Severe Postoperative Bleeding Research Articles

Sarcopenia among treated cancer patients before and after neoadjuvant chemotherapy: a systematic review and meta-analysis of high-quality studies.

Neoadjuvant chemotherapy, used to shrink tumors before surgery, is increasingly applied in clinical practice. However, retrospective studies indicate that it may increase sarcopenia rates and consequently result in an elevated occurrence rate of postoperative severe complications such as severe surgical incision infection, severe respiratory failure, and severe postoperative hemorrhage, especially in the elderly population. Currently, no systematic analysis examines the association between neoadjuvant chemotherapy and sarcopenia. This study aims to fill this gap with a comprehensive meta-analysis focused on this critical aspect of the field. A systematic literature search was conducted in the PubMed and Web of Science databases from their inception to January 2024. The included studies encompassed patients who received neoadjuvant chemotherapy and underwent computed tomography (CT) scans both before and after treatment to calculate skeletal muscle index (SMI) or categorize them for the presence of sarcopenia. The determination of sarcopenia status was based on well-established and validated threshold criteria. Data extraction was performed independently by two reviewers. A meta-analysis was employed to estimate the pooled odds ratio (OR) and its corresponding 95% confidence interval (95% CI) to assess the risk of neoadjuvant chemotherapy-induced muscle reduction. In the 14 studies with complete categorical variable data, comprising 1853 patients, 773 patients were identified as having sarcopenia before neoadjuvant treatment and 941 patients had sarcopenia after neoadjuvant therapy. The OR and its 95% CI was calculated as 1.51 [1.31, 1.73]. Among these, 719 patients had digestive system cancer, with 357 patients having sarcopenia before neoadjuvant treatment and 447 patients after, resulting in an OR of 1.74 [1.40, 2.17]. In the remaining 1134 patients with non-digestive system cancers, 416 were identified as having sarcopenia before neoadjuvant treatment, and 494 patients had sarcopenia after, with an OR of 1.37 [1.15, 1.63]. Additionally, in seven studies with complete continuous variable data, including 1228 patients, the mean difference in the change of SMI before and after neoadjuvant treatment was - 1.13 [- 1.65, - 0.62]. After excluding low-quality small-sample studies with fewer than 50 patients, the same trend was observed in the analysis. The risk of muscle reduction significantly increases in cancer patients after neoadjuvant chemotherapy and digestive system cancers tend to have a higher risk of developing sarcopenia post-treatment compared to non-digestive system cancers.

Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery.

Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.

Accelerated wound healing after topical application of hyaluronic acid cotton to hemorrhoidectomy wounds in a rat model.

Anal wounds following hemorrhoidectomy can lead to severe pain and postoperative bleeding, impacting patient recovery and quality of life. Hyaluronic acid (HA) stimulates tissue regeneration and wound healing by accelerating cell migration and proliferation. This study aimed to investigate the differences in wound healing rate and completeness of recovery of perianal wounds topically treated with HA-soaked cotton in a murine model. Forty-eight 8-week-old Sprague-Dawley rats with perianal wounds created using a biopsy punch were divided into 2 groups: simple dressing with gauze (control) and topical HA-soaked cotton. A single application of HA-soaked cotton was administered after surgery. Wound healing rate and completeness of recovery were evaluated by measuring the healed area and conducting histological analyses. The HA-cotton group exhibited a shorter complete wound healing duration compared to the control group (13.9 days vs. 16.4 days, P = 0.031). Differences in wound healing area between the 2 groups were greatest on postoperative day 2 (51.6% vs. 28.8%, P < 0.001). The HA-cotton group exhibited fewer cases of granulation tissue (2 vs. 5) or redness (0 vs. 3) upon complete wound healing. Histologically, the HA-cotton group showed accelerated reepithelialization, rapid shift to lymphocyte-dominant inflammation, enhanced fibroblast proliferation, and increased collagen deposition compared to the control group. Herein, topical application of HA-soaked cotton on perianal wounds in rats resulted in accelerated wound healing, particularly in the initial stages, and improved completeness of recovery, underscoring the potential of the topical application of HA-soaked cotton on hemorrhoidectomy wounds in human patients to improve wound healing.

