Postoperative Anticoagulation Therapy Research Articles

Successful Treatment for End—Stage Hepatic Alveolar Echinococcosis With ex vivo Liver Resection and Autologous Liver Transplantation: A Case Report

3045_A.tif Figure 1: Preoperative 3D imaging analysis system revealed the retro—hepatic IVC was involved (arrow)3045_B.tif Figure 2: The irregular outflow of right/short hepatic vein reconstruction (A: great saphenous veins; B—C: right/short hepatic vein reconstruction using the great saphenous veins wall)Objective To explore the surgical process of ex—vivo liver resection and autologous liver transplantation (ERAT) for end—stage hepatic alveolar echinococcosis (HAE) and evaluate the therapeutic effect and surgical benefit. Methods The clinical data of one end—stage HAE patient treated with ERAT combined complicated hepatic vein reconstructionwas analyzed retrospectively. Preoperative examination and intraoperative exploration revealed the second hepatic portal was involved. We successfully initiated an operation through ex—vivoliver resection, hepatic vein reconstruction with the autogenous saphenous vein, and subsequent piggyback autologous liver transplantation by wide—mouth hepatic vein—artificial inferior vena cava anastomosis (end to side). Results This patient discharged uneventfully 14 days after the operation. The injection of low—molecular—weight heparin sodium and consequent oral warfarin sodium tablets were administered for anticoagulant therapy. Regular autograft ultrasound examination revealed no tarombokinesis in autologous liver and inferior vena cava. Conclusion ERAT is an ideal surgical method for end—stage HAE. Wide—mouth hepatic vein reconstruction using an autogenous saphenous vein is the key procedure. Postoperative anticoagulant therapy is significant for the improvement of transplanted liver function.3045_C.tif Figure 3: Piggyback autologous liver transplantation (A—C)

Risk factors for bleeding complications of postoperative prophylactic anticoagulation therapy after cesarean section in preeclampsia cases

Risk factors for bleeding complications of postoperative prophylactic anticoagulation therapy after cesarean section in preeclampsia cases

Peripheral Blood Cells Changes After Two Groups of Splenectomy and Prevention and Treatment of Postoperative Complication

Objective: This study aimed to investigate the changes in peripheral blood cells after two groups of splenectomy in patients with traumatic rupture of the spleen and portal hypertension group, as well as causes and prevention and treatment of splenectomy related portal vein thrombosis.Methods: Clinical data from 109 patients with traumatic rupture of the spleen who underwent splenectomy in our hospital from January 2001 to August 2015 were retrospectively analyzed, and compared with those from 240 patients with splenomegaly due to cirrhotic portal hypertension who underwent splenectomy over the same period.Results: After splenectomy, peripheral platelet (PLT) count was significantly increased in both groups (P 0.05), while the white blood cell (WBC) count was significantly decreased (P 0.05), respectively, which was alleviated with urokinase.Conclusion: The significant increase of peripheral PLT count in both groups after splenectomy might be caused by the removal of the site that stored blood cells. The more significant increase of PLT in the traumatic rupture group might be related to a constant production and release of thrombopoietin by the normal liver into blood circulation. The lack of increase of RBC count in the traumatic rupture group indicated no storage of RBCs in the spleen, and the significant increase of WBC count was related to the control of inflammation. The significant increase of WBC and RBC counts in the portal hypertension group was related not only to the elimination of spleen storage, but also to the elimination of hypersplenism. Postoperative routine anticoagulant and thrombolytic therapy could prevent and treat portal vein thrombosis.

Strategy for Cardiovascular Surgery in Patients with Antithrombin III Deficiency.

Antithrombin III (ATIII) deficiency is a rare disorder in which thrombosis can be induced by stimuli that do not usually lead to thrombus formation, including minor injuries and surgery. Therefore, patients with ATIII deficiency undergoing cardiovascular surgery that involves heparinization require careful perioperative management. We experienced five patients with ATIII deficiency who underwent cardiovascular surgery and were managed with ATIII replacement. By administration of ATIII concentrate, preoperative ATIII activity was maintained at ≥120% and postoperative ATIII activity at ≥80%. All five patients were treated successfully without postoperative complications such as hemorrhage or thrombosis. In patients with ATIII deficiency undergoing cardiac surgery, it is important to perform ATIII replacement to achieve preoperative ATIII activity ≥120% and postoperative ATIII activity ≥80%, while the activated clotting time (ACT) is maintained at >400 seconds during cardiopulmonary bypass. In addition, long-term postoperative anticoagulant therapy is necessary in hereditary ATIII deficiency patients with a history of thrombosis.

