Uncontrolled Bleeding Research Articles

The use of andexanet alpha in the Polish setting: An interdisciplinary protocol. Expert consensus statement of the Polish Cardiac Society.

Andexanet alfa (AA) is a recombinant inactive analog of human activated factor X (FXa), effectively reversing the effects of its inhibitors - rivaroxaban and apixaban, which are available in Poland. The drug was approved for clinical use registration after the publication of the results of the ANNEXA-4 trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXa Inhibitors 4), in which its efficacy in restoring hemostasis in life-threatening hemorrhages in patients receiving using the aforementioned anticoagulants was demonstrated. Hence, AA is now recommended for patients on apixaban or rivaroxaban therapy with massive and uncontrollable hemorrhages, including hemorrhagic strokes (HS) and gastrointestinal bleeding. Drug-specific chromogenic anti-Xa assays are generally best suited for estimating rivaroxaban and apixaban plasma levels, aside from direct assessment of their concentrations. The absence of anti-Xa activity, determined using these assays, allows us to rule out the presence of clinically relevant plasma concentrations of any FXa inhibitor. On the other hand, the dose of AA should not be modified based on the results of coagulation tests, as it depends solely on the time that elapsed since the last dose of FXa inhibitor and oon the dose and type of FXa inhibitor. AA is administered as an intravenous (i.v.) bolus, followed by an i.v. infusion of the drug. The maximum reversal of anti-Xa activity occurs within two minutes of the end of the bolus treatment, with the continuation of the continuous i.v. infusion allowing the effect to be maintained for up to two hours afterwards. Because anticoagulant activity can reappear after the infusion is completed, it is currently unclear at what point after AA administration FXa inhibitors or heparin should be re-administered. In Poland AA is starting to become available and its urgent need to administer it to patients with severe bleeding on apixaban or rivaroxaban.

Perihepatic Packing: A Life Saving Procedure in Liver Trauma

Objective: Liver is one of the most common organ injured in Blunt and penetrating abdominal trauma and is the 2nd most common cause of mortality in these patients. The main objective of this study is to analyse the role and success rate of perihepatic packing in liver trauma Materials & Methods: This is a prospective study conducted on 200 patients of Liver trauma admitted in a tertiary care hospital over 2 year period with 3 months postoperative followup. Most of the High Grade liver injuries with uncontrolled venous bleeding were subjected to perihepatic Packing. The patient were shifted to ICU postoperatively and reexplored after 48 hours for pack removal. Results: 30 patients were subjected to Perihepatic packing with success rate of 80% in achieving haemostasis.24 cases were due to blunt while 6 due to penetrating trauma. Commonly seen in younger age group with male dominance. Majority of the injuries were AAST Grade III and IV type. Discussion: In Liver trauma the prime goal is Life Saving by control of Haemorrhage. Various advanced procedures are performed for the same, however it may not be possible to carry out all these in an emergency setting of Haemodynamically unstable patients. In these selected cases, Perihepatic packing is the Gold standard to achieve haemostasis as damage control or Definitive procedure. Conclusion: Perihepatic Packing is a highly recommended procedure in selected cases of High Grade liver injuries mainly for control of venous bleeding. Good postoperative ICU ventilator support under Broad spectrum Antibiotic cover is mandatory to minimize morbidity and mortality associated with the procedure. Keywords: Liver trauma, Perihepatic Packing, Blunt abdominal trauma, Reexploration.