Management of Microvascular Bleeding after On-Pump Cardiac Surgery in a Patient with Perioperative Diagnosis of Impairment of Platelet Responses to Adenosine Diphosphate: A Case Report and a Literature Review.

Impairment of platelet responses to adenosine diphosphate (ADP) is typified by mild to severe bleeding diathesis, easy bruising, excessive mucosal and post-operative bleeding. Patients lack full platelet activation and aggregation in response to ADP. Following research of the literature in Scopus, PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, we report only 18 patients described to date with impaired platelet response to ADP, none of whom in the high bleeding-risk surgical setting or exploring potential therapeutic options. Data regarding population, putative genetic mutations, modes of inheritance, functional defects, and related clinical manifestations were retrieved from case series and case reports. A 40-year-old woman was scheduled for on-pump cardiac surgery. Her past medical history included episodes of spontaneous mucocutaneous hemorrhages of the mild entity since childhood. Multiple electrode aggregometry (MEA, Multiplate® Roche Diagnostics, Rotkreuz, Switzerland) was used to evaluate platelet response to thrombin-activated peptide-6 (TRAP), arachidonic acid (ASPI), and ADP. An inadequate platelet aggregation induced using a high concentration of ADP with normal TRAP and ASPI tests was detected preoperatively. Therefore, intravenous desmopressin (DVVAP) 0.3 μg/kg body weight was administered to manage microvascular bleeding developed after weaning from cardiopulmonary bypass (CPB). Proper management of impaired platelet response to ADP requires a systematic assessment. The Multiplate analyzer is a valuable tool to promptly detect the disorder when a high clinical suspect is present and obtain insights during high bleeding-risk surgical procedures. DVVAP can be beneficial as first-line therapy in bleeding patients to improve platelet function.

Impact of intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery

ObjectiveRisk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration. MethodsWe retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding. ResultsOf 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P < .001) and 30-day mortality (14% vs 2%, P < .001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after ∼6 L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration. ConclusionsWe found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.

Influence of perioperative antiplatelet and anticoagulant medication management on bleeding events in dermatosurgery-A prospective observational study.

Perioperative management of antiplatelet and anticoagulant (AP/AC) therapy is a matter of balancing the risks of bleeding and thromboembolic events. Reliable data for dermatosurgery are still lacking, especially for direct oral anticoagulants (DOAC). The aim was to prospectively evaluate the influence of AP/AC-medication on bleeding risk in dermatosurgery with focus on exact intervals between DOAC intake and procedure performed on post-operative bleeding. Patients with or without AP/AC-therapy were included in the study without randomization. Exact times of DOAC-intake, procedure performed and post-operative bleeding were documented. Data collection was prospectively and standardized done by one person. We evaluated 1852 procedures in 675 patients. Post-operative bleeding occurred after 15.93% (n = 295) of all procedures, but only a few of them were severe (1.57%, n = 29). Compared to patients without AP/AC-medication, severe post-operative bleeding occurred significantly more often under dual antiplatelet therapy (11.76%, n = 2; p = 0.0166) and bridging of either vitamin K antagonist (9.09%, n = 2; p = 0.0270) or DOAC (15.38%, n = 2; p = 0.0099). There was no significant difference in the frequency of severe bleeding regarding to the preoperative DOAC-free period. Although AP/AC-therapy is associated with a significant higher rate of post-operative bleeding, no life-threatening bleeding was recorded. Long preoperative pausing or bridging of DOAC does not lead to significantly less severe bleeding events.

Comment on "Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery".