Does Postoperative Anticoagulation Therapy Lead to a Higher Success Rate for Microvascular Free-Tissue Transfer in the Head and Neck? A Systematic Review and Meta-Analysis.

Due to limited evidence, it is unclear whether postoperative anticoagulation therapy may lead to higher success rates for microvascular free-flap surgery in the head and neck. This review evaluated whether postoperative anticoagulation therapy can lead to a better result in head and neck reconstruction. PubMed, Embase, and the Cochrane Library were used to search for articles on the efficacy of postoperative antithrombotic therapy in free-flap transfer during head and neck reconstruction without language restrictions in February of 2017. A random-effects model was used to estimate the relative risk ratio (RR) with 95% confidence intervals (CIs). The measured outcomes were flap loss, thromboembolic events, and hematoma formation. A total of 2,048 free-flap surgery procedures in the head and neck were analyzed. There was no significant difference in the occurrence of flap loss and thromboembolic events in the anticoagulation group compared with the nonanticoagulation group (RR = 1.25, 95% CI = 0.85-1.81, p = 0.26; and RR = 1.05, 95% CI = 0.74-1.48, p = 0.79, respectively). The risk of hematoma was twice as high in the anticoagulation group than the nonanticoagulation group, which was statistically significant (RR = 2.02, 95% CI = 1.08-3.76, p = 0.03). The findings from our meta-analysis indicate that postoperative anticoagulation therapy barely decreases the risks of flap loss and thromboembolic events in free-flap surgery in the head and neck. However, it may significantly increase the risk of hematoma formation. Considering the limitations of this meta-analysis, additional high-quality, multicenter, prospective, randomized controlled studies are needed to confirm these findings.

Delayed Catheter-Related Intracranial Hemorrhage After a Ventriculoperitoneal or Ventriculoatrial Shunt in Hydrocephalus

Delayed catheter-related intracranial hemorrhage is not rare after a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt for the treatment of hydrocephalus. Immediate postoperative catheter-related intracranial hemorrhage is possibly due to the procedure itself; however, delayed intracranial hemorrhage may have other underlying mechanisms. This study aimed to investigate the clinical characteristics and reveal the risk factors of delayed catheter-related intracranial hemorrhage after a VP or VA shunt. We did a retrospective study to review patients with hydrocephalus and underwent VP or VA shunt in our department from September 2011 to December 2015. We reviewed the clinical characteristics of the patients with delayed catheter-related intracranial hemorrhage, and its risk factors were analyzed with SPSS 16.0. Of the 218 patients enrolled in the study (145 male, 73 female), 17 (7.8%) patients experienced delayed catheter-related intracranial hemorrhage, including 11 of 151 (7.3%) patients with a VP shunt and 6 of 67 (9.0%) patients with a VA shunt. Additionally, 4 of the 16 patients with postoperative low-molecular-weight heparin (LMWH) therapy and 13 of the 202 patients without LMWH experienced bleeding, showing a significant difference (25% vs. 6.4%, P= 0.026). The relative risk was 4.8 (95% confidence interval: 1.4-17.1). Delayed catheter-related intracranial hemorrhage is not rare after a VP or VA shunt. However, most patients can be cured after appropriate treatment. Postoperative anticoagulation therapy with enoxaparin may be associated with an increased risk of bleeding.

Efficacy and safety of postoperative anticoagulation therapy with enoxaparin in patients undergoing pancreatic surgery: a prospective clinical trial

