs and 900ml and 3600ml of cell saver blood, respectively. There was no grade 3 primary graft dysfunction (PGD) at 72hours after transplantation or in-hospital mortality in idarucizumab group. In the group without idarucizumab, there was one case of grade 3 PGD without any in-hospital mortality. Dabigatran reversal with idarucizumab provides reasonable hemostasis during lung transplantation.

Atlanto-Occipital Transarticular Screw Fixation for the Treatment of Traumatic Occipitocervical Instability in the Pediatric Population

Atlanto-occipital transarticular screw fixation (AOTSF) has rarely been reported for fixation of the craniovertebral junction (CVJ). A retrospective chart review of all pediatric patients (less than 18 years of age) with an attempt ofAOTSF for fixation of traumatic CVJ instability was conducted. A total of 4 patients (2 boys and 2 girls; ages 2, 3, 5, and 8 years) who suffered from acute traumatic CVJ instability managed during 2007-2018 underwent an attempted AOTSF. In 2 patients, this method was technically successful. In the other 2 instances, we were not able to engage the screw into the occipital condyle. These were converted to standard occipital plate, rod, and screw fixation. All were placed in a halo subsequently for a minimum of 3months. Three patients were fused at last follow-up (range, 17-48 months). One patient after successful AOTSF did not fuse. There were no surgical complications or revision procedures. AOTSF was feasible in half of pediatric patients suffering from traumatic CVJ instability. Therefore, intraoperative salvage options and strategies should be on hand readily. In the pediatric population, where bony anatomy may pose challenges to fixation, this technique may offer a viable first-line option in selected cases, despite the overall modest success rate.

An Intraoperative Salvage After Transection of the Greater Palatine Artery During Cleft Palate Repair: A Case for Buccal Fat and Buccal Myomucosal Flaps

Recently, several adjunctive procedures have gained traction to aid cleft surgeons in repairing especially challenging palatal clefts. Buccal fat flaps and buccal myomucosal flaps have demonstrated particular utility in reinforcing thin palatal flaps or tissue deficits. Although their use has not been widely accepted, they may be particularly helpful in the setting of significant scarring or vascular compromise. Here the authors describe the case of an intraoperative salvage using bilateral buccal fat flaps and a right buccal myomucosal flap after transection of the right Greater Palatine artery (GPA) during palatoplasty on a 14-month old female with Pierre Robin Sequence and a wide Veau II cleft palate. For this operative salvage, bilateral buccal fat flaps were used to reinforce the hard-soft palate junction and a 4 cm × 2 cm flap of the right-sided buccal mucosa and buccinator muscle was inset along the majority of the right-sided soft and posterior hard palate. At 2 years follow-up, the patient had no significant complications and was doing well with healthy-appearing palatal tissue and age-appropriate speech.

Ispitivanje funkcije trombocita i primena rotacijske tromboelastometrije u cilju racionalizacije hemoterapije tokom revaskularizacije miokarda i hirurškog tretmana srčanih zalistaka

Using intraoperative salvage of blood/erythrocytes (ISB/E) in the practice, rationalized application of allogeneic blood products and hemostatic-active drugs - based on "point-of-care" (POC) monitoring findings - it is possible to improve diagnosis and evaluate of transfusion hazards and increase efficacy of therapy of patients with excessive bleedings, with reduction of perioperative morbidity and mortality in cardiac surgery. This study was performed as a prospective analysis of platelet function using "multiple platelet function analyzer" (MEA; by Multiplate) system and examination of hemostasis by rotational thromboelastometry (ROTEM) during and immediately following myocardial revascularization and surgical treatment of valves in the Institute of Cardiovascular Diseases "Dedinje" for six years period for therapy of 1021 random selected patients. The study aim was to evaluate the influence of ISB/E and hemostatic drugs - indicated based on the results of platelet count and function (Multiplate) and hemostasis monitoring (ROTEM) in compared to allogeneic transfusions - on the incidence of bleedings, treatment efficiency and overall clinical outcome. In the perioperative period, a total of 617 (60.4%) patients were treated with ISB/E reinfusion only. Other patients (404; 39.6%) received allogeneic blood components too. Total 391 of them (38.3%) were treated (together by ISB/E) with transfusion of one to three units of allogeneic red blood cells (RBCs). There were only 13 (1.3%) polytransfunded (typically 10 - 15 units) patients. The rate of cardio-surgical reinterventions due to bleeding was only 2.5%. In conclusion, the application of the ISB/E strategy represents an effective and safe (reduced immune-mediated complications and risk of disease transmission) therapeutic approach. By monitoring MEA/ROTEM and implementation the algorithm of current transfusion therapy, it is possible to reduce significantly of allogeneic blood component therapy. The use of allogeneic RBCs is justified only when the possibilities of autologous transfusion and pharmacological hemostatic therapy have been exhausted.