We read with great interest a recently published work by Raphael et al.1 Their primary hypothesis was to establish independent causality of intraoperative transfusion of red blood cells (RBCs) on venous thromboembolism (VTE) after coronary bypass grafting surgery (n = 751,893) using the database of the Society of Thoracic Surgeons. In their secondary analyses, they further explored the types of VTE, mortality, readmission rate, and length of hospital stay. Their analyses of these data were extensive; however, there are issues that warrant further discussion. First, the overall exposure to RBCs was reported as 17.8% in the current study, but it is important to note the authors handled missing data on intraoperative/postoperative blood products as “no transfusion.” Previous studies in similar patients have shown that intraoperative transfusion rates varied between 12.8% and 60.3% due to variations in institutional practice.2 Missing data labeled as “no transfusion” and omission of any postoperative transfusion before any VTE might have skewed the relationship between intraoperative RBCs and VTE. Second, 37% of women versus 12% of men received blood transfusion. The women were 3 times more likely to receive more than 3–4 units of transfusion than men; however, the adjusted odds ratio for VTE was 0.90 for women. Others also demonstrated that women were more likely to receive >4 U RBC transfusion.3 Women tend to have a lower body mass index (BMI) compared with men, and thus they are more prone to dilutional anemia, and subsequently RBC transfusion. A causality relationship between RBCs and VTE was not supported by the lower odds of VTE in women. As a related issue, we would like to discuss their use of conditional imputation for handling missing data. The extent or presumed pattern of missing data was not specified, but BMI was mentioned as an example of conditional imputation. BMI is known to have a wide variation, particularly by geographic location. Conditional imputation without consideration of regional clustering might have distorted the relationship of BMI (and other predictors) and transfusion in development of the propensity score.4,5 Third, the authors attempted to isolate the effect of intraoperative RBCs by addressing or adjusting all the other risk factors for VTE. From Table 3, the exposures to non-RBC components, recombinant activated factor VII, and factor VIII inhibitor bypassing agent were increased in those with increased RBC transfusion. Hemostatic components were treated as a confounder in the model, but there may be causal associations with both acute and subacute VTE and arterial thromboses.6,7 Patients with severe postoperative bleeding tend to have prolonged hospital stay. The authors showed that cohorts with ≥3 units of RBC had longer hospital stay (mean, 9.8–11.2 days) compared with nontransfused patients (mean, 6.6 days). Although not captured in the database, delayed thromboprophylaxis during a prolonged hospital stay may also exacerbate VTE risk. Lastly, the authors utilized inverse probability treatment weighting method using inverse probability of treatment weighting based on the matching as shown in their Table 2; however, the authors did not mention the handling of extreme weights, which may lead to undue influence of otherwise less common groups (ie, patients with 3 or 4+ units of RBCs) (Tables S1–S10, https://links.lww.com/SLA/E307). While inverse probability treatment weighting adequately accounted for measured confounders pertinent to transfusion (eg, cardiopulmonary bypass [CPB] time), it is speculated that there are residual confounders that impact VTE rates.8 For example, extensive tissue injury and CPB are well known to trigger activations of endothelial cells and leukocytes. Cross-talks between coagulation and immune systems are referred to as “thrombo-inflammation,” and it plays a pivotal role in the pathogenesis of VTE.9 Patient-level inflammation parameters are neither routinely measured nor captured in the database. The statistical adjustment for CPB time does not account for inter-individual variability in inflammation and VTE risk. Given the modest area under the curve statistics they reported for these models, it seems clear there remains an unmet need to improve precision of VTE prediction by including patient-level biomarkers with sufficient sensitivity and specificity. ACKNOWLEDGMENTS A.L.B. conceptualized the letter, and writing up of the first draft of the letter. E.C.W., K.A.T., and K.S. have helped write the letter, and approved the final article. All authors have written and reviewed the article, and approved the final article.

A Retrospective Multicenter Experience: Does Packing the Surgical Field Help to Stop Bleeding After Cardiac Surgery.

Intractable bleeding after cardiac surgery is a well-documented complication. When conservative measures fail to control bleeding, re-exploration is required, and, in some cases, chest packing may be needed. The study included 148 patients admitted to eight cardiac surgery centers in Egypt with severe postoperative bleeding. All patients underwent chest re-exploration and chest packing to control postoperative bleeding. The mean age was 62.7 ± 5.6 years. Their mean BMI was 27.1 ± 3.9 kg/m2. One-hundred-ten (74.3%) of included patients were hypertensive, while 49 (33.1%) patients were diabetic. Twenty-seven (18.2%) patients had initially had a triple valve replacement. Sepsis was prevalent among 31 (20.9%) of included patients. Twenty (13.5%) patients died. Intractable bleeding is a well-documented complication following cardiac surgery. Chest re-exploration is required in certain situations when the traditional conservative options fail to stop bleeding. Chest packing is a modality that can be considered to control bleeding in certain situations.

