Late-onset Bleeding Research Articles

Vertebral Artery Injury in Cervical Spine Fracture Dislocation: An Observational Study in a Tertiary Care Center.

The incidence of traumatic vertebral artery injury (VAI) associated with cervical spine trauma varies widely in published trauma series. The primary aim of this study was to determine the incidence of traumatic VAIin patients who suffered cervical spine injuries by means of routine magnetic resonance imaging, and the secondary objective was to identify any associations with injury mechanism, level ofinjury, and neurologic injury severity. Materials and methods: A retrospective review was conducted on 96 patients who suffered cervical spine fracture dislocation with or without an associated spinal cord injury (SCI) in Indian Spinal Injuries Center (ISIC), New Delhi, Indiafrom January 2013 to April 2023. Cervical magnetic resonance imaging (MRI) was used to diagnose VAI. Patient's age, sex, cervical injury level, mechanism of injury, neurologic level of injury, association with foraminal fracture, facet dislocation,and clinical sequelae of vertebral artery injury were analyzed. In this study, of 96 patients who met the inclusion criteria, 18 patients (18.75%) had VAI on the MRI study. Thirteen (72.22%) of the eighteen patients had right-sided injuries, four (22.22%) had left-sided injuries, and one (5.55%) had bilateral injuries. There was an associated SCI in every VAI patient. VAI was significantly more common in patients who had ASIA A (61%, n = 11) and ASIA B (22%, n = 4)injuries, and no VAI was noted in neurologically intact patients (p<0.001). The incidence of VAI was higher in the flexion distraction type of injury (n = 12, 66%).The most commonly involved cervical spine injury level was C5-C6 (27%, n = 5), followed by 22% (n = 4) at C4-C5 and C6-C7 levels. About 27.8% (n = 5) of VAI was associated with foraminal fractures, and 72% (n = 13) of VAI was associated with facet dislocations, of which 44% (n = 8) were bifacetal and 28% (n = 5) were unifacetal dislocations. On clinical symptoms, only one (5.56%) patient had a headache, and 17 (94.4%) had no clinical features due to VAI. The incidence of traumatic vertebral artery disease is not very uncommon and requires careful and meticulous screening and management. Otherwise, complications like pseudoaneurysm, neurologic deficit, late-onset hemorrhage, infarction, and death can happen. Mostly, it is associated with high-velocity injuries and neurological injuries. MRI can be used as a good screening tool, which can be aided by a CT angiogram or digital subtraction angiographyfor confirmation. Proper pre-operative evaluation of vascular injury in cervical spine fracture dislocation is very important for patient counseling, patient management, and surgical planning.

A case of late-onset bleeding from an intercostal artery pseudoaneurysm after hemostasis using soft coagulation

BackgroundThe use of soft coagulation is becoming common in thoracic surgery. Soft coagulation provides rapid hemostasis from small vessels during surgery by dehydrating tissue and denaturing proteins, without burning the tissue.Case presentationA 68-year-old man, with a history of right lower lobectomy 3 years prior, underwent a partial resection of the right upper lobe for a pulmonary nodule suspicious for secondary lung cancer. During the surgery, dissection of the adhesion caused a bleeding from the 6th intercostal artery, and hemostasis was achieved using soft coagulation (some degree of tissue carbonization was noticed at later mortality and morbidity conference). He experienced hemoptysis at postoperative day 18 and was transferred to our hospital. Contrast-enhanced CT scan revealed bleeding from the pseudoaneurysm of the 6th intercostal artery. Embolization was performed by angiography to stop the bleeding.ConclusionsWe experienced a case of late-onset bleeding from a pseudoaneurysm related to soft coagulation hemostasis. Lessons learned from this patient are that additional hemostasis, such as ligation, would be considered for small arteries after hemostasis has been achieved by soft coagulation, especially when some degree of tissue carbonization is suspected.

Diagnostic Pitfalls of the Bleeding Origin after a Percutaneous Renal Biopsy: A Report of Two Cases.

