Risk Of Uncontrollable Bleeding Research Articles

Caesarean scar pregnancy – management

Caesarean scar pregnancy (CSP) is a potential complication of women having pregnancies after one or more previous caesa­rean deliveries. Its incidence varies between 1:1800 and 1:2200 pregnancies. The most important aspect is the diagnosis of CSP as early as possible, ideally around 7 weeks of gestation. The failure to diagnose CSP could lead to a high risk of uncontrolled bleeding and caesarean hysterectomy, with increased morbidity and mortality for both mother and fetus. Many management strategies have been presented, ranging from medical to surgical interventions or combining them. We recommend the use of Shirodkar cervical suture (to control the potential bleeding) preceding transcervical suction curettage of pregnancy.

P14. Abstract Title: Modulating Fibrinolysis using siRNA against Coagulation Factor XIII

High specificity, easy reversibility, and a half-life on the order of weeks; these are all major advantages that gene therapy has over traditional anticoagulants, add to that a strategy that weakens clots rather than preventing clotting altogether and prophylaxis of thrombosis may become much safer. Currently, anticoagulant drugs are used as a preventative measure for people susceptible to developing disease causing thrombi (which manifest as heart attacks, strokes, and pulmonary embolism), but they require frequent administration and their strict inhibition of clotting increases the risk of uncontrolled bleeding. They are the top drug class to be linked with related adverse events. This project will develop a safer alternative to prevent dangerous blood clots from forming, while avoiding the bleeding risks of current treatment options. siRNA delivered using lipid nanoparticles has been recently approved as a therapeutic; we aim to harness this strategy to target a protein that makes clots resistant to lysis, coagulation factor XIII. The objective being to still allow clots to form at the site of wounds, but enabling the body's clot clearance system to do so much easier in the case of pathological thrombi. In the event of an accident or major surgery, the effect of siRNA may be directly reversed by a simple blood transfusion. By inhibiting clot stabilizing proteins, we aim to maintain a safer hemostatic balance between clot formation, inhibition, and degradation, which we hope could improve the medical options available to the thousands of Canadians that suffer from conditions caused by thromboembolic clots each year.

Cavo-atrial thrombectomy prior to hepatectomy for hepatocellular carcinoma with tumor thrombus in the right atrium: a case report

BackgroundHepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition. The general consensus is to perform hepatectomy prior to cavo-atrial thrombectomy because of the risk of uncontrollable bleeding during the liver transection after heparinization. However, sudden cardiac arrest due to the ball-valve effect and pulmonary embolism have been reported in cases of TT. Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium was successfully performed to prevent sudden cardiac arrest and pulmonary embolism.Case presentationTumor thrombectomy under cardiopulmonary bypass with heparin and electrical ventricular fibrillation prior to hepatectomy was successfully performed to prevent sudden cardiac arrest or pulmonary embolism in a 75-year-old woman with a huge HCC and TT in the right atrium. After the neutralization of heparin, right hepatectomy with tumor thrombectomy in the inferior vena cava was performed. The total operation time was 9 h, and the total blood loss was 8200 mL. The patient’s postoperative course was uneventful, and she was discharged 14 days after surgery. One year after surgery, she is alive with HCC recurrence in the lung.ConclusionsCavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium can be performed safely to prevent sudden cardiac arrest and pulmonary embolism by collaboration of cardiovascular surgeons and gastroenterological surgeons.

Tumor lamination in mediastinal giant tumors.

Mediastinum tumors may grow slowly and reach giant proportions without symptoms, hindering surgical removal. Tumor big dimensions difficult surgical maneuvers, with risk of uncontrollable bleeding and prejudice to surrounding structures. It may be necessary the use of exceptional measures such as venous-venous circulatory deviation, pre-operatory embolization and total extracorporeal circulation. We describe the technique of tumor lamination that allows for complete or almost complete resection of such tumors that in many occasions are not resectable. The description is based on the results of four patients treated with mediastinum giant tumors.

Cusum analysis for learning curve of videothoracoscopic lobectomy.

