Troublesome Bleeding Research Articles

Confronting urethrorrhagia after Otis urethrotomy: a case report

BackgroundOtis urethrotomy can sometimes lead to troublesome bleeding after seemingly uneventful procedures. This case report highlights one such case which went unnoticed initially; the bleeding was erroneously ascribed to the prostate, thereby falsely indicting the “decoy” prostate.Case presentationA 78-year-old Asian gentleman was referred to our hospital with complaint of intractable bleeding after undergoing laser enucleation of prostate at another institute, wherein he further underwent unsuccessful bilateral angioembolization of pudendal arteries. On endoscopy (for hemostasis), we found a spurting vessel in the navicular fossa, which was effectively controlled.ConclusionsThis case report highlights the importance of performing prompt endoscopy in case of uncontrolled bleeding after prostate endoscopic surgery.

A Vascular Centered Surgical Approach to Radical Hysterectomy: Laparoscopic Anatomy of Pelvic Vascular System Revisited

As a standard therapy for locally invasive cervical cancer, radical hysterectomy (RH) has been in routine medical practice for more than a century [1]. However, challenges still exist due to the troublesome bleeding during parametrium dissection and resection, which could increase the risk of surgical complications and may probably affect surgical outcomes ultimately [2]. This video illustrated the three-dimensional anatomy of the pelvic vascular system with particular emphasis on "deep uterine vein" and further introduced a vascular-centered surgical approach to performing RH, which could facilitate parametrium dissection with less blood loss and obtain enough resection margins. A step-by-step, narrated video demonstration SETTING: A university hospital INTERVENTIONS: After systemic pelvic lymphadenectomy, ureter was then identified along the medial leaf of the broad ligament. By continuously exploring the pelvic cavity along the ureter, communicating branches of the uterine artery to the ureter, urinary bladder, corpus uteri, uterine cervix, and upper vagina were clearly identified in a cranial to caudal direction, demonstrating the arterial network surrounding the urinary system. Coagulating and cutting these blood vessels could free the ureter from retroperitoneum and subsequently excavate the ureteral tunnel easily. Next, a precise dissection of the area below the ureter revealed the whole distribution of currently named "deep uterine vein". Originated from an internal iliac vein, it is much more like a venous confluence than an accompanying vein, with branches crossing directly into the bladder, dorsally to the rectum, and traveling caudally to the anterolateral side of the uterus and vagina in a crisscross fashion, which mandates us to describe it as pampiniform-like venous plexus instead of "deep uterine vein" due to its anatomical distribution and function. Finally, after complete exposure of venous network, enough extent of parametrium could be adequately separated and resected by accurate coagulation of blood vessels on an individualized requirement. Recognizing the precise anatomy of pelvic vascular system, especially the entire distribution of currently named "deep uterine vein" and isolating the venous branches connecting to all three parts of parametrium, are key to the RH procedure. Careful attention to the complex vascular anatomy is critical to reducing intraoperative bleeding and avoiding complications in RH.

Nuance in Craniovertebral Junction Surgical Approach for Posterior C1-C2 Harms Stabilization: "Window Transposition" of the External Vertebral Venous Plexus for Bloodless C1 Lateral Mass Screw Insertion: Anatomical Aspects and Technical Notes.

Atlas and axis instrumentation may be necessary in cases of several craniocervical junction pathologies. According to the Harms technique, C1-C2 polyaxial screws are inserted respectively in the C1 lateral masses and in C2 pedicles. C1 lateral mass screw insertion requires the careful subperiosteal dissection of the posterior elements of C1, the identification of the screw entry point by the downward distraction of C2 nerve root, and the cautious sparing of the overlying posterior external vertebral venous plexus (peVVP), whose bleeding, obstructing the surgical field, is sometimes barely controlled by hemostatic agents and swabbing. The authors describe in detail the anatomical aspects of an alternative surgical technique developed for the microsurgical transposition of the C1-C2 interposed external vertebral venous plexus in the case of Harms C1-C2 screw stabilization. The longitudinal median incision of the atlantoaxial membrane, followed by bilateral subperiosteal dissection and microsurgical section respectively at the inferior borders of the C1 laminae and at the superior borders of the C2 laminae, allows, as a "window opening," the symmetrical mediolateral transposition of the peVVP. This procedure provides a faster and cleaner anatomical exposition of the posterior surface of the C1 lateral mass and the C2 isthmus, preventing troublesome intraoperative venous bleeding that hinders C1 lateral mass screw insertion.