A percutaneous renal biopsy (PRB) is a standard procedure for diagnosing renal disease, but can cause bleeding complications. Bleeding after a PRB can be classified as early- or late-onset, depending on the timing of the onset of the bleeding symptoms (<24 h or ≥24 h). We herein report two patients who experienced bleeding complications: one experienced early-onset bleeding from the 12th subcostal artery, and the other experienced late-onset bleeding from an arteriovenous fistula between a branch of the renal artery and renal vein. In both cases, the origin of the bleeding vessel was misjudged during the first examination. We discuss the diagnostic pitfalls of the origin of bleeding after a PRB and propose measures to avoid falling such pitfalls.

Onset Time and Characteristics of Postprocedural Bleeding after Endoscopic Resection of Colorectal Lesions: A Multicenter Retrospective Study

Introduction: Postprocedural bleeding is a major adverse event after endoscopic resection of colorectal lesions, but the optimal surveillance time after endoscopy is unclear. In this study, we determined onset time and characteristics of postprocedural bleeding events. Methods: We retrospectively screened patients who underwent endoscopic resection of colorectal lesions at three German hospitals between 2010 and 2019 for postprocedural bleeding events using billing codes. Only patients who required re-endoscopy were included for analysis. For identified patients, we collected demographic data, clinical courses, characteristics of colorectal lesions, and procedure-related variables. Factors associated with late-onset bleeding were determined by univariate and multivariate logistic regression analysis. Results: From a total of 6,820 patients with eligible billing codes, we identified 113 cases with postprocedural bleeding after endoscopic mucosal (61.9%) or snare resection (38.1%) that required re-endoscopy. The median size of the culprit lesion was 20 mm (interquartile range 14–30 mm). The median onset time of postprocedural bleeding was day 3 (interquartile range: 1–6.5 days), with 48.7% of events occurring within 48 h. Multivariate logistic regression analysis demonstrates that a continued intake of antiplatelet drugs (OR: 3.98, 95% CI: 0.89–10.12, p = 0.025) and a flat morphology of the colorectal lesion (OR: 2.98, 95% CI: 1.08–8.01, p = 0.031) were associated with an increased risk for late postprocedural bleeding (>48 h), whereas intraprocedural bleeding was associated with a decreased risk (OR: 0.12, 95% CI: 0.04–0.50, p = 0.001). Conclusion: Significant postprocedural bleeding can occur up to 18 days after endoscopic resection of colorectal lesions, but was predominantly observed within 48 h. Continued intake of antiplatelet drugs and a flat polyp morphology are associated with risk for late postprocedural bleeding.

S652 Prophylactic Epinephrine Injections for the Prevention of Postpolypectomy Bleeding: A Meta-Analysis