Severe coagulopathy and inflammation occurred after resection of giant right ventricular intimal sarcoma with cardiopulmonary bypass: a case report

BackgroundPrimary malignant cardiac tumors are rare in clinic, and surgical resection under cardiopulmonary bypass (CPB) remains the main treatment. The non-physiological perfusion process of CPB leads to contact activation, and the resulting coagulopathy and systemic inflammatory response syndrome (SIRS) are common complications. However, it is difficult to predict the impact of foreign tumor fragments on this pathophysiological process once they enter the bloodstream, making this phenomenon more complex and challenging.Case PresentationWe report a case of cardiac intimal sarcoma who developed severe coagulopathy and widespread inflammation after excision of massive right ventricular tumor and replacement of tricuspid valve by median sternotomy under CPB. Although the procedure was expected to cause tumor cell necrosis and precautions were taken, uncontrolled massive postoperative bleeding, persistent fever, abnormally elevated inflammatory markers, and recurrent malignant arrhythmias occurred after surgery. In addition to common factors, the most possible underlying mechanism is contact activation triggered following surgical procedure for intimal sarcoma with CPB.ConclusionPatients with intracardiac malignant tumors are at a high risk for serious contact activation during CPB. Preventive application of comprehensive anti-inflammatory measures such as drugs and adsorptive CPB technology, as well as point-of-care (POC) monitoring of coagulation status will be helpful for individualized guidance and optimization of CPB management, and improvement of patient prognosis.

Evaluation of the Factors Associated with Post-Operative Outcome in Patients of Ulcerative Colitis Undergoing Ileal Pouchanal Anastomosis with Comparison of Functional Outcome between Stapler and Hand-Sewn Anastomosis

ntroduction Ulcerative colitis defined as a non-granulomatous idiopathic inflammatory disease which mainly affects the colon and rectum. The disease may arise at any age but most commonly affects the adults between the age group of 30–40 years.1,2. The etiology of the disease is multifactorial, involving genetic predisposition, dysregulated immune responses, epithelial barrier defects and environmental factors. No sex predilection is seen in ulcerative colitis.3,5 The peak age of onset of disease is between 30 to 40 years.4,6 The environmental factors has also been found to play an important role in the etiopathogenesis of ulcerative colitis. Cigarette smoking is one of the major factor associated with ulcerative colitis, non-smokers have a milder disease course and active smokers are less likely to develop ulcerative colitis7 Appendectomy also confers a protective effect against ulcerative colitis, especially in young patients operated for acute appendicitis.8. Classic findings in endoscopy in patients with ulcerative colitis include loss of normal vascular pattern, erythema, erosions, granularity, friability, ulcerations and bleeding9 . The primary aim of medical management is to induce and maintain remission with the long-term goals of improving quality of life and prevent disability. Absolute indications for surgery include uncontrolled hemorrhage, perforation, and colorectal carcinoma or dysplastic lesions not amenable to endoscopic removal.10 Surgery is also indicated in refractory acute severe ulcerative colitis or medically refractory disease. The most commonly performed surgery for ulcerative colitis is restorative proctocolectomy with ileal pouchanal anastomosis (IPAA). An important aspect of the surgery is the use of either sutures or staplers for anastomosis. Two types of ileal pouch-anal anastomosis (IPAA) have been described: a mucosectomy of the rectal stump followed by a hand-sewn ileal pouch-anal anastomosis.11 The alternative technique is to retain the mucosa of the rectal stump and perform a stapled pouch-anal anastomosis.

The two therapeutic strategies of surgical intervention and medical management in a patient with enhanced-fibrinolytic type of disseminated intravascular coagulation after aortic replacement for Stanford type A aortic dissection with chronic heart and renal failure

BackgroundManagement of the enhanced-fibrinolytic type of disseminated intravascular coagulation (DIC) caused by aortic disorders is the two strategies of surgical intervention and medical treatment based on the patient’s age and comorbidities.Case presentationAn 81-year-old woman with a history of two previous aortic surgeries and chronic heart and renal failure was admitted for uncontrollable subcutaneous hemorrhage. The hemorrhage was caused by the enhanced-fibrinolytic type of disseminated intravascular coagulation (DIC) caused by periprosthetic graft hematoma after aortic replacement for Stanford type A aortic dissection. Open thoracic hemostasis temporarily controlled the subcutaneous hemorrhage, but she was readmitted for the recurrence seven months after discharge. On the second admission, the combination of anticoagulant and antifibrinolytic agents was successful.ConclusionManagement of the enhanced-fibrinolytic type of DIC caused by aortic disorders is important of a successful combination of surgical and medical therapy tailored the patient’s condition.