Uterine volume, menstrual patterns, and contraceptive outcomes in users of the levonorgestrel-releasing intrauterine system: A cohort study with a five-year follow-up

ObjectiveThe aim of our study was to evaluate the effects of the LNG-IUS on uterine volume, bleeding patterns, and LNG-IUS-related outcomes among women using the device to treat abnormal uterine bleeding caused by fibroids, adenomyosis, HMB (without structural cause), or contraception. Study designThis was a 5-year cohort study with LNG-IUS users. We selected 147 women, who were allocated to four groups: a) control (contraception indication); b) fibroids; c) adenomyosis; d) HMB. The visits for clinical and ultrasound evaluations were made at baseline and at 3, 6, 12, 24, 36, 48, and 60 months postinsertion. All data are expressed as mean and standard deviation (SD) or absolute and relative (%) frequency. Differences among groups were established by using the χ2 (chi-square) test and Fisher's exact tests for categorical outcomes, as well as the Mann-Whitney and the Kruskal-Wallis tests and Friedman’s ANOVA for continuous variables. We used the 5% significance level as an indication of statistical significance. Logistic regression analyses were performed to study the association between predictors and outcomes. Results are expressed as odds ratios (ORs) with a 95% confidence interval (CI 95%). Results: Although all groups had real rates of bleeding patterns, troublesome bleeding appeared to be more frequent in the fibroid group (∼15%). Also, along the 60 months of follow-up, uterine volume slightly decreased in the groups of HMB, adenomyosis, and fibroids, but not in the contraception group. However, the isolated volume of fibroids remained unchanged. In this cohort, we observed high continuation rates among LNG-IUS users. The uterine volume ≥200 cm3 was the main predictor of hysterectomy or IUS expulsion in the adenomyosis and fibroid groups. ConclusionThe LNG-IUS may control uterine menstrual bleeding as well as uterine volume in adenomyosis, fibroids, and HMB. An initial uterine volume smaller than 200 cm3 is an important predictor of adherence to treatment and better outcomes.

An international multidisciplinary peer-driven consensus on the optimal use of hemostatic powders in surgical practice.

Bleeding is a consequence of insufficient hemostasis and excessive bleeding at a surgical site is associated with an increased risk of post-operative infection, transfusion and re-operation, in addition to increased hospital length of stay and costs. Surgeons employ a range of methods to achieve hemostasis, including topical hemostatic agents of differing composition and properties. Hemostatic powders are a sub-group of topical hemostats, which can be used in helping as adjuncts to manage troublesome bleeding in a variety of situations. As this technology is relatively new and potentially not well known by the broad surgical community, no specific guidelines or recommendations for the optimal use of hemostatic powders in surgery currently exist. A steering group throughout Europe of multidisciplinary surgeons, expert in hemostasis and hemostatics, identified from literature and from personal experience, five key topics. When to use hemostatic powder, the evidence for use, benefits of use, safety remarks and considerations in various surgical specialties. Thirty-seven statements were subsequently drawn from these five key topics. An online survey was sent to 128 high-volume surgeons working in breast surgery, gynaecological and obstetric surgery, general and emergency surgery, thoracic surgery and urological surgery in Europe to assess agreement (consensus) with these statements. Consensus was defined as high if ≥ 75% and very high if ≥ 90% of respondents agreed with a statement. A total of 79 responses were received and consensus among the surgical experts was very high in 27 (73%) statements, high in 8 (22%) statements and was not achieved in 2 (5%) statements. Based on the consensus scores, the steering group produced 16 key recommendations which they considered could improve patient outcomes by reducing post-operative bleeding and its associated complications using hemostatic powder.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13304-021-01136-x.

