Late Hemorrhage Research Articles

Case Report of Placenta Accreta Spectrum and Arteriovenous Malformations with Successful Preservation of Fertility After Birth

Uterine arteriovenous malformations (UAVMs) that occur after birth are a rare cause of late postpartum hemorrhage. Acquired UAVMs usually occur in conjunction with pathology of the placenta. In the spectrum of placenta accreta (PAS), subinvolution of the placental bed plays an important role in its pathophysiology. We present a case of UAVM in a pregnant woman with PAS who presented with marked metrorrhagia after delivery, which was treated with classical management. Then, 35 days later, she presented to the emergency room with severe metrorrhagia. As it was suspected that she had placental remnants, an instrumental uterine control was performed, but the bleeding persisted, requiring further uterine packing and blood administration. Later, uterine artery embolization was performed with good results. Color Doppler ultrasound, magnetic resonance imaging, and angiography were the methods with the greatest diagnostic value. The differential diagnosis was as complex as the treatment. We hypothesize that UAVM may develop from minimal residual PAS in this late postpartum period. Moreover, they may recover rapidly after local surgical ablation. Considering the clinical condition, hemodynamic status, and desire to preserve fertility, we were able to avoid a hysterectomy, which is often chosen in such cases of severe, life-threatening bleeding complications.

HEMORRAGIA PÓS-PARTO: FATORES DESENCADEANTES E IMPLICAÇÕES PARA À PRÁTICA CLÍNICA: UMA REVISÃO NARRATIVA DA LITERATURA

Postpartum hemorrhage (PPH) is a critical obstetric condition characterized by excessive blood loss after childbirth. It can occur immediately after delivery or develop within the first 24 hours, referred to as early postpartum hemorrhage, or up to 12 weeks after childbirth, known as late postpartum hemorrhage. This study is a bibliographic research, configured as a narrative review of the literature related to postpartum hemorrhage, focusing on its main triggering factors and clinical practice implications, aiming to synthesize published research on this topic. The final review sample consisted of 20 articles, after the exclusion of 133 during the full reading and application of inclusion and exclusion criteria. Initially, the screening of titles and abstracts reduced the sample from 346 to 153 articles, with 193 excluded at this stage. The original sample, obtained after applying the descriptors, included 483 articles, but was reduced to 346 after the removal of 137 duplicates. In the literature found, all studies were categorical in presenting the main triggering factors for postpartum hemorrhage. In this sense, the authors mainly discuss the "4Ts" as key risk factors associated with this obstetric emergency, a serious complication and one of the leading causes of maternal mortality worldwide. The term "4Ts" refers to four potential causes of postpartum hemorrhage: Tone, Trauma, Tissue, and Thrombin. In summary, postpartum hemorrhage is a complex and multifactorial condition that requires a multidisciplinary approach.

Preliminary result of combined treatment with scanning carbon-ion radiotherapy and image-guided brachytherapy for locally advanced cervical adenocarcinoma.

Although there is growing evidence of the efficacy of carbon-ion radiotherapy (CIRT) for locally advanced cervical adenocarcinoma, reports on combined treatment with CIRT and image-guided brachytherapy (IGBT) are scarce. We retrospectively analyzed patients with International Federation of Gynecology and Obstetrics (2008) stage II-IVA locally advanced cervical adenocarcinoma who received combined scanning CIRT (sCIRT) and IGBT between April 2019 and March 2022. sCIRT consisted of whole-pelvic irradiation with 36Gy (relative biological effectiveness [RBE]) in 12 fractions and subsequent local boost irradiation with 19.2Gy (RBE) in 4 fractions. Three sessions of IGBT were administered after completion of sCIRT. Concurrent chemotherapy using weekly cisplatin (40mg/m2/week) was also administered. Efficacy, toxicity and dose-volume parameters were analyzed. Fifteen patients were included in the analysis. The median follow-up period was 25months. The 2-year overall survival, progression-free survival and local control rates were 92.3% (95% confidence interval [CI] = 77.8-100%), 52.5% (95% CI = 26.9-78.1%) and 84.8% (95% CI = 65.2-100%), respectively. Neither severe acute toxicity necessitating treatment cessation nor grade 3 or higher late toxicity were observed. The sigmoid D2cm3 of the patient who developed grade 2 late sigmoid hemorrhage was 65.6Gy, which exceeded the standard deviation and target dose. The combination of sCIRT and IGBT for locally advanced cervical adenocarcinoma showed acceptable efficacy and safety. Further large-scale and long-term studies are warranted to confirm the efficacy and safety of this treatment.