P643 Magnifying Endoscopy with Narrow Band Imaging for Graft Failure and Disease Recurrence in Patients with Crohn’s Disease after Intestinal Transplantation

Abstract Background Crohn’s disease (CD) is one of the common causes of short bowel syndrome (SBS) and intestinal failure (IF). Intestinal transplantation (IT) is sometimes needed for patients with CD who develop IF after multiple intestinal resections due to CD-related complications, such as uncontrollable bleeding and penetrating diseases. However, there have been limited case reports concerning the endoscopic surveillance of CD patients after IT. Methods We retrospectively investigated two patients with CD who underwent IT because of SBS-IF after multiple intestinal resection. We administered post-transplantation immunosuppressants and conducted regular magnifying endoscopy with narrow-band imaging (ME-NBI) via ileostomy chimney for surveillance of grafte rejection. Endoscopic prediction of rejection were based on our previously published "VENCH" score which is composed of five parameters: "V" (villi appearance), "E" (erythema), "N" (capillary network), "C" (crypt widening), and "H" (heterogeneity). Endoscopic biopsy were taken for histologic confirmation of graft rejection severity. Results Case 1 was a 60-year-old male patient with CD who received three times of intestinal resection for small bowel stricture and perforation, followed by IT due to SBS-IF. He lived uneventful until seven years thereafter with bloody diarrhea presented. Endoscopic surveillance revealed normal VENCH score of background mucosa but deep longitudinal ulcers which was indicative of recurrence of CD rather than graft rejection. Anti-tumor necrosis factor alpha with adalimumab was prescribed and his diarrhea and graft ulcers improved. Case 2 was a 39-year-old male patient with CD who received extensive intestinal resection due to multiple perforations, followed by IT because of SBS-IF. Endoscopic surveillance revealed normal VENCH score without histologic graft rejection two years thereafter. Both enrolled cases demonstrated favorable outcomes after endoscopic surveillance of intestinal graft with ME-NBI and management accordingly. Conclusion The post IT follow-up of CD patients remains challenging. We highlight the usefulness of the ME-NBI using VENCH score for early detection of graft rejection and its value in monitoring CD patients after IT. Additionally, ulcerations without changes in morphology of surrounding villi should take into consideration the disease recurrence of underlying CD. Further research is needed in endoscopic follow-up and molecular genetics to better understand CD after IT.

Comparison of Low Dose Recombinant Factor VIIa and 4-Factor Prothrombin Complex Concentrate for Treatment of Bleeding Related to Cardiac Surgery

Background: Recombinant factor VIIa (rFVIIa) and prothrombin concentrate complex (PCC) are used for uncontrolled bleeding in cardiac surgery (CS), however, there are limited direct comparisons of these agents. Objective: To evaluate the efficacy and safety of rFVIIa and PCC in CS related bleeding. Methods: This retrospective study included adult CS patients who received either low dose rFVIIa (<30 mcg/kg) or 4-factor PCC. The primary outcome was transfusion requirements of packed red blood cells (pRBC) within 6 hours of factor administration. Secondary efficacy outcomes included transfusion requirements 0-18 hours, doses of additional factor product, thrombotic events, and acute kidney injury (AKI). Results: A total of 179 patients were included (n = 78 rFVIIa; n = 101 PCC). Of patients who received blood products, there was no difference in the requirement of pRBCs within 6 hours (73.8 vs 68.9%, P = .5359) or in the median amount of pRBC transfused (500 mL vs 640 mL, P = .0723) in the rFVIIa and PCC groups respectively. Patients in the PCC group were more likely to require additional factor products (24.4% vs 47.5%, P = .0015), develop AKI (12.8% vs 25.7%, P = .0325), have longer ICU lengths of stay [2 (IQR 1-5) vs 4 (IQR 2-6), P = .0487] and greater in-hospital mortality (2.6% vs 10.9%, P = .033). There was no difference in thrombotic events. Conclusion: Although, there was no difference in pRBC transfusion requirements between PCC and rFVIIa, more patients in the PCC group required additional factor products and had increased adverse effects. Further comparisons of PCC and rFVIIa are warranted.