Severe Postoperative Bleeding Secondary to Ibrutinib Intake.

Llull-Ramos, Ana MD*; Gracia-Darder, Inés MD*; Hernando, Javier del Pozo MD*; Izquierdo-Herce, Noelia MD* Author Information

Epidemiology of severe bleeding in children following cardiac surgery involving cardiopulmonary bypass: use of Bleeding Assessment Scale for critically Ill Children (BASIC).

To describe the epidemiology of severe bleeding in the immediate post-operative period in children who undergo cardiopulmonary bypass surgery using the Bleeding Assessment Scale for critically Ill Children (BASIC). Retrospective cohort study in a paediatric ICU from 2015 to 2020. 356 children were enrolled; 59% were male with median (IQR) age 2.1 (0.5-8) years. Fifty-seven patients (16%) had severe bleeding in the first 24 hours post-operatively. Severe bleeding was observed more frequently in younger and smaller children with longer bypass and cross-clamp times (p-values <0.001), in addition to higher surgical complexity (p = 0.048). Those with severe bleeding received significantly more red blood cells, platelets, plasma, and cryoprecipitate in the paediatric ICU following surgery (all p-values <0.001). No laboratory values obtained on paediatric ICU admission were able to predict severe post-operative bleeding. Those with severe bleeding had significantly less paediatric ICU-free days (p = 0.010) and mechanical ventilation-free days (p = 0.013) as compared to those without severe bleeding. Applying the BASIC definition to our cohort, severe bleeding occurred in 16% of children in the first day following cardiopulmonary bypass. Severe bleeding was associated with worse clinical outcomes. Standard laboratory assays do not predict bleeding warranting further study of available laboratory tests.

Effectiveness of Oxidized Regenerated Cellulose-Based Haemostat (Surgicel®) for Monopolar Electrosurgical Conization and Its Risk Factors for Postoperative Rebleeding: An Observational Study

Background: Prompt detection and treatment of high-grade cervical intraepithelial neoplasia (CIN), namely, CIN3, are important for preventing malignant transformation. In most cases, such treatment is performed through conization, but minimally invasive procedures must also be considered. Therefore, we present a surgical method using a combination of monopolar electrosurgical conization (MESC) and oxidized regenerated cellulose-based haemostat (ORCH) (Surgicel®) and discuss its merits and risk factors. Methods: The medical records of 274 patients treated at our hospital from January 1, 2015, to December 31, 2021, were retrospectively reviewed. To detect risk factors for postoperative problems, we considered 2 indicators: postoperative recurrence and haemostatic suture for severe postoperative bleeding. We also focused on the following 10 representative factors for predicting significant risk for postoperative problems: (1) advanced age, (2) high BMI, (3) nulliparity, (4) smoking history, (5) long operation time, (6) intraoperative suture, (7) positive margin, (8) invasive squamous cell carcinoma (SCC), (9) no dysplasia, and (10) cervical glandular neoplasia (CGN). Results: Among the 274 patients, 19 instances of postoperative recurrence and 8 instances of haemostatic suture were detected. In a multivariate analysis of the 10 factors, we detected no significant impact except for “no dysplasia” on both indicators. This result indicated that our method had no specific risk and could provide a certain extent of usability. Conclusions: The combination of MESC and ORCH for the treatment of CIN3 could be performed effectively and safely with minimal intraoperative haemostatic suturing of the cut surface.