Evaluation of the results of the modified Blumgartpancreatic-intestinal anastomosis technique according to Satoi in pancreaticoduodenectomy at Bach Mai Hospital

Objectives: This study aims to research on the safety and effectiveness of the modified Blumgart pancreaticojejunostomy anastomosis by Satoi in Bach Mai Hospital. Research subjects: Seventy-three patients underwent modified Blumgart pancreaticojejunostomy anastomosis by Satoi after pancreaticoduodenectomy at Gastrointestinal and Hepato-Biliary-Pancreatic Surgery Department, Bach Mai Hospital between October 2020 and April 2023. Method: Cross-sectional study combining retrospective and prospective studies. The Blumgart anastomosis was modified to simplify with 2 U-shaped sutures. Results: The average age of the study subjects was 58.49±12.69 years; the age group over 60 accounted for over 50%; male/female ratio was ~1. The number of patients with complications was 22/73; the total number of complications was 33, including 3 grade-III-or-above complications, according to Clavien-Dindo: 1 case had complications of grade C pancreatic fistula causing late hemorrhage, from the common hepatic artery wall, needs re-surgery, 1 case needs hemostasis under intervention radiology, 1 case needs to be drained under ultrasound guidance, and no patient deaths. Conclusion: The modified Blumgart pancreaticojejunostomy by Satoi is a safe and effective technique.

Choriocarcinoma presenting as late postpartum hemorrhage in a 21-year-old primipara

INTRODUCTION: Obstetrical hemorrhage remains to be one of the most common causes of maternal morbidity and mortality. Postpartum hemorrhage occurs after delivery and is usually secondary to uterine atony, genital tract lacerations, and retained placental fragments. CASE: A case of a 21-year old, primipara, presented with profuse vaginal bleeding and hemoptysis at 3 weeks' postpartum. A clinical diagnosis of gestational trophoblastic neoplasia was established after an elevated serum beta human chorionic gonadotropin was obtained and an intrauterine mass was seen on ultrasonography, including metastasis to the lungs and liver seen through imaging studies. DISCUSSION: Chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and oncovin (EMACO) is the mainstay treatment for Stage IV disease. However, complications such as hemorrhage and tumor rupture are best managed surgically. Although rare, a diagnosis of choriocarcinoma should be considered in patients with persistent bleeding after a normal pregnancy to institute proper management and avoid associated complications of tumor progression.

Comparison of tranexamic acid plus intramuscular oxytocin with intramuscular oxytocin alone for prophylaxis of primary postpartum haemorrhage in vaginal delivery

In contemporary obstetrics, postpartum hemorrhage is one of the primary causes of maternal mortality. Postpartum hemorrhage is defined as blood loss of more than 500 mL within the first 24 hours of birth. The term, late postpartum hemorrhage is used when the bleeding lasts more than 24 hours. Due to the physiological changes that occur during pregnancy, the body may sustain a 500 mL blood loss without experiencing any severe negative consequences. However, even a modest amount of blood loss might be harmful in cases of comorbidities like anemia. However, even a modest amount of blood loss might be harmful in cases of comorbidities like anemia. Postpartum hemorrhage poses a double threat because it decreases the mother's strength and immunity, leaving her more vulnerable to puerperal illnesses. Second, the loss of blood could be fatal. Maternal death occurs gradually as a result of constant trickle-like blood loss. There are predictors which may help us in scrutinizing patients to be labeled as high risk for postpartum hemorrhage, however, there are no formulized criteria for postpartum hemorrhage. The active management of the third stage of labor is a management protocol made to prevent as well as manage this potentially life-threatening condition. It has significantly led to a reduction in maternal mortality rates. However, with more permutation - combinations of medical management and using different pharmacological agents we can devise a better algorithm for further deduction in the mortality rates. Here we propose to randomly allocate and administer an additional drug, tranexamic acid, in addition to uterotonics prophylactically given during the active management of the third stage of labor in vaginal deliveries. In doing so we compare the differences between groups in which only oxytocin was given and in which oxytocin plus tranexamic acid was given.