Introduction: Bleeding is the most common major complication from colonoscopic polypectomy. We performed a meta-analysis to evaluate whether submucosal epinephrine injections prevent postpolypectomy bleeding. Methods: The dataset was defined by searching PubMed for randomized controlled and retrospective studies published before December 2021 that compared the use of epinephrine (alone or with another preventative measure) to no prophylaxis for bleeding. Groups were defined as either epinephrine injection only (group A), mechanical prophylaxis via detachable snare and/or clip only (group B), combined therapy group (group C), and a control group. Group differences were analyzed by using a random-effects models. Effect sizes were calculated as Cohen’s d for continuous data or a log of the odds ratio (OR) for percentage (binary) data. Results: In all, we identified ten studies: six used in a prior meta-analysis and four additional studies (Table). Overall, 2,125 patients with 2,287 total polyps were included in nine randomized controlled trials and one retrospective chart review. Overall bleeding was lower in group A than in controls on the basis of five studies (OR, -1.038; confidence interval [CI] -1.560 to -0.515; p≤0.001). One study indicated that overall bleeding was lower in group B than in the controls (OR, -1.524; CI, -2.799 to -0.249; p=0.019) (Figure A). Early bleeding was lower in group A than in the controls on the basis of five studies (OR, -1.626; CI, -2.535 to -0.718; p≤0.001) and lower in group B on the basis of one study (OR, -2.719; CI, -4.175 to -1.263; p≤0.001) (Figure B). There were no significant group differences associated with late onset bleeding. Group A was significantly older than group C (Figure C) and had larger polyps than group B (Figure D). Homogeneity tests indicated homogeneity among the effect sizes suggesting examination of moderating variables was not necessary and there were no differences among the groups in terms of patient sex, polyp histology, polyp morphology, or stalk size. Conclusion: The results indicate that epinephrine prophylaxis reduces overall and early postpolypectomy bleeding but does not affect late bleeding.Figure 1.: Comparison of (A) overall and (B) early postpolypectomy bleeding in the epinephrine and control group. (C) Group A was significantly older than Group C. (D) Group A identified larger polyp size than Group B. Table 1. - Study Characteristics (NA, not available; mm, millimeters) Study Population Group Comparisons Number of patients Age (year) Number of polyps Polyp size (mean) (mm) Rohde NA A: Epinephrine B: No prophylaxis NA A: 70 (53–88), B: 65 (33–78) 40 A: 15 (7–28), B: 15 (11–35) Lee SH. Multicenter A: Epinephrine B: No prophylaxis 486 A: 51.6 ± 11.4, B: 56.8 ± 11.3 561 A: 14.5 ± 5.7, B: 15.0 ± 6.8 Hsieh Yh. Single center A: Epinephrine B: No prophylaxis 129 A: 62.9 (59.8–62.1), B: 64.9 (62.1–67.8) 151 A: 8.0 (8–13), B: 8.0 (8–11) Dobrowolski S. Single center A: Epinephrine B: No prophylaxis 69 A: 63.7 ± 9.7, B: 66.8 ± 11.5 100 A: 16.3 ± 5.4, B: 16.1 ± 5.9 Paspatis GA. Multicenter A: Combined therapy (detachable snare with epinephrine) B: Epinephrine 159 A: 61.7 ± 13.8, B: 64.5 ± 11 159 A: 27.1 ± 8.9, B: 26.3 ± 8.1 Kouklakis G. Single center A: Mechanical therapy (Endoloop with postpolypectomy clipping) B: Epinephrine 64 A: 57.9 ± 9.7, B: 58.8 ± 11.2 64 A: 25.6 ± 12.0, B: 27.0 ± 11.0 Di Giorgio P. Single center A: Mechanical therapy (detachable snare) B: Epinephrine C: No prophylaxis 488 A: 64 ± 9.2, B: 63 ± 8.9, C: 62 ± 9.0 488 A: 22.2 ± 5.9, B: 24.7 ± 5.3, C: 21.6 ± 4.8 Yamaguchi Single center A: Epinephrine B: No prophylaxis 204 A: 73.7 ± 8.7, B: 73.7 ± 8.3 204 A: 10.0 ± 5.8, B: 10.0 ± 5.0 Bahin Multicenter A: Combined therapy (epinephrine and succinylated gelatin injection with electrocoagulation) B: Epinephrine and succinylated gelatin injection 347 A: 66.0, B: 70.0 347 A: 39.5, B: 39.8 Park Multicenter A: Combined therapy (clipping with epinephrine) B: Mechanical therapy (clipping) 148 A: 59 ± 11, B: 60 ± 10 173 A: 17.5 ± 6.7, B: 17.2 ± 6.6

Fixed-dose aspirin monotherapy compared with thromboelastography directed antiplatelet therapy in long-term management of left ventricular assist devices.