Renal pelvis mucosal artery hemorrhage after percutaneous nephrolithotomy: a rare case report and literature review

BackgroundFollowing a percutaneous nephrolithotomy (PCNL) procedure, the most common complications are considered to be intraoperative and postoperative bleeding. Many patients with postoperative bleeding can be treated conservatively, causing the perirenal hematoma to resolve spontaneously. The major causes of severe postoperative bleeding are pseudoaneurysms, arteriovenous fistula, and segmental arterial injury. Typically, the first choice of treatment to manage severe bleeding complications is selective angioembolization (SAE) because of the very high success rate associated with this procedure.Case presentationThis clinical case involves a 56-year-old man who underwent dual-channel PCNL treatment after diagnosing a left kidney staghorn stone and urinary tract infection. The operation was successful, with no apparent signs of bleeding. Tests revealed continued decreasing hemoglobin levels following the procedure. After the conservative treatment failed, renal angiography was performed immediately, indicating renal pelvis mucosal artery hemorrhage. In the three hours post-surgery, the SAE still failed to prevent bleeding. Further discussions led to formulating a new surgical plan using a nephroscope to enter the initial channel where hemostasis began. The hemostasis origin was found precisely in the mucosal artery next to the channel during the operation and was successfully controlled.ConclusionsThis case reveals there is poor communication and inadequate discussions about the potential failures of an SAE procedure. Swift clinical decision-making is imperative when dealing with high-level renal trauma to prevent delays in surgery that can threaten the safety of patients.

Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy.

Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding. Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance. One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5days, p < 0.001). Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.

Clinical Evaluation of Titanium-Alloy Bands for Sternal Closure after Median Sternotomy: Single-Center Experience.

Background Median sternotomy is the most applied approach in open-heart surgery, while potential complications such as postoperative bleeding, sternal dehiscence, and deep sternal wound infection (DWSI) still remain a challenge to cardiac surgeons. Several new sternum-closure products instead of stainless wire have been brought into clinical application. The objective of this retrospective study is to evaluate the novel sternum-fixing product in terms of clinical outcomes. Methods 689 consecutive cases undergoing cardiac surgery through median sternotomy between February 2015 and December 2018 in our center were enrolled in this study. All the cases were divided into two groups according to different sternum fixation methods: wire cerclage group and rigid fixator group. The demographic as well as clinical data including the mediastinal drainage of first, second, and third post-op 24 hours, the total mediastinal drainage of post-op 72 hours, ICU duration, length of hospital stay, and post-op mortality in 30 days were collected and compared between the two groups. Results 278 cases were enrolled in the wire cerclage group and 411 cases in the rigid fixator group. There is no significant difference in the demographic data between the two groups, while the mediastinal drainage in the first and third 24 hours after surgery and the total mediastinal drainage in postoperative 72 hours of the rigid fixator group were significantly less than those of the wire cerclage group (P < 0.05). No significant difference was found in other clinical outcomes between the groups including ICU duration, LOS in hospital, and 30-day mortality. 14 cases (5.0%) in the wire cerclage group and 11 cases (2.7%) in the rigid fixator group had sternotomy-related complications including severe postoperative bleeding, sternal dehiscence, and DSWI. Conclusion Compared with the conventional wire cerclage, the new rigid fixator is superior in median sternotomy closure in terms of postoperative mediastinal bleeding as well as incidence of sternotomy-related complications.