To evaluate the results of the implementation of an enhanced recovery programme (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital.A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien–Dindo stage >2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared.No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54–2.981; p = 0.601) nor in Clavien–Dindo > 2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492–2.167; p = 0.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112–10.123; p < 0.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165–28.92; p < 0.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ] = 325 (285–355) vs. 540 (360–600) min; p < 0.0001).Enhanced recovery programmes in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.Evaluar los resultados de la instauración de un programa de recuperación intensificada (ERAS) para cistectomía radical en abordaje abierto con respecto a la cohorte histórica de un mismo hospital.Estudio de análisis retrospectivo de 138 pacientes sometidos a cistectomía radical con derivación ileal tipo Bricker o Studer de forma consecutiva (97 históricos vs. 41 ERAS). Se compararon tasa de complicaciones a 30 días, complicaciones estadio Clavien-Dindo > 2, mortalidad, estancia y tasa de readmisión en el hospital y en cuidados críticos, reintervención y necesidad de sondaje nasogástrico, trasfusión o nutrición parenteral.No se hallaron diferencias estadísticamente significativas en cuanto a la tasa de complicaciones globales tras 30 días de alta (73,171 vs. 77.32%; OR 1,25, IC 95% 0,54-2,981; p = 0,601) ni en Clavien-Dindo > 2 (41,463 vs. 42.268%; OR 1.033, IC 95% 0,492-2,167; p = 0,93), así como en mortalidad, estancias o tasas de readmisión y reintervención. La necesidad de sondaje nasogástrico fue menor en el grupo ERAS (43,902 vs. 78,351%; OR 4,624, IC 95% 2,112-10,123; p < 0,0001), así como la necesidad de nutrición parenteral total (26,829 vs. 34,021%; OR 12,234, IC 95% 5,165-28,92; p < 0,0001) y el tiempo bajo intubación orotraqueal desde la inducción anestésica (mediana [RIC] = 325 (285-355) vs. 540 (360-600) min; p < 0,0001).Los programas de recuperación intensificada en cistectomía radical disminuyen el intervencionismo sobre el paciente sin aumentar la morbimortalidad.

Efficacy and safety of postoperative anticoagulation prophylaxis with enoxaparin in patients undergoing pancreatic surgery: A prospective trial and literature review

Background/Objectives: Enoxaparin is low-molecular-weight heparin that is used for postoperative thromboprophylaxis. The purpose of this study was to evaluate the efficacy and safety of enoxaparin after pancreatic resection. We additionally carried out a literature review regarding venous thromboembolism (VTE) and postoperative bleeding mainly after hepatobiliary-pancreatic surgery. MethodsThis was a prospective, single-arm study. Patients aged 20–79 years who planned to undergo pancreatic resection followed by postoperative anticoagulation therapy with enoxaparin were enrolled from 2013 to 2016. The exclusion criteria were low renal function, active bleeding, clinical signs of VTE at screening, or evidence of thromboembolic disease before surgery. The primary endpoint was the incidence of postoperative VTE. The secondary endpoint was the incidence of postoperative complications. For the literature review, PubMed was searched for relevant articles and the PRISMA guidelines were used. ResultsIn total, 103 patients were analyzed. Two patients (1.9%) developed asymptomatic VTE, and no patients developed symptomatic VTE. No in-hospital mortality occurred. Morbidities (Clavien–Dindo grade ≥ IIIa) occurred in 29 patients (28.1%). Three patients (2.9%) developed intra-abdominal hemorrhage due to pseudoaneurysm formation after pancreaticoduodenectomy or distal pancreatectomy. The literature review included nine articles, and all indicated that the results of this study were feasible. ConclusionThis is the first prospective trial to focus on pharmacologic prophylaxis with enoxaparin after pancreatic surgery. Postoperative anticoagulant therapy with enoxaparin was used in patients who underwent pancreatic surgery with a low incidence of VTE and no increase in postoperative bleeding events compared with existing evidence.

Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires?

BackgroundRe-exploration for bleeding accounts for increased morbidity and mortality after major cardiac operations. The use of temporary epicardial pacemaker wires is a common procedure at many departments. The removal of these wires postoperatively can potentially lead to a serious bleeding necessitating intervention.MethodsFrom Jan 2011 till Dec 2015 a total of 4244 major cardiac procedures were carried out at our department. We used temporary epicardial pacemaker wires in all cases. We collected all re-explorations for bleeding and pericardial tamponade from our surgical database and then we focused on the late re-explorations, meaning on the 4th postoperative day and thereafter, trying to identify the removal of the temporary pacemaker wires as the definite cause of bleeding. Patients’ records and medication were examined.ResultsThirty-nine late re-explorations for bleeding, consisting of repeat sternotomies, thoracotomies and subxiphoid pericardial drainages, were gathered. Eight patients had an acute bleeding incidence after removal of the temporary wires (0.18%). In four of these patients, a pericardial drainage was inserted, whereas the remaining patients were re-explorated through a repeat sternotomy. Two patients died of the acute pericardial tamponade, three had a blood transfusion and one had a wound infection. Seven out of eight patients were either on dual antiplatelet therapy or on combination of aspirin and vitamin K antagonist.ConclusionsA need for re-exploration due to removal of the temporary pacemaker wires is a very rare complication, which however increases morbidity and mortality. Adjustment of the postoperative anticoagulation therapy at the time of removal of the wires could further minimize or even prevent this serious complication.