The role of thromboelastography (TEG) in managing antiplatelet therapy (APT) in left ventricular assist devices (LVADs) is controversial. Our aim was to determine whether removal of TEG from an LVAD-specific APT protocol reduced late-onset bleeding without increasing thromboembolic complications. We performed a single-center, retrospective cohort study including all recipients of a continuous-flow LVAD between April 2005 and November 2019 (n = 293). LVAD recipients before June 1, 2017 (n = 221) whose APT was monitored and adjusted using TEG were compared with LVAD recipients after June 1,2017 (n = 72) where TEG was not utilized. Occurrence of late-onset bleeding events after postoperative Day 7 and thromboembolic events were collected. APT doses, warfarin use and International normalized ratio (INR) values were collected at discharge and at 1, 3, 6, and 12-months postimplantation. Over a median 12-month follow-up, INTERMACS major bleeding events occurred in 35% of patients where TEG was utilized compared with 29% where TEG was not utilized (p = 0.375), and procedural intervention was required in 29% compared with 18%, respectively (p = 0.058). Use of TEG was associated with higher doses of aspirin (>325 mg) (41% compared with none) and use of a second antiplatelet (dipyridamole) (43% compared to 1%). Despite this, there was no significant difference in thromboembolic events (15% in each). Our study suggests the use of TEG led to increased doses of aspirin as well as adding a second antiplatelet agent, without improving outcomes in LVAD recipients. Furthermore, the removal of TEG from an LVAD-specific APT protocol did not worsen thromboembolic outcomes.

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.

Does a three-dose oral vitamin K regimen at birth, one week old, and one month old prevent late-onset bleeding from vitamin K deficiency?

Does a three-dose oral vitamin K regimen at birth, one week old, and one month old prevent late-onset bleeding from vitamin K deficiency?

Thromboelastography of Limited Benefit in LVAD Patient Management

Purpose The role of utilizing thromboelastography (TEG) in managing antiplatelet therapy (APT) in LVAD patients is controversial. The purpose of this study was to determine if the removal of TEG from APT protocol reduced late onset bleeding without an increase in thromboembolic events. Methods We performed a single-center retrospective cohort study at the University of Florida including all recipients of a HeartMate II, HeartMate III, or Heartware LVAD between April 2005 and November 2019 (n=293). LVAD recipients before June 1st,2017 (n=221) whose APT was monitored and adjusted using TEG were compared to LVAD recipients after June 1st,2017 (n=72) where TEG was not utilized. The occurrence of late-onset bleeding events after post-operative day 7, as defined by INTERMACs major bleeding, as well as thromboembolic events were collected. Patients were followed up to one year post-implantation or to time of death, transplant, or pump exchange. APT doses, warfarin use and INR values were collected at discharge as well as 1, 3, 6 and 12 months post-implantation. Results Over a median follow-up period of 12 months, INTERMACS major bleeding events occurred in 35% of patients where TEG was utilized compared to 29% where TEG was not utilized (p-value 0.375), and procedural intervention was required in 29% compared to 18% respectively (p-value 0.058). After June 1st 2017, patients had a higher average BMI (31 compared to 29, p-value 0.020), were more likely to be on digoxin on discharge (24% compared to 12%, p-value 0.019), and were less likely to be of white race (p-value 0.043) or have ischemic cardiomyopathy (p-value 0.019). In a multivariable Cox proportional-hazards regression model including all these variables, older age was the only independent predictor of bleeding events (HR 1.03 for each additional year of age, 95% CI 1.01-1.05, p 0.008). Use of TEG was associated with use of higher doses of aspirin (>325mg 41% vs. 0%), and use of a second antiplatelet (43% vs. 1%). There was no significant difference in thromboembolic events (15% in each). Conclusion In this single center retrospective study, thromboelastography monitoring after LVAD implantation was associated with significantly higher rates of multidrug antiplatelet regimen use, at significantly higher doses, with no difference in thromboembolic events compared to LVAD patients managed without TEG. Bleeding events were more common in elderly recipients.

Radiofrequency Ablation of Liver Tumors in Patients on Antithrombotic Therapy: A Case-Control Analysis of over 10,000 Treatments