Reduced Anticoagulation Strategy with HeartMate 3

<h3>Purpose</h3> The use of anticoagulation is the standard of care for management of patients with a Heartmate 3 LVAD (Abbott; Chicago, IL).With the advanced magnetically levitated design of the HM3, there is more flexibility for patients unable to tolerate traditional anticoagulation regimens. We review the clinical outcomes of our single center experience with HM3 patients off anticoagulation or with reduced INR goals. <h3>Methods</h3> All patients implanted at our center with a Heartmate 3 VAD from January 2018 to August 2021 were retrospectively reviewed. Patients off anticoagulation or reduced INR goals were included in this study. <h3>Results</h3> There were a total of 27 patients implanted with a HM3 at our center from 2018-2021 with a mean age 65.4 years, 85.2% (n=23) were male. Thirty-seven percent of patients (n=10) were taken off of anticoagulation entirely or had a reduced INR goal. due to concerns for tolerance of traditional INR goals. Ten percent of these patients (n=1) were not started on any anticoagulation due to severe postoperative bleeding, while 20% (n=2) were stopped within 6 months of VAD implantation and 50% (n=5) stopped within two years due to adverse events. Twenty percent (n=2) of patients had a reduced INR goal of 1.5-2. The most common reason for discontinuation of anticoagulation or reduction of INR goals included persistent gastrointestinal bleeding (40% n=4). Remainder of etiologies included subdural hematoma, noncompliance, and presence of TTR amyloid. Nintey percent (n=9) of patients who were managed off anticoagulation or with reduced INR goals survived greater than one year without clinical signs of device thrombosis or malfunction, including significant fluctuations of device parameters, LDH or echocardiographic abnormalities. Additionally this population remained free from adverse events including stroke or thromboembolism. Sixty percent (n=6) of patients remained event free for 2 years. <h3>Conclusion</h3> THis single center real world retrospective analysis, suggests that, similar to published data, it is reasonable to conclude that HM3 patients canminimal to no anticoagulation without significant adverse events. Patients should continue to have judicious montioring for signs of adverse events and detection of hemolysis and pump thrombosis.

Blood loss in the post-operative period following robotic assisted laparoscopic prostatectomy (RALP) and its impact on recovery times

Background/introduction: Severe post-operative hemorrhage following robotic assisted laproscopic prostatectomy (RALP) has been reported in 0.5% - 1.6% of cases. Impact of post-operative blood loss following RALP on outcomes has little coverage. The aim was to assess the blood loss in the initial post-operative period following RALP and its significance upon length of stay.

Pressure dressings versus nonpressure dressings after hemorrhoidectomy: study protocol for a randomized controlled trial

BackgroundPressure dressings have been used after open hemorrhoidectomy to protect surgical wounds and manage postoperative bleeding for many years. However, pressure dressings may increase the incidence of postoperative complications, such as urinary retention, medical adhesive-related skin injury, and pain. A previous controlled trial included 67 patients who underwent Milligan-Morgan hemorrhoidectomy. The data indicated that the use of a nonpressure dressing after hemorrhoidectomy reduces the incidence of urinary retention and catheterization. However, the incidence of severe postoperative bleeding and other postoperative complications was not assessed. There is no consensus on whether it is necessary and beneficial to use a nonpressure dressing after hemorrhoidectomy. The results of this randomized clinical study will help answer this question.MethodsIn this study, we plan to include 186 patients who have undergone modified Milligan-Morgan hemorrhoidectomy, which only sutured external hemorrhoids to reduce the risk of bleeding. The purpose is to determine whether the use of nonpressure dressings after open hemorrhoidectomy is inferior to the use of pressure dressings in terms of severe postoperative bleeding and postoperative complications. The primary endpoints of the trial are the incidence of urinary retention within 24 h after surgery and the incidence of severe postoperative bleeding 1 h after dressing removal, which requires revision surgery within 24 h after the surgery. The secondary endpoints of the study are the pain score, anal distension score, postoperative use of analgesics, and incidence of medical adhesive-related skin injury, all of which will be assessed before removing the dressings. The length of hospitalization in days and hospitalization expenses will be recorded. Safety will be assessed with consideration of all adverse and severe adverse events related to the study treatment.DiscussionThe study received full ethics committee approval. The first patient was enrolled on 27 November 2020. The results of this trial will finally answer the question of whether a nonpressure dressing after open hemorrhoidectomy is necessary and beneficial.Trial registrationChinese Clinical Trial Registry ChiCTR2000040283. Registered on 28 November 2020.

Emergency gastrointestinal surgery in patients undergoing antithrombotic therapy in a single general hospital: a propensity score-matched analysis