Possible role of soluble fibrin monomer complex after gastroenterological surgery.

AIMTo examine the role of soluble fibrin monomer complex (SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.METHODSWe collected data on the clinical risk factors and fibrin-related makers from patients who underwent gastroenterological surgery at Hiroshima University Hospital between April 1, 2014 and March 31, 2015. We investigated the clinical significance of SFMC, which is known to reflect the early plasmatic activation of coagulation, in the view of these fibrin related markers.RESULTSA total of 123 patients were included in the present study. There were no patients with symptomatic VTE. Thirty-five (28%) patients received postoperative anticoagulant therapy. In the multivariate analysis, a high SFMC level on POD 1 was independently associated with D-dimer elevation on POD 7 (OR = 4.31, 95%CI: 1.10-18.30, P = 0.03). The cutoff SFMC level was 3.8 μg/mL (AUC = 0.78, sensitivity, 63%, specificity, 89%). The D-dimer level on POD 7 was significantly reduced in high-SFMC patients who received anticoagulant therapy in comparison to high-SFMC patients who did not.CONCLUSIONThe SFMC on POD 1 strongly predicted the hypercoagulable state after gastroenterological surgery than the clinical risk factors and the other fibrin related markers.

Incidence of venous thromboembolism and hemorrhage related safety studies of preoperative anticoagulation therapy in hip fracture patients undergoing surgical treatment: a case-control study.

BackgroundVenous thromboembolism is a common postoperative complication following orthopedic surgeries, with morbid and potentially fatal consequences. Perioperative low-molecular-weight heparin (LMWH) therapy can reduce the incidence of venous thromboembolism, but may also increase the risk of bleeding complications. Current literature reflects the need to balance the improved efficacy of early initiating prophylaxis with increased risk of perioperative bleeding. The purpose of this study was to compare the effectiveness and hemorrhage related safety of preoperative versus postoperative LMWH therapy for prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) in hip fracture patients.MethodsWe retrospectively evaluated 222 patients who underwent surgical treatment at Peking University People's Hospital between January 2009 and December 2010. Patients were allocated to two groups, receiving either preoperative or postoperative initiation of LMWH therapy for venous thromboembolism prophylaxis. Preoperative anticoagulation therapy was initiated 1–12 days prior to surgery (133 patients), and postoperative anticoagulation therapy was initiated 12 h after completion of surgery (89 patients). The preoperative group was further subdivided into four subgroups according to the time of initiation of therapy: 1–3 days before surgery (group A, 54 patients), 4–6 days before surgery (group B, 57 patients), 7–9 days before surgery (group C, 15 patients), and 10–12 days before surgery (group D, 7 patients). Occurrences of DVT, PE, adverse drug effects, intraoperative and postoperative bleeding were recorded, along with concentrations of preoperative and postoperative hemoglobin and length of hospital stay. The above parameters were compared between groups.ResultsAmong recipients of preoperative anticoagulation therapy, two patients developed postoperative PE (1.5 %), one patient developed DVT (0.75 %). In the group receiving postoperative initiation of anticoagulation therapy, one patient each developed PE and DVT (1.1 %, 1.1 %). There was no difference in the occurrence of PE and DVT between the two groups (P>0.05, Chi-square tests). We identified the incidences of major bleeding, minor bleeding, and intraspinal hematoma after spinal anesthesia, which were 0 %/0 %, 3.76 %/3.37 %, and 0 %/0 %, respectively in preoperative and postoperative anticoagulation groups. There was no significant difference in the incidence of bleeding complications between patients receiving preoperatively initiated LMWH with patients receiving postoperatively initiated LMWH. Spinal anesthesia was administered to 168 patients, with no cases of postoperative intraspinal hematoma.ConclusionsPreoperative anticoagulation therapy with LMWH may not increase intraoperative or postoperative blood loss, or the rate of intraspinal hematoma after spinal anesthesia, but also does not significantly reduce the risk of postoperative DVT or PE, compared to postoperative initiation.