“Transcallosal” periventricular anastomosis in moyamoya disease: the fourth periventricular anastomosis and a potential predictor of hemorrhage

ObjectivesChoroidal anastomosis is a risk factor for hemorrhage in moyamoya disease. One variant of choroidal anastomosis, “transcallosal anastomosis,” originates from the medial posterior choroidal artery, and penetrates the corpus callosum to reconstruct the pericallosal artery. We aimed to investigate the prevalence and the bleeding rate of transcallosal anastomosis using sliding thin-slab maximum intensity projection reformatted from magnetic resonance angiography (MRA). Materials and MethodsThis study included 222 patients. We defined transcallosal anastomosis grades (0-2) and the stenosis of the anterior (ACA, 0-2), middle (MCA, 1-3), and posterior cerebral artery (PCA, 0-2) by MRA scores, independently by two coauthors. ResultsGrade-2 transcallosal anastomosis was detected in 21 patients (9.5 %). There were no correlations of the incidence of transcallosal anastomosis with previous bypass surgery (P = 0.23). Multivariate analysis revealed a significantly higher incidence in hemorrhagic onset and younger age (odds ratio [OR] 3.77, and 0.97). Transcallosal anastomosis had statistically significant correlation with ACA and PCA scores (P = 0.01 and 0.03), but not with MCA scores (P = 0.1). In multivariate analysis, ACA scores 1 and 2 were significantly higher (OR, 15.44 and 11.17), and PCA score 1 was also higher (OR, 3.07), but PCA score 2 was not. Interrater agreement for judgment of transcallosal anastomosis grade was strong (κ = 0.89). Two patients with Grade-2 transcallosal anastomosis had late hemorrhage in the corpus callosum (bleeding rate: 2.5 % per year). ConclusionsTranscallosal anastomosis may be associated with both advanced ACA and moderate PCA stenosis, and cause hemorrhage at the corpus callosum.

Отдаленные результаты применения вискодиссекции с контрастированием в хирургии пролиферативной диабетической ретинопатии

Purpose. To evaluate long-term results of surgery for proliferative diabetic retinopathy using contrast-enhanced viscodissection. Material and methods.The study involved 30 patients with type 1 diabetes mellitus (DM) and PDR with traction retinal detachment (TRD). All patients were divided into two groups. In the main group, viscodissection with contrast was performed; in the control group, segmentation and membrane removal were performed using a vitreotome and endovitreal forceps. The observation period was 12 months. Results. During dynamic observation, all patients showed a positive dynamics of morphofunctional parameters. In patients of the control group, in the vast majority of cases, it was necessary to resort to tamponade with silicone oil (60%) or gasair mixture (33%), while in the main group, the main postoperative media were sterile BSS solution (73%) and gas-air mixture (27%). 60% of patients in the control group required a reoperation to remove silicone oil. In patients of the control group in the late postoperative period, IOP values were significantly higher (main group 14.3 ± 1.1; control group 18.7 ± 1.5; p < 0.05), and late postoperative vitreous hemorrhage developed more often (2.3 ± 0.5 in the main group, 4.1 ± 0.6 in the control group; p < 0.05). Conclusion. In the long-term follow-up, the use of this method reduces the need for repeated endovitreal intervention, reduces the risk of developing late postoperative vitreous hemorrhage, and has a positive effect on IOP by reducing the need for endotamponade with silicone oil. Keywords: diabetes mellitus, proliferative diabetic retinopathy, vitreoretinal surgery, contrastenhanced viscodissection

Dosimetric Predictors of Toxicity after Prostate Stereotactic Body Radiotherapy: A Single-Institutional Experience of 145 Patients