PurposeTo evaluate the safety of radiofrequency ablation (RFA) for liver tumors in patients on antithrombotic therapy. Materials and MethodsA total of 10,653 consecutive RFA treatments in 3,485 patients with liver tumors were analyzed. The incidence of complications was analyzed on a treatment basis. The treatments for patients who had received antithrombotic medication up to 1 week prior to RFA comprised the antithrombotic therapy group (n = 806), and the others comprised the control group (n = 9,847). Antithrombotic agents were ceased prior to RFA (aspirin, ticlopidine, clopidogrel, and prasugrel ceased 7 days before RFA; cilostazol, 2 or 3 days before RFA; warfarin, 3 days before RFA; and direct oral anticoagulants, 1 day before RFA) and resumed as soon as possible after RFA. Logistic regression analysis was performed to assess whether the antithrombotic therapy increased the risk of hemorrhagic complications. ResultsHemorrhagic complications were diagnosed after 6 treatments (0.7%) in the antithrombotic group and 48 (0.5%) in the control group, and there was no significant difference between the groups (P = .30). In 3 treatments, hemorrhage was diagnosed on or after 8 days of RFA, all of which were in the antithrombotic group. Thrombotic complications were diagnosed after 2 treatments (0.2%) in the antithrombotic group and after 5 (0.1%) in the control group. In a multivariate analysis, receiving antithrombotic therapy was not an independent risk factor for hemorrhagic complications (adjusted odds ratio, 1.52; 95% confidence interval, 0.60–3.87; P = .38). ConclusionsRFA of liver tumors in patients on antithrombotic therapy is generally safe with appropriate cessation and resumption. Late-onset hemorrhage should be noted in the patients on antithrombotic therapy.

Hemocoagulase agkistrodon can prevent bleeding and induce hypofibrinogenemia inhepatic disease cases .

Hemocoagulase is often used for hemostasis in patients with bleeding and hemorrhagic diseases, and to avoid or stanch bleeding after surgery. Herein, three patients with hepatic diseases suffering from hypofibrinogenemia were treated with hemocoagulase agkistrodon (HCA) in Peking University People's Hospital during September 2018. All the 3 patients were chronic hepatitis B patients: Patient 1 presented with hepatic carcinoma and chronic hepatitis B, and right hepatectomy was performed; patient 2 presented with chronic hepatitis B and gastrointestinal bleeding; patient 3 presented with chronic hepatitis B, acute liver failure with hematemesis, and was awaiting liver transplantation. All three patients were percutaneously injected with HCA to prevent late-onset bleeding. After HCA was discontinued, coagulation was restored to >60 mg/dL on day 6, without injection of fibrinogen. HCA significantly reduced the need for fibrinogen in patients with hepatic diseases, and the level of fibrinogen should be carefully monitored in clinical applications.

Arteriovenous fistula-related renal bleeding 5\xa0days after percutaneous renal biopsy

A 32-year-old Japanese woman was admitted to our hospital for evaluation of microscopic hematuria with a positive family history. Percutaneous renal biopsy was performed under real-time ultrasound guidance using a 16-gauge automated needle and three specimens were obtained. She had no risk factors for hemorrhage. However, macroscopic hematuria developed from 5 days after biopsy and persisted for 4 days. Her Hb decreased markedly from 15.0 to 8.1 g/dL. Enhanced computed tomography revealed urinary tract hematoma, while the early arterial phase showed inflow of contrast medium into the left renal vein from a pseudoaneurysm on a branch left renal artery. Renal transcatheter arterial embolization was performed using platinum microcoils and the arteriovenous fistula was occluded. The patient did not require blood transfusion. Severe renal bleeding that causes urinary tract hematoma usually occurs within 24 h after renal biopsy, but the possibility of late-onset renal bleeding should be kept in mind.

Comparative evaluation of colonoscopy-assisted transanal minimally invasive surgery via glove port and endoscopic submucosal dissection for early rectal tumor

BackgroundEarly rectal tumor is usually managed by local excision. A novel method—colonoscopy-assisted transanal minimally invasive surgery via glove port (CA-TAMIS-GP)—for resecting early rectal tumor was developed and compared with endoscopic submucosal dissection (ESD). Materials and MethodsWe performed CA-TAMIS-GP surgery on 26 patients from January 2014 to February 2016. For better analysis, we retrospectively collected data from 31 patients who underwent ESD between October 2012 and December 2013; overall, 57 patients diagnosed with early rectal tumor were included in this study. Perioperative conditions and long-term outcomes of both groups were compared. ResultsAll lesions were dissected completely and successfully without conversion to open surgery or major complications. On histopathologic examination, all specimens in this study had negative margins. All patients had uneventful postoperative recoveries, except 3 patients of CA-TAMIS-GP with minor hematochezia, which resolved spontaneously; 7 ESD patients had late-onset bleeding and 3 needed colonoscopic hemostasis; 2 patients in each group had mild fever. The CA-TAMIS-GP group had a shorter operation time, less hemorrhage, and a lower average consumable cost than the ESD group (P < 0.05); moreover, the CA-TAMIS-GP group had no recurrence or long-term complications during a follow-up of 10–32 months, whereas3 patients in the ESD group developed local recurrence during a follow-up of 24–36 months. ConclusionsThe CA-TAMIS-GP is a new method that is safe and effective in patients with early rectal tumor and appears to have a shorter operation time and less blood loss as compared with ESD.