Improved outcomes with the comprehensive stage 2 procedure after an initial hybrid stage 1

ObjectiveTo report our improving institutional experience with the hybrid alternative surgical strategy for the management of hypoplastic left heart syndrome, in which hybrid stage 1 is followed by a comprehensive stage 2 procedure (removal of patent ductus arteriosus stent and pulmonary artery [PA] bands, aorta and PA reconstruction, Damus–Kaye–Stansel, atrial septectomy, Glenn). MethodsIn this Institutional Review Board–approved retrospective review of all patients undergoing a comprehensive stage 2 procedure between January 2002 and December 2014, data were compared between the pre-protocol group (n = 64; January 2002 to March 2010) and the post-protocol group (n = 55; March 2010 to December 2014). These 2 groups flank the implementation of a perioperative management protocol to prevent PA thrombosis. ResultsPre-protocol mortality was 19% (12 of 64), with the most common mode of death involving PA thrombosis in at least 7 patients, with an urgent indication for surgery and age as contributing factors. Care modifications instituted in March 2010 included avoidance of procedures on an emergent basis or in patients aged <3 months, use of a systemic PA shunt in cases of too-small superior vena cava and/or PA, completion angiogram with a low threshold for intraoperative stenting, and postoperative anticoagulation therapy for 6 weeks. There was a significant decrease in mortality (2 of 55; 4%; P = .01), PA thrombosis (0 of 55; 0%; P = .01), and use of extracorporeal membrane oxygenation (0/55 [0%] compared with 7 of 64 [11%]; P = .01) after protocol implementation. ConclusionsDespite the technical challenges of the comprehensive stage 2 procedure, excellent outcomes are attainable. Experience coupled with an internal quality review drove the implementation of a successful perioperative management protocol.

Clinical observation of postoperative warfarin anticoagulation in 300 patients undergoing mitral valve replacement with a carbomedics mechanical valve.

The objective of this study was to evaluate the safety and efficacy of low-intensity warfarin treatment in Chinese patients after mitral valve replacement as well as the rationality of the INR standards of the hospital (The First People's Hospital of Jining City). We retrospectively analyzed 270 cases in our hospital from January 2009 to December 2013; 239 patients completed the 5-year follow-up. There were 192 male and 78 female subjects, age 32-65 years old with a mean age 51.51 ± 12.12 years old. All eligible candidates received a Carbomedics artificial mechanical valve replacement and were anticoagulated under this hospital's current guidelines for postoperative anticoagulant therapy mitral valve replacement (INR 1.8-2.5). We analyzed the patient's regularly recorded prothrombin times (PTs) and the occurrence of anticoagulation-related complications, such as bleeding, thrombosis, and embolism. A follow-up for 239 of 300 patients was performed for 3-60 months. Within this group, one patient died from cerebral hemorrhage, there was 1 case of subcutaneous bleeding, 1 case of epistaxis, 12 cases of gingival bleeding, in 15 menstrual quantity increased, and in 1 case we found cerebral infarction. In conclusion, low-intensity anticoagulation after mitral Carbomedics valve replacement is therapeutically effective and safe. There is room to improve the anticoagulation standard currently used, perhaps at a slightly lower level than this standard suggests. From our research we can formulate individualized treatment plans and effectively reduce the occurrence of complications.

Analysis of risk factors for occlusions of a synthetic femoropopliteal bypass graft.