The indications for stereotactic body radiotherapy (SBRT) for prostate cancer have increased. However, the relationships between adverse events and risk factors remain unclear. This study aimed to clarify associations between adverse events and dose index for prostate SBRT. Participants comprised 145 patients irradiated with 32-36 Gy in 4 fractions. Radiotherapy-related risk factors such as dose-volume histogram parameters and patient-related risk factors such as T stage and Gleason score were evaluated in a competing risk analysis. Median follow-up duration was 42.9 months. A total of 9.7% had acute Grade ≥ 2 GU toxicities and 4.8% had acute Grade ≥ 2 GI toxicities. A total of 11.1% had late Grade ≥ 2 GU toxicities and 7.6% had late Grade ≥ 2 GI toxicities. Two (1.4%) patients suffered from late Grade 3 GU toxicities. Similarly, two (1.4%) patients suffered from late Grade 3 GI toxicities. Acute GU and GI events correlated with prostate volume and dose to the hottest 10 cc volume (D10cc)/volumes receiving a minimum of 30 Gy (V30 Gy) of rectum, respectively. Late GI toxicity, frequency, and rectal hemorrhage correlated with rectal D0.1 cc/D1 cc, maximum dose to the bladder, and rectal D0.1 cc, respectively. Toxicities after prostate SBRT using 32-36 Gy/4 fractions were acceptable. Our analysis showed that acute toxicities correlated with volume receiving a medium dose level, and late toxicities correlated with highest point dose of organs at risk.

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence.

Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups. Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013). The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center.

Late hemorrhage following pancreatic surgery is associated with significant morbidity and mortality. Pseudoaneurysm (PSA) is an important source of late hemorrhage, which is effectively and safely managed by embolization. We aim to retrospectively review the outcomes of embolization for pseudoaneurysms causing late post-pancreatectomy hemorrhage over a period ofsix-years at our tertiary care center. Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed. Sixteen of 25 patients had PSA on digital subtraction angiography. Embolization was performed in these patients with technical and clinical success rates of 94.1% and 100%, respectively. Compared to patients without PSA, patients with PSA had significant hemoglobin drop (2.5g/dL vs. 1.5g/dL, p = 0.01), higher incidence of sentinel bleed (50% vs. 11.1%, p = 0.05) and lower requirement for surgery for bleeding (0% vs. 44.4%, p = 0.02). Clincally relevant postoperative pancreatic fistula and bile leak were seen in 72% and 52% of patients, respectively. Eight of these embolized patients died due to sepsis. The long-term outcome was good, once the patients were discharged. Late hemorrhage after pancreatic surgery was associated with high mortality due to complications such as pancreatic fistula and bile leak. Sentinel bleeding was an important clinical indicator of PSA. Angiographic embolization is safe and effective without any adverse short or long-term outcomes.

Data Science Application for Creation of Maternal Morbidity and Mortality Predictive Software

In Mexico, the estimated Maternal Mortality Ratio is 34.6 deaths per 100,000 estimated births. Consequently, healthcare facilities and services have given precedence to prenatal care, childbirth services, and postpartum care. In Mexico, the Ministry of Health maintains an open database concerning maternal deaths, encompassing 58 variables. Among these variables is the CIE (International Statistical Classification of Diseases and Related Health Problems), which covers a total of 248 diseases linked to maternal deaths. Currently, there is no software that classifies women undergoing pregnancy check-ups (according to their socio-clinical risk of mortality), using variables selected with data science. This project is rooted in the methodology advanced by International Business Machines (IBM) for the implementation of data science. The software's utilized model was constructed through the Naïve Bayes supervised learning algorithm, yielding an accuracy of 0.7236. The overall precision stood at 0.75, with an overall recall of 0.74, and an overall F1-score of 0.71. For the eclampsia during labor class, precision reached 0.71, recall was 0.94, and the F1- score attained 0.81. As for secondary or late postpartum hemorrhage, precision scored 0.81, recall measured 0.43, and the F1-score was 0.56.

REBOA in pancreatic bleeds

Background: Late post-pancreatectomy haemorrhage (PPH) can be lethal. Surgical options of proximal and distal control whilst present, are not ideal. With the advent of angiographic procedures, these may become the mainstay resuscitative strategy. We present our experience with endovascular aortic occlusion and angiography.

Postoperative morbidity and mortality after adenoidectomy: A national population-based study of 51 746 surgeries.