Application of intraoperative red cell salvage and autologous blood transfusion in cesarean section of pregnant women with central type of placenta previa

Objective To observe the safety and effect of intraoperative cell salvage and autologous blood transfusion during cesarean section with central placenta previa. Methods From April 2015 to March 2016, 25 pregnants with central placenta previa diagnosed by MRI and ultrasound and underwent selected caesarean section in the People′s Hospital of Wenzhou were included. When the amount of blood in the recovery tank was 450 mL or the obstetrician required, the wash and retransfusion device was started-up. Hb and Hct were measured before and after the parturient, and the blood was recovered. The blood loss, recovery of blood, blood transfusion, allogeneic RBC infusion and the side effects after transfusion and 42 d of postpartum were recorded. Results No serious complications were recorded in all pregnants. Five cases(20%) were only recovered and the autologous blood transfusion and transfusion of the allogeneic RBC were not carried out. In 14 cases(56%), only the autologous blood was returned to the puerpera. The volume of blood transfusion was 705 mL(430, 1 535). Six cases(24%) had massive bleeding during the operation, 3690 mL(1 900, 8 750), and the autologous blood transfusion volume was 2939 mL(1 167, 4 206), and the allogeneic RBC transfusion was 3.5U(1.5, 11.5). Conclusion Autologous blood transfusion can be used safely in the caesarean section of the central placenta previa, and can reduce the allogeneic RBC transfusion. Key words: Placenta previa; Cesarean section; Operative blood salvage; Erythrocytes; Hemoglobins; Hematocrit

Upotreba autolognih hemoprodukata u mirnodopskim uslovima, vanrednim situacijama i ratu

Introduction In industrialized countries, autologous transfusion (AT) of blood and/or autologous blood products is often used. Objective To perform an analysis on the possibilities of using autologous blood products (ABP) in peace and in war. Methods In peacetime conditions, all AT strategies can be performed: 1) planned preoperative autologous blood and/or blood components collection (PPAB-BCC); 2) acute normovolemic hemodilution (ANH); 3) intraoperative blood salvage of autologous blood; 4) postoperative blood salvage; 5) administration of autologous platelets; 6) the use of autologous fibrin glue and autologous tissue adhesives; 7) the collection and storage of autologous erythrocytes and autologous fresh plasma. In emergency situations and war, the most applicable strategies are: a) ANH; b) intraoperative blood salvage; c) postoperative blood salvage; d) application of autologous fibrin glue and autologous tissue adhesives. Results In peace. PPAB-BCC was used for 314 patients, who were planned for elective surgery. AB was collected using intraoperative blood salvage in the amount of 520 ml for 281 patients. ANH was performed for 30 patients. For 20 of those, 780ml of blood was collected and they were operated on for colon cancer with rectum amputation and one nephrectomy was performed on a patient with single kidney neoplasm. ANH was performed on 9 orthopedic patients. Intraoperative autologous blood salvage in peaceful conditions was performed for 52 adult patients who underwent cardiac surgery procedures. The amount of autologous blood collected and reinfused ranged from 1,500 to 3,500 ml per patient. With the help of a Cell-Saver, autologous blood salvage was performed on 63 patients during pediatric heart surgery. The amount of intraoperative salvaged autologous blood per operation ranged from 210 ml to 620 ml. During the 1990s, doctors at the Military Medical Academy (MMA) used plateletrich autologous plasma on 38 patients who had diseased blood vessels replaced with dacron grafts. In war. During the civil war on the territory of former Yugoslavia, intraoperative salvage of autologous blood was performed on 25 wounded patients who suffered from closed pneumothorax due to blast injury, in which cased 500 ml to 1500 ml of autologous blood was collected. With the help of the 'Pleur-Evac autotransfusion system', immediately after collection, reinfused to the wounded patient during the helicopter transport to the MMA. Autologous fibrin glue was used to treat 10 wounded patients during reconstructive surgery procedures. Conclusion In peacetime conditions, the AT program should be organized in every hospital that has adequate conditions for its implementation. The implementation of AT is very important because it can serve as an alternative to homologous transfusion. Our experiences from the war on the territory of the former Yugoslavia tell us that certain strategies of the AT program can successfully be implemented even in emergency situations and during war.