Troublesome bleeding following early medical abortion

### Key messages Early medical abortion (EMA) (ie, using combination mifepristone and misoprostol to terminate pregnancies of less than 10 weeks’ gestation) is the the most common method of induced...

Fatigue, executive function and psychological effects in children with immune thrombocytopenia: a cross-sectional study.

Childhood ITP is often considered to be a relatively mild haematological disorder, with only a minority of patients requiring treatment for troublesome bleeding. Over recent years, wider effects of the condition have been identified in some adults, particularly relating to fatigue and cognitive impairment. In this study, we sought to investigate such effects in a group of children with ITP and further our understanding of their psychological profile. Children attending routine haematology outpatient clinics and their parents were asked to complete standardised questionnaires designed to assess a range of psychological and cognitive factors. Although the majority of children had some scores within the normal range, a significantly high proportion had difficulties with fatigue (70·6%), emotional and behavioural symptoms (25·7%) or executive functioning (19·4%). Quality of life and subjective evaluation of the illness (appraisal) correlated significantly with each of these domains, but bleeding severity and platelet count did not. Our findings provide valuable insight into the broader impact of childhood ITP, which could aid in providing holistic care, potentially contribute to decisions regarding medical treatment, and guide future research.

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS: A PROSPECTIVE STUDY

Acute cholecystitis (AC) is a potentially life-threatening condition. LC was initially considered to be a relative contraindication for laparoscopic cholecystectomy (LC), but with increase in general expertise, early LC was recommended in selected patients1. Aprospective study of LC in grade 1 and 2 AC patients with mild to moderate inflammatory changes in the gallbladder and no significant organ dysfunction, was performed during October 2016 to July 2019. A total of 78 patients, out of 408 cholecystectomies performed during this period, were included in this study. Criteria for diagnosing AC was, recent onset of pain in right hypochondrium, fever, leucocytosis, pericholecystic fluid collections, subserosal oedema on ultrasound, pyocele and other pathological evidence of AC. Patients presented and operated within 4 days of onset of symptoms showed better results as compared to those who could be operated after 4 days and within 14 days. Five patients required conversion to open cholecystectomy because of complex adhesions in 2, critical view of safety was unachievable in 2 and in 1 for troublesome bleeding.

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS: A PROSPECTIVE STUDY.

Acute cholecystitis (AC) is a potentially life-threatening condition. LC was initially considered to be a relative contraindication for laparoscopic cholecystectomy (LC), but with increase in general expertise, early LC was recommended in selected patients1. Aprospective study of LC in grade 1 and 2 AC patients with mild to moderate inflammatory changes in the gallbladder and no significant organ dysfunction, was performed during October 2016 to July 2019. A total of 78 patients, out of 408 cholecystectomies performed during this period, were included in this study. Criteria for diagnosing AC was, recent onset of pain in right hypochondrium, fever, leucocytosis, pericholecystic fluid collections, subserosal oedema on ultrasound, pyocele and other pathological evidence of AC. Patients presented and operated within 4 days of onset of symptoms showed better results as compared to those who could be operated after 4 days and within 14 days. Five patients required conversion to open cholecystectomy because of complex adhesions in 2, critical view of safety was unachievable in 2 and in 1 for troublesome bleeding.

Antegrade Cardioplegia Decannulation Using the COR-KNOT System in Minimally Invasive Mitral Valve Surgery.

A right mini-thoracotomy approach may be used for mitral valve repair without compromising clinical outcomes. Compared with conventional sternotomy, there is an increased distance to the cardiac structures from the mini-thoracotomy incision, which makes certain technical acts more demanding. One particular challenge is hemostasis at the antegrade cardioplegia cannula site. We propose a novel technique to remove an antegrade cardioplegia cannula using the COR-KNOT system. This technique negates the need for tying with a knot pusher and reduces the risk of aortic injury and troublesome bleeding.