BackgroundVideo assisted thoracoscopic (VATS) lobectomy has a demanding learning curve due to its technical complexity and risk of uncontrollable bleeding. We investigated the case number required for gaining technical proficiency by applying cumulative sum analysis on initial VATS lobectomy operations of a single surgeon.MethodsCALGB definition was used for the definition of VATS lobectomy. The data of the initial cases evaluated and cumulative sum (CUSUM) analysis was applied to duration of the operations and length of hospital stay.ResultsFifty-eight patients underwent VATS lobectomy. Of those 51 were malignant and 7 were benign. Fifty-five of the procedures were lobectomy, 2 were inferior bi-lobectomy and 1 was left upper lobectomy with chest wall resection. CUSUM analysis reached to proficiency at 27 cases for duration of the operations.ConclusionsThe length of learning curve depends on previous experience of the surgeon on open lobectomy and simpler VATS operations, potential number of VATS lobectomy cases and VATS capability of the surgeon. Depending on these factors, it is possible to obtain technical proficiency with an inferior number of procedures compared with existing literature (50-200).

Learning curve associated with VATS lobectomy.

The first VATS lobectomy was performed in 1991 (1). Since then the implementation of VATS lobectomy has been rather slow. Data from the STS database shows a 32% rate of VATS lobectomies in 2006 (2). But it is only the best academic units that report to the STS database. This percentage is hence probably not representative for all the thoracic units in the USA. The implementation in Europe has been even slower than in the USA. But in the past years interest is rising, and in a recent report from The Society for Cardiothoracic Surgery in Great Britain and Ireland, the percentage of lobectomies performed by VATS has increased from 7% to 14% in just one year (2010). The slow adoption despite the obvious advantages is considered by many to be due to a demanding learning curve. The procedure is considered technically demanding and has the risk of uncontrollable bleeding. The introduction of VATS lobectomies in the surgical community was performed by self taught surgeons experienced in open surgery. The approaches varied from anterior, inferior to posterior, using 2-5 ports (3-6). These surgeons were pioneers and in case of intraoperative difficulties, conversion was their only option. The conversion rate was in many cases rather high (6). In Figure 1, the conversion rate and number of VATS lobectomies in Copenhagen between 1999 and 2011 is illustrated. The conversion rate declines with experience and number of cases per year. In the centres of the pioneers, the next generation learned the technique under guided supervision. The conditions for those surgeons’ learning curves were better due to the possibility of learning under supervision by an experienced VATS surgeon and a better possibility for selecting cases suitable for a training surgeon. Furthermore the surgical outcome was very satisfactory with low conversion and complication rates (7,8). Figure 1 Number of VATS lobectomies performed in Copenhagen 1999 to 2011 and conversions in % Since the introduction of VATS lobectomy in 1991, there has been a substantial improvement in the image quality. The introduction of firstly the digital thoracoscopes and later high definition (HD), has made precise dissection close to major vessels possible. Furthermore, several companies have designed curved instruments tailored to VATS surgery and a continuous improvement in these instruments have made it easier to perform and learn the technique. The quality of staplers has also improved significantly resulting in less air leak and fewer bronchial leaks.

Partial abdominal evisceration and intestinal autotransplantation to resect a mesenteric carcinoid tumor

BackgroundMidgut carcinoids are neuroendocrine tumors that commonly metastasize to the intestinal mesentery, where they predispose to intestinal obstruction, ischemia and/or congestion. Because of their location, many mesenteric carcinoid tumors are deemed unresectable due to the risk of uncontrollable bleeding and prolonged intestinal ischemia.Case PresentationWe report the case of a 60-year-old male with a mesenteric carcinoid tumor obstructing his superior mesenteric vein, resulting in intestinal varices and severe recurrent GI bleeds. While his tumor was thought to be unresectable by conventional techniques, it was successfully resected using intestinal autotransplantation to safely gain access to the tumor. This case is the first described application of this technique to carcinoid tumors.ConclusionsIntestinal autotransplantation can be utilized to safely resect mesenteric carcinoid tumors from patients who were not previously thought to be surgical candidates. We review the literature concerning both carcinoid metastases to the intestinal mesentery and the use of intestinal autotransplantation to treat lesions involving the mesenteric root.

Greater use of fibrinolytic agents urged

The thrombolytic agents urokinase and streptokinase are safe and more effective than traditional anticoagulants in treating deep-vein thrombosis and pulmonary embolism in carefully selected patients, a panel of experts convened by the National Institutes of Health (NIH) has concluded. In an official statement following a two-day NIH consensus development conference on fibrinolytic therapy held earlier this spring, the panel members agreed that the risk of uncontrolled bleeding that has been associated with the two drugs is actually far less than was indicated by the original clinical trials. In addition, the long-term benefits of streptokinase and urokinase make them far superior to heparin sodium in most cases. In urging that the two drugs be used more often, the consensus panel, headed by Sol Sherry, MD, chairman of the Department of Medicine at Temple University School of Medicine, Philadelphia, was attempting to overcome a marked hesitance on the part of clinicians to