Risk of Hemorrhage Attributed to Underlying Chronic Diseases and Uninterrupted Aspirin Therapy of Patients Undergoing Minor Oral Surgical Procedures: A Retrospective Cohort Study.

ObjectivesThis study aimed to estimate the risk of bleeding following minor oral surgical procedures and uninterrupted aspirin therapy in high-risk patients or patients with existing chronic diseases compared to patients who did not use aspirin during minor oral surgery at a public hospital.MethodsThis retrospective cohort study analyzed the data of 2912 patients, aged 20 years or older, who underwent 5251 minor oral surgical procedures at a district hospital in Thailand. The aspirin group was comprised of patients continuing aspirin therapy during oral surgery. The non-aspirin group (reference) included all those who did not use aspirin during surgery. Immediate and late-onset bleeding was evaluated in each procedure. The risk ratio of bleeding was estimated using a multilevel Poisson regression.ResultsThe overall cumulative incidence of immediate bleeding was 1.3% of total procedures. No late-onset bleeding was found. A significantly greater incidence of bleeding was found in the aspirin group (5.8% of procedures, p<0.001). After adjusting for covariates, a multilevel Poisson regression model estimated that the bleeding risk in the aspirin group was 4.5 times higher than that of the non-aspirin group (95% confidence interval, 2.0 to 10.0; p<0.001). However, all bleeding events were controlled by simple hemostatic measures.ConclusionsHigh-risk patients or patients with existing chronic diseases who continued aspirin therapy following minor oral surgery were at a higher risk of hemorrhage than general patients who had not used aspirin. Nonetheless, bleeding complications were not life-threatening and could be promptly managed by simple hemostatic measures. The procedures could therefore be provided with an awareness of increased bleeding risk, prepared hemostatic measures, and postoperative monitoring, without the need for discontinuing aspirin, which could lead to more serious complications.

Niemann-pick type a: A rare case presenting with late onset bleeding due to Vitamin K deficiency

K vitamini eksikligine bagli kanama (KVEBK) nadir gorulmekle birlikte erken sut cocuklugu doneminde hayati tehdit edebilir. Kanamanin gorulme zamanina gore erken (0-1 gun), klasik (1-7 gun) ve gec (8 gun-6 ay) KVEBK olarak siniflandirilir. Kanamanin en sik 3-8 hafta arasinda basladigi gec tipte genellikle daha once tani konmamis kolestaz mevcuttur. Niemann Pick hastaligi, sfingomyelin birikimi sonucu kopuksu histiyositleri andiran ozel depo hucreleriyle iliskili bir grup lizozomal depo hastaligidir. Hastaligin A ve C tipinde yenidogan doneminde kendiliginden gerileyen kolestaz gelisebilecegi bilinmektedir. Bir ayliktan itibaren uc defa gobeginden kanama olmasi nedeniyle tarafimiza basvuran iki aylik hastanin tetkiklerinde PT ve PTT uzamasi mevcuttu. Gec tip KVEBK icin bir risk faktoru olan kolestaz arastirildi ve saptandi. K vitamini uygulamasi sonrasi kanama tekrarlamadi. Takiplerinde kolestazi gerileyen ancak karaciger ve dalak boyutlari artan hastanin ileri incelemeleri sonucunda SMPD1 geninde homozigot yeni bir mutasyon gosterilerek Niemann-Pick tip A tanisi kondu. Bu yazida K vitamini eksikligine bagli gobek kanamasi ile gelen ve ilk defa bildirilen Nieman-Pick hastaligi tip A tanili olgu sunuldu.