Combined oral contraceptive treatment for bleeding complaints with the etonogestrel contraceptive implant: a randomised controlled trial

Objective: Estimate symptom improvement rate of women with bleeding complaints using the etonogestrel contraceptive implant when started on continuous combined oral contraceptives (COC).Methods: We conducted a double-blinded randomised controlled trial of women reporting troublesome bleeding related to their etonogestrel contraceptive implant and desiring intervention. Participants received continuous COCs or placebo for four weeks to evaluate self-reported bleeding improvement at four weeks. Participants could continue study treatment or prescribed COCs for another eight weeks if desired. We planned to enroll 130 participants between two sites (80% power to detect a 20% effect size at a 0.05 significance level, with 10% loss to follow up).Results: We closed the study after enrolling 26 participants due to recruitment futility. All women on COCs and 75% of placebo users reported bleeding improvement at four weeks (p = 0.09), with 92% and 42%, respectively, reporting significant improvement (p = 0.03). The median number of days until bleeding stopped for at least four days in COC and placebo users was 1 day (range 1–9) and 4.5 days (range 1–28), respectively (p = 0.63). Eight (75%) COC and five (42%) placebo users opted to continue study treatment (p = 0.41). Despite bleeding improvement, women who desired implant removal at enrollment were more likely to re-request removal than those who initially considered other interventions (3 of 5 [60%] vs 1 of 17 [6%], p = 0.03).Conclusion: Although women who have troublesome bleeding while using the contraceptive implant may experience improvement with no treatment over 4 weeks, women using COCs are more likely to report significant improvement.Clinicaltrials.gov registration number: NCT01963403.

An Extra Step to Prevent Troublesome Uterine Artery Bleeding: Retroperitoneal Dissection and Ligation of the Uterine Artery at the Source

An Extra Step to Prevent Troublesome Uterine Artery Bleeding: Retroperitoneal Dissection and Ligation of the Uterine Artery at the Source

A Study of the Management of Patients Taking Novel Oral Antiplatelet or Direct Oral Anticoagulant Medication Undergoing Dental Surgery in a Rural Setting.

Purpose: Novel oral antiplatelet (NOAP) (prasugrel and ticagrelor) and direct oral anticoagulant drugs (DOAC) (dabigatran, rivaroxaban and apixaban) have emerged in the last decade. This study was undertaken to determine current approaches taken to the management of patients taking these agents in dental practice in a remote and rural setting. Methods: A small retrospective study was carried out in a small island population that identified patients taking one of the above drugs. All national health service and private dental records were examined to determine the type of treatment carried out and whether drug therapy, treatment plans or actual treatment were modified as a result of NOAP or DOAC therapy. In addition other outcomes such as referral to another service for advice or treatment and any adverse bleeding events were noted. Results: 156 dental encounters for 95 patients taking one of the drugs were identified. Significant events were identified in sixteen encounters and the management of patients taking each drug type differed significantly between cases but no patients returned with troublesome post-operative bleeding. Conclusions: The approaches taken by dental surgeons in Orkney in the management of the NOAPs and DOACs varied and this is likely to be a reflection of the limited literature available.

Artery to Cystic Duct: A Consistent Branch of Cystic Artery Seen in Laparoscopic Cholecystectomy.

Uncontrolled arterial bleeding during laparoscopic cholecystectomy is a serious problem and may increase the risk of bile duct damage. Therefore, accurate identification of the anatomy of the cystic artery is very important. Cystic artery is notoriously known to have a highly variable branching pattern. We reviewed the anatomy of the cystic artery and its branch to cystic duct as seen through the video laparoscope. A single artery to cystic duct with the classical “H-configuration” was demonstrated in 161 (91.47%) patients. This branch may cause troublesome bleeding during laparoscopic dissection in the hepatobiliary triangle. Careful identification of artery to cystic duct is helpful in the proper dissection of Calot's triangle as it reduces the chances of hemorrhage and thus may also be helpful in prevention of extrahepatic biliary radical injuries.

Thymic artery: uncommon origin from proximal aortic arch or distal ascending aorta.