To investigate postoperative morbidity and mortality after paediatric adenoidectomy. This was a retrospective national population-based cohort study of data from the Swedish National Patient Register (NPR) and The Swedish Cause of Death Register (CDR). All patients aged 0-18 years who underwent adenoidectomy from 2007 to 2017 (without concomitant tonsil surgery) were included in this study. To evaluate postoperative morbidity and mortality, all diagnostic and surgical codes registered in the NPR for health care contacts within 30 days of surgery were analysed. The patients retrieved from the NPR were matched with the CDR to identify any deaths occurring within 30 days of the surgery. A total of 51746 adenoidectomies were included in this study. No deaths related to adenoidectomy were identified. All types of haemorrhagic complications were rare. Only 0.1% of the surgeries resulted in an outpatient contact due to postoperative haemorrhage and only 0.1% of the adenoidectomies resulted in a readmission due to haemorrhage. The rarest haemorrhagic complication was RTT (return to theatre), with only 4 events (0.01%). Postoperative haemorrhage was most frequent on the first day after surgery. Other complications were rare as well, requiring a total of 922 (2.6%) outpatient visits and 75 (0.2%) readmissions in the adenoidectomy group, with postoperative infection being the most commonly reported. Overall, adenoidectomy should be considered a safe surgical procedure associated with few postoperative complications. No deaths related to adenoidectomy were found. Severe complications, such as late postoperative haemorrhage after adenoidectomy, were rare, and haemorrhage resulting in RTT was even rarer. The highest rate of postoperative haemorrhage was observed the first day after surgery, and most haemorrhagic complications occurred within a week. Comparisons with studies on tonsil surgery show that adenoidectomy is associated with substantially lower postoperative morbidity.

Conbercept for late postoperative vitreous cavity haemorrhage in patients with proliferative diabetic retinopathy

Conbercept for late postoperative vitreous cavity haemorrhage in patients with proliferative diabetic retinopathy

Direct, Indirect, and Combined Extracranial-to-Intracranial Bypass for Adult Moyamoya Disease: An Updated Systematic Review and Meta-Analysis.

Moyamoya disease is a chronic, progressive cerebrovascular disease involving occlusion or stenosis of the terminal portion of the internal carotid artery. We conducted an updated systematic review and meta-analysis to investigate clinical and angiographic outcomes comparing direct, combined, and indirect bypass for the treatment of moyamoya disease in adults. Two independent authors performed Preferred Reporting Items for Systematic reviews and Meta-Analyses guided literature searches in December 2021 to identify articles reporting clinical/angiographic outcomes in adult moyamoya disease patients undergoing bypass. Primary end points used were ischemic and hemorrhagic strokes, clinical outcomes, and angiographic revascularization. Study quality was evaluated with Newcastle-Ottawa and the Oxford Center for Evidence-Based Medicine scales. Four thousand four hundred fifty seven articles were identified in the initial search; 143 articles were analyzed. There were 3827 direct, 3826 indirect, and 3801 combined bypasses. Average length of follow-up was 3.59±2.93 years. Pooled analysis significantly favored direct (odds ratio [OR], 0.62 [0.48-0.79]; P<0.0001; OR, 0.44 [0.32-0.59]; P<0.0001; OR, 0.56 [0.42-0.74]; P<0.0001; OR, 3.1 [2.5-3.8]; P=0.0001) and combined (OR, 0.53 [0.41-0.69]; P<0.0001; OR, 0.28 [0.2-0.41]; P<0.0001; OR, 0.41 [0.3-0.56]; P<0.0001; OR, 3.1 [2.8-4.3]; P=0.0001) over indirect bypass for early stroke, late stroke, late intracerebral hemorrhage, and favorable outcomes, respectively. Indirect bypass was favored over combined (OR, 3.1 [1.7-5.6]; P<0.0001) and direct (OR, 4.12 [2.34-7.25]; P<0.0001) for early intracerebral hemorrhage. The meta-analysis significantly favored direct (OR, 0.37 [0.23-0.60]; P<0.001; OR, 0.49 [0.31-0.77]; P=0.002) and combined (OR, 0.23 [0.12-0.43]; P<0.00001; OR, 0.30 [0.18-0.49]; P<0.00001) bypass over indirect bypass for late stroke and late hemorrhage, respectively. Combined bypass was favored over indirect bypass for favorable outcomes (OR, 2.06 [1.18-3.58]; P=0.01). Based on combined meta-analysis (43 articles) and pooled analysis (143 articles), the existing literature indicates that combined and direct bypasses have significant benefits for patients suffering from late stroke and hemorrhage versus indirect bypass. Combined bypass was favored over indirect bypass for favorable outcomes. This is a strong recommendation based on low-quality evidence when utilizing the Grades of Recommendation, Assessment, Development, and Evaluation system. These findings have important implications for bypass strategy selection.