Algorithmic Approach for Intraoperative Salvage of Venous Congestion in DIEP Flaps.

Flap congestion is a frequently described intraoperative complication during autologous breast reconstruction with abdominal perforator flaps, which, if not addressed, can lead to detrimental results such as flap failure. Here, we describe our institution's algorithm of intraoperative salvage of congested flaps and present their outcomes. All patient charts from 2002 to 2016 of a single plastic surgeon were reviewed for patients who underwent deep inferior epigastric perforator flap breast reconstruction resulting in 602 patients and 831 flaps. Of those, 38 women (6.3%) with 40 congested flaps (4.8%) were included in this study. Based on the algorithm guiding the selection of additional venous anastomosis, the patients' surgical details, outcomes, as well as their demographic characteristics are evaluated. Average age and body mass index of our cohort were 47.0 ± 8.0 years and 26.1 ± 3.9, respectively. Ten patients (26.3%) were current or former smokers while 20 (52.6%) required external radiation. Thirty-two congested flaps (80.0%) were predominantly salvaged with a superficial inferior epigastric vein (SIEV)-to-deep inferior epigastric vein (comitante) anastomosis. An SIEV-to-internal mammary vein comitante anastomosis was the second favorite option (5 flaps, 12.5%). Five patients suffered minor complications within a mean follow-up of 18.8 ± 12.3 months without flap failure, bleeding, or infection. Venous flap congestion is an uncommon intraoperative intricacy during free tissue transfer for autologous breast reconstruction. Our proposed algorithm primarily recommends adding an additional venous anastomosis between the superficial and deep drainage system and results and favorable outcomes without major complications.

Obstetric intra-operative cell salvage and maternal fetal red cell contamination.

The significance of fetal red blood cell (RBC) contamination in obstetric intra-operative cell salvage is not fully known. It is unclear if we re-infuse a larger volume of fetal RBCs into the maternal circulation than the amount that occurs secondary to transplacental haemorrhages is unclear. We also do not know if there is a critical volume required to cause alloimmunisation or if larger volumes increase the risk. The aim of this study is to provide data on the level of fetal RBC contamination in the maternal circulation prior to delivery and immediately post-partum and to compare these levels to those found in processed cell-salvaged blood. In the first part of this study, we quantified the levels of fetal RBCs circulating in women immediately prior to delivery. This was then repeated with a separate group measuring the levels of fetal RBCs pre- and post-delivery. We found that 37% of women had fetal cells detected in their circulation, median 0·00 mL (IQR 0-0·24; average 0·3mL, maximum 4·56 mL). Fetal RBCs were present pre-delivery (maximum 0·66 mL) in 16% of women, increasing to 53% post-delivery (median 0·66 mL; IQR 0·22-2·20, maximum 21·20 mL). We have shown that fetal RBCs are present in the maternal circulation throughout pregnancy and that the volumes are comparable to that obtained from intra-operative salvage, with contamination amounts of up to 19 mL. At the Royal Cornwall Hospital, our experience and evidence supports offering intra-operative salvage to all women, and we have not noted an increase in antibody formation, compared to allogeneic transfusion.

When medicine and religion do not mix: Overlooking or misunderstanding the religious and spiritual beliefs of patients can present significant obstacles to cancer care.

When medicine and religion do not mix: Overlooking or misunderstanding the religious and spiritual beliefs of patients can present significant obstacles to cancer care.

Effectiveness of proximal intra-operative salvage Palmaz stent placement for endoleak during endovascular aneurysm repair.