Internal thoracic and inferior thyroid arteries mainly supply the thymus. However, very few studies have been reported on the arterial variations of the thymus. The first author, a cardiac surgeon, happened upon a thymic artery arising from either proximal aortic arch or distal ascending aorta in a few cases during routine cardiac surgery in infants and neonates. Hence a study on the prevalence of the variant thymic artery during open heart surgery was contemplated, as knowledge of its presence could avoid its injury during surgical and diagnostic procedures of the region. The prevalence of the variant thymic artery was observed during 100 consecutive cardiac surgeries in infants and neonates. In addition to two branches from internal thoracic and inferior thyroid arteries, a thymic artery originating from the distal ascending aorta or proximal arch was found in 15 (15%) out of 100 patients who underwent open heart surgery for the correction of congenital heart defects. The artery took origin from the anterior surface of aorta, a little to the left. These were small arteries, single in origin, which started at right angles from the aorta and pierced the pericardium at its reflection, from visceral to parietal, to reach the posterior surface of the thymus where they divided into two branches, one for each lobe. Since this variant artery was present in 15% cases, being aware of its presence can help prevent troublesome bleeding during surgical thymectomy, and more importantly, during surgical and diagnostic interventions in the mediastinum.

Contributing Factors for Fever After Tubeless Percutaneous Nephrolithotomy

To evaluate the contributing factors for fever after tubeless percutaneous nephrolithotomy (PCNL). Between May 2009 and December 2013, 395 tubeless PCNLs were performed at our hospital. After stone extraction, the bleeding points were cauterized for hemostasis to enable tubeless modification. In patients with troublesome bleeding after cauterization, oxidized regenerated cellulose (Surgicel) strips were used to tamponade the access tract to facilitate bleeding control. The contributory factors for fever were evaluated by a retrospective chart review. Forty-four patients (11.7%) developed fever after tubeless PCNL. There was no difference in gender, age, and body mass index in the development of fever. Episodes of febrile or septic urinary tract infection before PCNL were found to have occurred in 35 patients, but the incidence of postoperative fever was not significantly higher in these patients. There is no significant difference in the mean stone size in fever and nonfever patients. Complete staghorn stones were noted in 40 patients, and their fever rate was not significantly higher than patients with nonstaghorn stone. The operation time is not significantly higher in the group with urinary tract infection. Patients with postoperative fever had a high incidence of residual stones than the remaining patients (38.9% vs 20.4%). There was no significant difference in incidence of postoperative fever in patients with struvite stones than patients with nonstruvite stones. In patients who received Surgicel packing, the incidence of fever was not significantly higher. Incomplete stone extraction is a major contributing factor for the development of fever after tubeless PCNL.

Recombinant Activated Factor VII, as a Remedy for Intractable Coagulopathy Following Massive Transfusion in a Case of Giant Cranial Neurofibroma

Introduction: Neurosurgical interventions have been associated with troublesome bleeding during and after the procedures. There are cases of intractable coagulopathy with life threatening bleeding. In this study, we reported a patient with neurofibromatosis type 1, and huge cranial neurofibroma, associated with massive bleeding after excision. Case Presentation: A 22 year-old man was referred to this center with facial deformity due to a large craniofacial neurofibroma. He underwent craniotomy and tumor resection, but intraoperative blood loss was massive, and epidural hematomata developed at the operative site due to coagulopathy. The drains still were draining fresh blood and the patient was severely anemic. After consultation with a hematologist, rFVIIa was administered intravenously to successfully control the bleeding. Conclusions: While using recombinant rFVIIa is life-saving, it should not be a substitute for life saving urgent surgeries and should be cautiously used as a last resort in conjunction with conventional medico-surgical care.

Proposed Modification for Valve-Sparing Aortic Root Replacement

Valve-sparing aortic root replacement (ARR) is the procedure of choice in young patients with aortic root aneurysm and preserved aortic valve leaflets; however, coronary ostial anastomoses remain an issue. Troublesome bleeding sometimes occurs during surgery, and in the long term, there is a risk of aneurysmal formation in the residual aortic wall of the ostial "button." We describe a technique of valve-sparing ARR wherein each coronary button along with its flange of aortic tissue is implanted within the prosthetic graft used for ARR, thereby eliminating the risk of both immediate surgical bleeding and late coronary button aneurysms.

PTU-050 Efficacy of Endoscopically Applied 5% Intra-Rectal Formalin to Treat Radiation-Induced Rectal Bleeding

IntroductionUp to 50% of patients develop rectal bleeding after pelvic radiotherapy. Radiation-induced bleeding may be trivial and after appropriate endoscopic assessment, patients can be reassured and do not need treatment....