Femoropopliteal bypass is a revascularization technique of lower extremities with excellent outcome. The great saphenous vein is the best graft material, but if it is not adequate or has been removed, synthetic grafts are an useful alternative. Graft occlusion is the most significant complication with the most serious consequences. The aim of this study was to analyse predictive factors for the synthetic femoropopliteal bypass occlusions. This retrospective case-control study included all patients who underwent synthetic femoropopliteal bypass due to peripheral arterial occlusive disease at the Vascular Surgery Center, Clinical Center of Kragujevac, Serbia, from 2007 to 2013. The cases group were the patients with femoropopliteal graft occlusion (n = 44), with the control group consisted of the patients without such an outcome (n = 88). Significant effects to occlusion were: concomitant cardiovascular disease (adjustedOR 27.05; 95% CI 4.74; 154.35), a type of femoropopliteal bypass (adjustedOR 16.50; 95% CI 4.05; 67.24), previous vascular intervention (adjustedOR 4.67; 95% CI 1.20; 18.14), clinical stage of the disease (adjustedOR 3.73; 95% CI 1.94; 7.18), administration of postoperative oral anticoagulant therapy (adjustedOR 0.05; 95% CI 0.01; 0.23) and the use of angiotensin converting enzyme inhibitors (adjustedOR 0.14; 95% CI 0.03; 0.70). A significant synergism was shown for the following combinations of the observed risk factors: type of femoropopliteal bypass and cardiovascular disease, type of femoropopliteal bypass and previous vascular intervention, previous vascular intervention and cardiovascular disease, previous vascular intervention and beta blockers, cardiovascular disease and diabetes, type of femoropopliteal bypass and antiaggregant therapy, clinical stage of disease and cardiovascular disease, previous vascular intervention and antiaggregant therapy. Concomitant cardiovascular disease, below-knee femoropopliteal bypass, advanced stage of vascular disease and non-use of anticoagulant therapy and angiotensin-converting enzyme inhibitors are the significant predictors of graft occlusion after synthetic femoropopliteal bypass. Their synergistic effect determines the importance of diabetes, use of beta blockers and platelet antiaggregant therapy.

Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer

BackgroundsEnoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery. Study designA retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n=228) and an enoxaparin (+) group (n=53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared. ResultsIn the enoxaparin (+) group, the patients’ age (65 vs. 69years; p=0.01) and BMI (22.9 vs. 24.4; p<0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p=0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p=0.04). The independent risk factors for PVT were an operation time≥300minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49). ConclusionsPostoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.

Surgical Management of Left Circumflex Coronary Artery Fistula: A 25-Year Single-Center Experience in 29 Patients

Left circumflex coronary artery (LCX) fistula is rare, and surgical experience is limited. We report our experience with 29 patients with LCX fistula during a 25-year period in terms of clinical features, pathology, surgical procedure, and late outcomes. Between June 1988 and July 2013, 29 patients (19 males, 10 females; median age, 10 years) with LCX fistula were treated surgically and followed up. Preoperative diagnosis was made echocardiographically in 29 patients and angiographically in 17. The fistula drained into the right atrium in 12, the right ventricle in 8, left atrium and left ventricle, each in 3, main pulmonary artery in 2, and coronary sinus in 1. Surgical procedure included endocardial closure in 17 patients, epicardial closure in 5, endocardial and epicardial closure in 2, suture ligation in 1, and off-pump suture ligation in 4. Postoperative anticoagulation was prescribed for at least 6 months. There were no operative deaths. Complications included residual shunt in 2 patients, and LCX thrombosis, pneumothorax, hemoglobinuria, and wound infection, each in 1 patient. At the latest follow-up extending to 25 years (mean, 10.1±4.6 years), 17 patients were asymptomatic and in New York Heart Association functional class I, 4 in II and 2 in III. Residual shunt, myocardial infarction, and right atrial thrombosis occurred, each in 1 patient. Surgical repair of LCX fistula is safe and effective, with low risks and favorable late outcomes. Our experience implies the necessity for postoperative anticoagulation therapy to achieve good long-term outcomes.

Prospective Study of Venous Thromboembolism in Patients With Head and Neck Cancer After Surgery

Venous thromboembolism (VTE) is associated with significant morbidity and mortality in surgery patients, but little data exist on the incidence of VTE in head and neck cancer surgical patients. To determine the incidence of VTE in postoperative patients with head and neck cancer. A prospective study of 100 consecutive patients hospitalized at a tertiary care academic surgical center who underwent surgery to treat head and neck cancer. Routine chemoprophylaxis was not used. On postoperative day (POD) 2 or 3, participants received clinical examination and duplex ultrasonographic evaluation (US). Participants with negative findings on clinical examination and US were followed up clinically; participants with evidence of deep venous thrombosis (DVT) or pulmonary embolism (PE) were given therapeutic anticoagulation. Participants with superficial VTE underwent repeated US on POD 4, 5, or 6. Participants were monitored for 30 days after surgery. Total number of new cases of VTE (superficial and deep) identified within 30 days of surgery and confirmed on diagnostic imaging. Of the 111 participants enrolled, 11 withdrew before completing the study; thus, 100 participants were included. The overall incidence of VTE was 13%. Eight participants were identified with clinically significant VTE: 7 DVT and 1 PE. An additional 5 participants had asymptomatic lower extremity superficial VTE detected on US alone. Fourteen percent of patients received some form of postoperative anticoagulation therapy; the rate of bleeding complications in these patients (30.1%) was higher than that in patients without anticoagulation therapy (5.6%) (P = .01). Hospitalized patients with head and neck cancer not routinely receiving anticoagulation therapy after surgery have an increased risk of VTE. Bleeding complications are elevated in patients receiving postoperative anticoagulation.