Long-term Outcome over Five Years after Surgical Revascularization in Adult Moyamoya Disease

The long-term outcome of patients with adult moyamoya disease following revascularization surgery remains unclear. Here, we investigated these outcomes more than five years after revascularization surgery. This study included 48 cerebral hemispheres from 26 patients who underwent revascularization surgery for adult moyamoya disease. The mean follow-up duration was 14.3(5.5-25.6)years. The risk factors of late-onset hemorrhage after revascularization surgery were compared between the bleeding and non-bleeding groups. We also estimated cumulative bleeding-free survival rates using Kaplan-Meier curves. Four patients experienced late-onset bleeding during the follow-up period. Bleeding occurred after an average of 11(8.5-16.4)years following revascularization surgery. The annual hemorrhagic rate was 1.14%. In the bleeding group, higher Suzuki stage(p=0.02), posterior cerebral artery(PCA)involvement(p<0.01), cerebral aneurysm(p=0.04), microbleeds(p=0.03), and post-operative periventricular anastomosis, especially in the thalamus and the choroidal artery(p<0.01 and p=0.01 respectively), were significantly different from those in the non-bleeding group. Kaplan-Meier analysis showed that the probability of late-onset bleeding was higher with postoperative periventricular anastomosis(p<0.01 for thalamic type, p=0.01 for choroidal type), higher Suzuki stage(p<0.01), PCA involvement(p<0.01), and cerebral aneurysm(p=0.02). In spite of good perfusion and reduction in moyamoya vessels after revascularization surgery, the risk of bleeding persisted. Periventricular anastomosis, especially in the thalamus and choroidal artery, after surgery, higher Suzuki stage, presence of obstructive lesions in the PCA, and cerebral aneurysm may be associated with late-onset bleeding after surgery. More studies are needed to identify the risk factors for late-onset bleeding after revascularization surgery for moyamoya disease.

Is it safe to perform adenotonsillectomy in children with Down syndrome?

This retrospective review aims to evaluate the postoperative morbidity and mortality of 30 patients with Down syndrome who underwent adenotonsillectomy between June 2012 and December 2015 in a tertiary referral center. Mean age was 7.8 with a range of 3-12. There were 20 (66.6%) male and ten (33.3%) female patients. Mean follow-up was 23months with a range of 7-43months. 23 (76.6%) of 30 patients had been operated due to obstructive tonsillar and adenoid hypertrophy, whereas seven (23.3%) of them operated for chronic recurrent infections. All of the patients had undergone adenotonsillectomy operation; one patient had also bilateral tympanostomy tube insertion. Hospital stay was noted 1.3days in average with a range of 1-3days. Anesthetic complications of persistent bradycardia and postextubation respiratory difficulty occurred in two (6.6) patients. Patient who had intraoperative bradycardia necessitated intensive care unit stay and pacemaker implantation during follow-up. 3 (10%) patients had late onset hemorrhage between days 7 and 10 and required intraoperative bleeding control. We did not experience any other morbidity and mortality except the abovementioned ones. In conclusion, adenotonsillectomy in patients with Down syndrome is a worthwhile operation with certain risks and these operations should better be performed by the tertiary referral centers which have the capacity to deal with the complications.

Postoperative portal vein thrombosis and gastric hemorrhage associated with late-onset hemorrhage from the common hepatic artery after pancreaticoduodenectomy