Distal resection for pancreatic tumors

Aim. To study the specific features of the splenic artery architectonics and evaluate the results of distal pancreatic resection for various tumors.Materials and Methods. In the anatomical part, we examined 88 organ complexes taken from people whose death was not associated with diseases of the abdominal organs. We studied the topography of the splenic artery and the dependence of the number of its branches to the pancreas on the vessel tortuosity. The clinical part of the study presents the results of 122 distal resections performed during 2016-2021. 79 operations were carried out using the traditional method, 32 operations were robot-assisted, and 11 were performed laparoscopically.Results. The research found a relationship between the degree of the splenic artery tortuosity and the number of branches to the pancreas, which varies from three to nine. Out of the 122 operated patients, in 24 (19.7%) cases a clinically relevant (type B) pancreatic fistula that required additional treatment was formed. Intra-abdominal bleeding developed in 15 (12.3%) patients: early – in 10, late arrosive hemorrhage associated with a pancreatic fistula – in 5 cases. One (0.8%) patient died.Conclusion. It is necessary to consider the architectonics of the splenic artery during distal pancreatic resection. The frequency of pancreatic fistula formation does not depend on the method of performing the operation. Of the prognostic factors, the body mass index is statistically significant. Late arrosive bleeding develops against the background of a clinically relevant pancreatic fistula.

Conduits in Vascular Pancreatic Surgery: Analysis of Clinical Outcomes, Operative Techniques, and Graft Performance.

We analyze successes and failures of pushing the boundaries in vascular pancreatic surgery to establish safety of conduit reconstructions. Improved systemic control from chemotherapy in pancreatic cancer is increasing the demand for surgical solutions of extensive local vessel involvement, but conduit-specific data are scarce. We identified 63 implanted conduits (41% autologous vessels, 37% allografts, 18% PTFE) in 56 pancreatic resections of highly selected cancer patients between October 2013 and July 2020 from our prospectively maintained database. Assessed parameters were survival, perioperative complications, operative techniques (anatomic and extra-anatomic routes), and conduit patency. For vascular reconstruction, 25 arterial and 38 venous conduits were utilized during 39 pancreatoduodenectomies, 14 distal pancreatectomies, and 3 total pancreatectomies. The median postoperative survival was 2 years. A Clavien-Dindo grade ≥IIIa complication was apparent in 50% of the patients with a median Comprehensive Complication Index of 29.6. The 90-day mortality in this highly selected cohort was 9%. Causes of mortality were conduit related in 3 patients, late postpancreatectomy hemorrhage in 1 patient, and early liver metastasis in 1 patient. Image-based patency rates of conduits were 66% and 45% at postoperative days 30 and 90, respectively. Our perioperative mortality of vascular pancreatic surgery with conduits in the arterial or venous system is 9%. Reconstructions are technically feasible with different anatomic and extra-anatomic strategies, while identifying predictors of early conduit occlusion remains challenging. Optimizing reconstructed arterial and venous hemodynamics in the context of pancreatic malignancy will enable long-term survival in more patients responsive to chemotherapies.