The use of a proximal Palmaz stent is a well-recognised technique to treat proximal endoleak in endovascular aortic repair. This study aimed to report the effectiveness and safety of an intra-operative Palmaz stent for immediate type 1a endoleak in Hong Kong patients. This case series was conducted at a tertiary hospital in Hong Kong. In a cohort of 494 patients who underwent infrarenal endovascular aortic repair from July 1999 to September 2015, 12 (2.4%) received an intra-operative proximal Palmaz stent for type 1a endoleak. Immediate and subsequent proximal endoleak on follow-up image was documented. Morphological review of the pre-repair aneurysm neck showed five conical, one funnel, five cylindrical and one undetermined short neck, with a median neck angle of 61 degrees (range, 19-109 degrees). Stent grafts used included seven Cook Zenith, one Cook Aorto-Uni-Iliac device, three Metronic Endurant, and one TriVascular Ovation. Eleven Palmaz stents were placed successfully as intended, but one of them was accidentally placed too low. Of the 12 type 1a endoleaks, postoperative imaging revealed immediate resolution of eight whilst four had improved. After a median follow-up of 16 (range, 1-59) months, none of the subsequent imaging showed a type 1a endoleak. The mean size of the aneurysm sac reduced from 7.4 cm preoperatively to 7.3 cm at 1 month, 6.9 cm at 6 months, 7.1 cm at 1 year, and 6.1 cm at 2 years postoperatively. None of these patients required aortic reintervention or had device-related early- or mid-term mortality. One patient required delayed iliac re-interventions for an occluded limb at 10 days post-surgery. In our cohort, Palmaz stenting was effective and safe in securing proximal sealing and fixation.

Intraoperative salvage endoscopy performed during orthotopic liver transplantation due to esophageal bleeding.

IntroductionLiver transplantation (LTx) is a widely accepted method of treatment for end stage liver diseases. There are many reports on the management of gastrointestinal bleeding (GIB) after LTx, however the number of studies concerning salvage endoscopic procedures during LTx are scarce.AimWe present our material of intraoperative endoscopic procedures due to GIB during LTx.Material and methodsDuring this period there were 4 females and 1 male at the mean age of 52.2 (35–65) years who underwent LTx and 1 patient had Re-LTx. All patients were Child-Pugh group C and mean MELD score was 17.75. Esophageal and/or gastric varices were present before surgery in all patients but only 1 female patient didn't experience GIB prior to LTx. Variables such as operating time, cold ischemic time, blood loss, blood transfusion, PLT count, international normalized ratio, albumin levels were similar in all patients thus making it statistically insignificant as the cause of GIB.ResultsIn all cases a single IOE was necessary and bleeding from ruptured varices succumbed to endoscopic ligation. In 2 patients besides trials of ligating the varix, histoacryl was put in use which proved success. In both these last female patients the endoscopic physician had to insert a Danis stent. A follow up endoscopy was performed on the 7–10 POD.ConclusionsIntra-operative endoscopy performed during LTx does not interrupt surgery. Performed as soon as possible results in less future endoscopic interventions due to GIB. Intraoperative endoscopy may be considered as a salvage procedure and should be performed in the shortest possible time.

Intraoperative Conversion from Endoscopic to Open Transcortical-Transventricular Removal of Colloid Cysts as a Salvage Procedure.

Objective: To describe the transcortical-transventricular as an intraoperative salvage procedure and its effect of operative time and outcome.Methods: Thirty-three patients were included in the study. Twenty patients had an endoscopic operation, five had a transcortical-transventricular approach, and eight underwent an interhemispheric approach for resection. Based on common cyst location in the roof of the third ventricle, we propose a simple classification of surgical operative zones based on relationships defined by the anterior column of the fornix, the septal vein, and the medial atrial vein.Results: Complete capsule removal was achieved in 35% of endoscopic operations, 100% of transcortical-transventricular operations, and 63% of the interhemispheric operations. Operative time was 176 minutes for endoscopic operations, whereas the operative time for cases that converted to the transcortical-transventricular approach was 190 minutes (p=0.39).Conclusion: A surgical-based classification of zones within the roof of the third ventricle that can be accessed with microsurgical techniques is proposed. Both endoscopic and microsurgical cyst aspiration and excision remain options. We believe that younger patients, patients with large cysts that fill the third ventricle, or those with recurrence after prior treatment would benefit from open transcortical excision as a safe and effective operative approach using modern image-guided systems.Consent was formally obtained or waived for all subjects present within this study.