Portal vein thrombosis (PVT) is a rare but serious postoperative complication of pancreaticoduodenectomy (PD). We reported a case of late-onset postoperative PVT with hemorrhage from the common hepatic artery (CHA) in a 73-year-old man who underwent pylorus-preserving pancreaticoduodenectomy (PPPD) for duodenum papilla cancer, followed by reconstruction using the modified Child's technique. The pancreaticojejunostomy was achieved by end-to-side, 2-layer invagination anastomosis without pancreatic duct stenting. Drain removal and hospital discharge were scheduled on postoperative day (POD) 18, but blood-stained fluid in the drain and sudden hematemesis were noted. Emergency surgery was performed because PVT and imaging findings were suggestive of necrosis of the lifted jejunum. Although no jejunal necrosis was identified during surgery, bleeding from the side of the CHA was detected and the bleeding point was suture-closed to achieve hemostasis. We suspected late-onset postoperative arterial hemorrhage and subsequent hematoma formation, which caused portal vein compression and PVT formation. We chose a conservative treatment strategy for PVT, taking into account the operation time, intraoperative vital signs and blood flow in the portal vein. Despite the complicated postoperative course, he was discharged home in a fully ambulatory state on POD 167.

口蓋扁桃摘出術後に投与する鎮痛薬別にみた鎮痛効果と術後出血の頻度:セレコキシブとロキソプロフェンの比較

Hemorrhage following tonsillectomy is still a major complication despite the progress in medical technology. Celecoxib is a selective COX-2 inhibitor and has a lower effect of platelet aggregation compared with conventional non-steroidal anti-inflammatory drugs (NSAIDs). We investigated whether or not the selection of celecoxib would reduce the risk of hemorrhage and provide a good analgesic effect following tonsillectomy in comparison with the use of loxoprofen (a conventional NSAID). We divided 107 cases of tonsillectomy into two groups by the kind of analgesic prescribed; the celecoxib group (n=55) and the loxoprofen group (n=52). Regarding the effective rate of the analgesic effect, the loxoprofen group scored 93.3% and the celecoxib group scored 68.6%. There was a significant difference between them (p=0.0003). Regarding side effects, the celecoxib group showed no side effects, whereas 8.0% of the loxoprofen group developed abdominal pain. There were no statistically significant differences between the changes in the VAS scale regarding the pain (p=0.834), the prescription periods of analgesic (p=0.485), the amount of food intake during the hospitalization (p=0.579), the rescue dosage rate (p=0.585), periods of usage (p=0.198) and the last dosage day. As for the tendency and the grade of postoperative hemorrhage, there were no statistically differences between the two groups (p=0.220). The rates of occurrence of late-onset hemorrhage (i.e. after the postoperative eleventh day) were 0.0% (0/11) in the the celecoxib group (n=11) and 31.2% (5/16) in the the loxoprofen group showing a statistically differences between them (p=0.049). Our results suggest that Celecoxib might reduce the risk of late-onset hemorrhage after the postoperative eleventh day with few side effects, so it could be a useful analgesic drug following tonsillectomy. However, it might be necessary to consider administration in combination with acetaminophen because Celecoxib has insufficient analgesic effect following tonsillectomy.

Flexible endoscopic treatment for Zenker's diverticulum with the SB Knife. Preliminary results from a single-center experience.

Flexible endoscopic septum division is becoming a prominent treatment option for Zenker's diverticulum (ZD). Over the years, various techniques have been developed and many cutting tools have been tested with varying results. We report our experience with a recently designed, monopolar, rotating, scissor-shaped device (SB Knife). Data on 31 consecutive patients that underwent flexible endoscopic treatment for ZD with the use of the SB Knife were retrieved. Dysphagia, regurgitation, and respiratory symptom severity before the procedure were graded. Procedure duration, rate of complications, symptom changes after the procedure and rate of relapsing patients during follow up were recorded. The procedure was carried out successfully in all patients. Median procedure time was 14 min. One case of late-onset bleeding developed 1 week after the procedure, and was managed endoscopically. A significant symptom improvement was achieved (dysphagia: median score <3, median score >0, P < 0.001; regurgitation: median score <2, median score >0, P < 0.001; respiratory symptoms: median score <2, median score >0, P = 0.009). Two patients had mild relapsing symptoms, respectively, after 4 and 9 months from the procedure but refused further treatment. Endoscopic treatment of ZD using this new device is safe and efficient at short term follow up. No perforations were observed and there was a substantial reduction of symptoms after the treatment. Larger studies are needed to fully assess advantages of this new device for endoscopic treatment of ZD.