BackgroundThis study aimed to review and evaluate the surgical outcomes, particularly intraoperative severe blood loss and postoperative blood complications, of emergency gastrointestinal surgery in patients undergoing antithrombotic therapy (AT). Emergency surgeries for patients with antithrombotic medication have been increasing in the aging population. However, the effect of AT on intraoperative blood loss and perioperative complications remains unclear.MethodsWe retrospectively reviewed 732 patients who underwent emergency gastrointestinal surgery between April 2014 and March 2019. Patients were classified into AT group and Non-AT group, and propensity score-matched analysis was performed to compare the short surgical outcomes between the groups. Additionally, risk factors in severe estimated blood loss (EBL) and postoperative bleeding complications were assessed.ResultsAltogether, 64 patients received AT; 50 patients and 12, and 2 were given antiplatelet and anticoagulant, and both drugs, respectively. After propensity score matching, EBL (101 vs. 99 mL; p = 0.466) and postoperative complications (14 vs. 16 patients; p = 0.676) were similar between the groups (63 patients matched paired). Intraoperative severe bleeding (EBL ≥ 492 mL) occurred in 44 patients. Multivariate analysis using the full cohort revealed that antithrombotic drug use was not an independent risk factor for severe bleeding and postoperative bleeding complications.ConclusionsThis study demonstrated antithrombotic drugs do not adversely affect the perioperative outcomes of emergency gastrointestinal surgery.

Frequency and risk factors of severe postoperative bleeding after proctological surgery: a retrospective case-control study.

The aim of this study was to assess frequency and risk factors of severe bleeding after proctological surgery requiring hemostatic surgery observed after publication of the French guidelines for anticoagulant and platelet-inhibitor treatment. All patients who underwent proctological surgery between January 2012 and March 2017 in a referral center were included. Delay, severity of bleeding, and need for blood transfusion were recorded. Patients with severe postoperative bleeding were matched to controls at a 2:1 ratio adjusted on the operator, and the type of surgery. Among the 8,890 operated patients, 65 (0.7%) needed a postoperative hemostatic procedure in an operating room. The risk of a hemostatic surgery was significantly increased after hemorrhoidal surgery compared with other procedures (1.9% vs. 0.5%, P<10-4) and was most frequent after Milligan-Morgan hemorrhoidectomy (2.5%). Mean bleeding time was 6.2 days and no bleeding occurred after day 15. Blood transfusion rate was 0.1%. Treatment with anticoagulants and platelet inhibitors were managed according to recommendations and did not increase the severity of bleeding. The risk of severe bleeding was significantly lower in active smokers vs. non-smokers in univariate (16.9% vs. 36.2%, P=0.007) and multivariate (odds ratio, 0.31; 95% confidence interval, 0.14-0.65) analysis whereas sex, age, and body mass were not significantly associated with bleeding. Severe postoperative bleeding occurs in 0.7% of patients, but varies with type of procedure and is not affected by anticoagulant or antiplatelet treatment. These treatments given in accordance with the new guidelines do not increase the severity of postoperative bleeding.

Phenotype and genotype analysis of patients with severe factor XI deficiency in Shaanxi Province, China.

Congenital coagulation factor XI (FXI) deficiency is a rare bleeding disorder with a heterogeneous haemorrhagic phenotype and various hotspot gene mutations associated with race and geography. Studies on FXI deficiency in Shaanxi Province, China, are scarce. In this study, seven patients with severe FXI deficiency and several family members were analysed. The International Society on Thrombosis and Hemostasis-Bleeding Assessment Tool (ISTH-BAT) was applied to assess bleeding symptoms. FXI activity was determined using a one-stage method, and the FXI antigen was measured by enzyme-linked immunosorbent assay. Targeted capture next-generation sequencing and Sanger sequencing were applied to detect FXI gene mutations. The bleeding phenotype varied, although none of the participants had a history of spontaneous bleeding. One maternal received replacement therapy during the perinatal period, one female patient presented with menorrhagia, one male patient experienced severe postoperative bleeding and others were asymptomatic. Family members with heterozygous mutations were all asymptomatic. The FXI activity of all the patients ranged from less than 1 to 3.1 IU/dl, and a synchronous decrease in the FXI antigen was observed. Two missense mutations (p. Gly350Glu and p. Cys482Trp), one nonsense mutation (p. Gln384∗) and one novel frameshift mutation (p. Ser225Phefs∗16) were detected. The bleeding manifestations and severity of severe FXI deficiency varied and were not related to its activity. Three reported mutations and one novel frameshift mutation were identified, thus extending the mutation spectrum of FXI deficiency.