Fashionably late: A characterization of late coagulopathies in rattlesnake envenomations between Fab and F(ab’)2 antivenoms

BackgroundRattlesnake envenomation may lead to a multitude of clinical effects, including a late onset hemorrhage. Laboratory values such as platelets and fibrinogen are commonly used to assess the risk of developing a life-threatening bleed. To date, no specific threshold has been identified that links a lab value to the risk of bleeding. This has led to widespread practice variability among clinicians managing snake bites. In assessing risk for patients, we apply the concept that the more abnormal the lab values are, the higher the risk probably is. Late onset coagulopathies pose a unique clinical challenge because they indicate the potential risk for a life-threatening hemorrhage, yet they have been identified after hospital discharge. There are currently two antivenom (AV) products on the US market to treat rattlesnake envenomations, a Fab product, CroFab® (BTG, UK) and a F (ab’)2 product, Anavip® (Bioclon, Mexico). ObjectiveThis study intended to characterize the incidence and severity of late coagulopathies reported to a Regional Poison Center (RPC) and hypothesized that late coagulopathies occur at rates higher than previously reported in the literature. Additionally, we sought to compare rates of late coagulopathy between Fab and F (ab’)2 AV. MethodsThe investigators performed an in-depth review of all suspected snakebite envenomations from 2018 to 2020 that presented to an Arizona healthcare facility in the RPC's catchment area between January 2018 through December of 2020. Patients were excluded from analysis if they did not receive any antivenom, had an incomplete medical record with the APDIC, were diagnosed as something other than a rattlesnake bite or had a known medical history that clouded the diagnosis or assessment of a rattlesnake envenomation. ResultsIn total, 522 records were reviewed of which 283 patients met the inclusion criteria. There were 149 patients who received Fab AV and 134 who received F (ab’)2. No significant baseline or demographic differences existed between the groups. 95 of the 283 patients developed a late onset coagulopathy. 39% of the late onset coagulopathies were delayed, 32% were recurrent and 29% were persistent. When comparing the two different AV products, delayed or recurrent coagulopathies occurred in 36% of Fab AV- and 10% of F (ab’)2 treated patients. Persistent coagulopathies occurred in 17% of Fab AV- and 8% of F (ab’)2 treated patients. Interestingly, there were zero cases of late hypofibrinogenemia in any of the 134 F (ab’)2 treated patients compared to 26% of all Fab treated ones. The average onset of late coagulopathy post-bite was 8 days for Fab AV and 7 for F (ab’)2. ConclusionThe results from this study suggest the total rate of late onset coagulopathies may be underestimated. Additionally, our results suggest the potential that F (ab’)2 AV may be associated with fewer late onset coagulopathies, especially late onset hypofibrinogenemia.

Long-Term Results of a Phase 2 Study of Definitive Chemoradiation Therapy Using S-1 for Esophageal Squamous Cell Carcinoma Patients Who Were Elderly or With Serious Comorbidities.

BackgroundThe optimal evidence-based management for the subsets of locally advanced esophageal squamous cell carcinoma (ESCC) patients who rejected or were intolerant to intravenous chemotherapy due to old age or serious comorbidities is currently lacking. This study aimed to assess the safety and local control rate (LCR) of S-1 (tegafur–gimeracil–oteracil potassium) combined with radiotherapy in these subsets of ESCC patients.MethodsLocally advanced ESCC patients who rejected or were intolerant to intravenous chemotherapy due to age >75 years or serious comorbidities were enrolled in a prospective, single-arm, phase 2 trial. The patients were treated with definitive concurrent chemoradiotherapy with S-1, which was administered orally twice daily for 28 days. The radiotherapy dose was 61.2 Gy delivered in 34 fractions. The primary end-point was the 3-year LCR.ResultsOne hundred five ESCC patients were recruited between March 2013 and October 2015. At the median follow-up of 73.1 months (IQR 65.5–81.4 months), 3-year LCR was 61.1%, and 1, 3, and 5-year overall survival was 77.9, 42.3, and 24.8% respectively. For safety analysis, ≥grade 3 acute adverse events included thrombocytopenia (6.7%), leukopenia (2.9%), anemia (1.0%), anorexia (1.0%), fatigue (10.5%), hiccup (1.0%), pneumonitis (4.8%), and esophagitis (3.8%). Two patients (1.9%) died of late esophageal hemorrhage, and one patient (1.0%) died of late radiation-induced pneumonitis.ConclusionS-1 is a promising regimen in concurrent chemoradiotherapy with low toxicity and a favorable LCR in ESCC patients who rejected or were intolerant to intravenous chemotherapy due to old age or serious comorbidities.Clinical Trial Registration ClinicalTrials.gov, NCT01831531.