Acquired factor V deficiency in a patient without evidence of a classical inhibitor

Acquired factor V deficiency in a patient without evidence of a classical inhibitor

Comparative Clinical and Economical Analysis of Drugs for Primary Prevention of Thrombotic Complications after Orthopaedic Operations

Cost minimization analysis was performed on the basis of the efficacy and safety evaluation of dabigatran etexilate (DE, Pradaxa®) versus other common anticoagulants (AC). Total costs including laboratory and instrumental examinations, consultations related to venous thromboembolism (VTE) and post-operative anticoagulation therapy were calculated by the data of 828 individual registration cards. All patients were divided into 2 groups: 761 patients (91.9%) after total hip and knee arthroplasty (1 st group) and 67patients (8.1%) after other orthopaedic operations (2 nd group). In 1 st group costs for drug prophylaxis of VTE and total costs per patient were significantly lower (by 1196.66 and 432.41 rbl, respectively) when DE was used as compared to AC application. After other orthopaedic operations reliable differences neither in costs for drug prophylaxis of VTE nor in total costs per patient were detected. However the significance of obtained results was limited by the number as well as the differences in initial condition of patients.

Invited Commentary

Dr Ohtaka and his colleagues [1Ohtaka K. Hida Y. Kaga K. et al.Thrombosis in the pulmonary vein stump after left upper lobectomy as a possible cause of cerebral infarction.Ann Thorac Surg. 2013; 95: 1924-1929Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar] have documented a study that is both insightful and provocative. Thrombosis in the stump of the superior pulmonary vein after left upper lobectomy introducing a potential cause of embolic morbidity to vital organs, including the brain, heart, kidney, and intestines, is not widely recognized. It is doubtful that many thoracic surgeons have appreciated the association of a postlobectomy systemic embolus with a thrombus from the pulmonary vein stump. Reflecting on a career in academic thoracic surgery, I do not recall this complication being discussed in our morbidity and mortality conferences. Using contrast-enhanced chest computed tomography (CT), retrospectively interpreted to check for thrombus in the pulmonary vein stump, the authors have now effectively clarified the frequency, risk factors, and probable cause of this complication: using three-dimensional CT images, the left superior pulmonary vein stump was determined to be significantly longer than the left inferior, right superior, and right inferior vein stumps. The rationale that length contributed to thrombus formation is compelling. The true incidence of thrombus in the stump of the left superior pulmonary vein is surely underestimated. The authors detected a thrombus in the pulmonary vein stump in 3.6% of all patients and in 13.5% of left upper lobectomy patients. It is reasonable to assume that the systematic application of postresection contrast medium–enhanced chest CT, at an early interval, will significantly increase the frequency of detection. Finally, univariant analyses revealed that left upper lobectomy and operative time were notable risk factors for the presence of thrombus. Importantly, the authors recommend routine contrast medium–enhanced CT of the chest for all patients after left upper lobectomy to help identify patients with a high risk for thromboembolism. Their study represents a significant contribution to our appreciation and understanding of the inherent pathology of postresection pulmonary vein thrombus and provides a specific clinical implementation: the institution of postoperative anticoagulant therapy. The routine election of intrapericardial division of the left superior pulmonary in an effort to shorten the stump would be challenging, problematic, and premature at this time. However, a multicenter clinical study founded on the use of contrast medium–enhanced chest CT would be timely. Thrombosis in the Pulmonary Vein Stump After Left Upper Lobectomy as a Possible Cause of Cerebral InfarctionThe Annals of Thoracic SurgeryVol. 95Issue 6PreviewThrombus in the stump of the pulmonary vein (PV) is not a well-known complication after lung resection, and it has the potential to cause embolism to vital organs. To clarify the frequency, risk factors, and cause of this complication, a retrospective clinical study of patients who underwent lobectomy was performed. Full-Text PDF