Composite Facial Part Replantation

Sir:FigureWe report two cases involving tissue loss of varying magnitudes on the face that were replanted successfully. Replantation is the ideal method of reconstructing amputated small facial parts. However, the small-caliber vessels in this region make such replantation challenging. The 6-year-old boy in our series, who had avulsion of the entire nose with nasal cartilages, part of the cheek, and the upper lip, is the recipient of the largest successful composite facial replantation thus far published. In the first case, a 6-year-old boy was injured in a road traffic accident and suffered avulsion of the entire midface, including the nose, with nasal cartilages, upper lips, and part of the cheek, with palatal disruption (Fig. 1). Warm ischemia time was 9.5 hours. The amputated part (Fig. 2) was grossly contaminated. This was cleansed thoroughly and the angular vessels were identified.Fig. 1: Case 1. Preoperative photograph shows loss of the entire nose with nasal cartilages, upper lip, and part of the cheek.Fig. 2: Case 1. The amputated part.The palate was repaired first. The angular vessels were identified, and the amputated part was replaced anatomically. The angular and supratrochlear veins were first anastomosed end-to-end with 11-0 Ethilon (Ethicon, Inc., Somerville, N.J.) followed by the angular artery. Dextran 40 infusion was administered postoperatively. The child was ventilated overnight. By the tenth day, he was back on a normal diet. The entire replant survived. His 6-month follow-up was uneventful (Fig. 3). He has no problems with regard to speech, breathing, or deglutition.Fig. 3: Case 1. The patient is shown at 6-month follow-up.In the second case, a 35-year old man suffered a nose amputation in an assault, and had an ischemia time of 18 hours. The right angular vessels were revascularized and dextran 40 was infused. The patient had epidermal loss over the nasal dorsum in the postoperative period, which epithelialized with conservative measures. There are several reports of successful replantation of the scalp, and fewer reports for small part composite replantation of the face.1–7 The problems peculiar to this area are the small caliber of the facial vessels, venous congestion, and a paucity of reports in the literature to guide the approach. Several authors have suggested tips for circumventing these problems. Newer techniques involve artery-to-vein anastomosis for improved venous return and consequent survivability.1,3,4 We used several points in our surgical plan that facilitated an uneventful and successful postoperative result. The venous anastomosis was planned intentionally first to reduce troublesome bleeding that would have ensued with an initial arterial anastomosis. This would have obscured the surgical field and added significant difficulty to working in this region. An additional vein reduced venous congestion. We report two successful cases of composite facial replantation (Table 1). End-to-end anastomosis of small-caliber vessels was achieved, with a smooth postoperative course. The cosmetic and functional recovery was excellent. The young boy who had successful replantation of his nose, upper lip, and most of the cheek represents the largest successful replantation attempt reported in the medical literature.Table 1: Comparative Analysis of the Patients Who Had Composite Facial ReplantationsNo amount of reconstruction can compare with the functional and cosmetic outcome of a composite facial replantation. Thus, it is worthwhile to attempt a replantation in every case of small facial parts amputation, irrespective of the ischemia time. The survival rates are likely to be high, because the muscle mass is less, with greater vascularity on the face. R. Jayakumar, M.S., M.Ch.Plast.Surg. Jewel Raj Zachariah, M.S., M.Ch.Plast.Surg. M. Senthilkumar, M.S., M.Ch.Plast.Surg. A. J. Guild, M.B.B.S. Asha Cyriac, M.S., M.Ch.Plast.Surg. Girija Nair, M.S., M.Ch.Plast.Surg. Department of Plastic Surgery, Specialists'Hospital, Kaloor, Ernakulam, Kerala PATIENT CONSENT Parents or guardians provided written consent for use of the patient's images. DISCLOSURE None of the authors have any financial interests in the cases presented. ACKNOWLEDGMENTS The authors thank Dr. Nisheed Joseph and Dr. J. Shina, who were the anesthetists, and Dr. George K. Joseph, the maxillofacial surgeon involved in performing the cases.