Investigation of platelet activation and calcium store release by a topical hemostatic xerogel dressing for improved blood clotting

AbstractAdequate topical hemostatic dressings are required as first‐line approach for reduction of uncontrolled hemorrhage, a leading cause of mortalities. Platelets play a major role during blood clotting to prevent hemorrhage during injuries. Here, we demonstrate the mechanisms activated through protease activating receptor 1 (PAR1), a platelet membrane protein in response to a porous composite xerogel dressing incorporating SiNPs (size 122 ± 10 nm) and calcium (2.5 mM), characterized by scanning electron microscopy–energy dispersive x‐ray spectroscopy and Fourier transform infrared spectroscopy. The composite displayed 13.9‐fold improved blood clotting index in comparison to commercial dressing. The composite displayed increased platelet aggregation due to development of well‐formed pseudopodia as compared to bare xerogel, SFLLRN (a thrombin mimic), adenosine di‐phosphate (a platelet activator), and heparin (a thrombin inhibitor). Further, PAR1 gene was significantly upregulated in model A549 epithelial cell line (1.2‐fold) and human platelets (1.4‐fold). The composite enhanced calcium release and its extrusion in A549 cells. Upregulation of PAR1 on the platelet surface and calcium release are crucial for platelet shape change and aggregation. The data indicate that xerogel composite containing SiNPs and calcium enhanced blood clotting through activation of PAR1. Such dressings can provide a potential hemostatic solution to reduce blood loss, disability, and mortality during surgery and trauma care.

A Visible Light Cross-Linked Underwater Hydrogel Adhesive with Biodegradation and Hemostatic Ability.

Hydrogel adhesives with integrated functionalities are still required to match their ever-expanding practical applications in the field of tissue repair and regeneration. A simple and effective safety strategy is reported, involving an in situ injectable polymer precursor and visible light-induced cross-linking. This strategy enables the preparation of a hydrogel adhesive in a physiological environment, offering wet adhesion to tissue surfaces, molecular flexibility, biodegradability, biocompatibility, efficient hemostatic performance, and the ability to facilitate liver injury repair. The proposed one-step preparation process of this polymer precursor involves the mixing of gelatin methacryloyl (GelMA), poly(thioctic acid) [P(TA)], poly(acrylic acid)/amorphous calcium phosphate (PAAc/ACP, PA) and FDA-approved photoinitiator solution, and a subsequent visible light irradiation after in situ injection into target tissues that resulted in a chemically-physically cross-linked hybrid hydrogel adhesive. Such a combined strategy shows promise for medical scenarios, such as uncontrollable post-traumatic bleeding.

Bioactive glass incorporated dressing matrix for rapid hemostatic action with antibacterial activity

Uncontrolled bleeding stands as a leading cause of preventable death in both civilian trauma and military battlefield scenarios. Existing hemostatic dressings like HemCon, Celox, and QuickClot, often lack instant hemostasis at the bleeding site and may have biodegradability and exothermic issues. To address the above in this communication, we have synthesized a hemostatic glass (acronym AlBG, CaO-SiO2 system, incorporated with Al2O3 and ZnO) by sol gel route and carried out detail physicochemical characterizations, e.g., XRD, FESEM, FTIR, BET and particle size analysis etc. The AlBG of particle size range 140–253 nm was incorporated into the nonwoven surgical cotton gauze to obtain AlBGscg. In vitro biological assays including cytocomtability, hemocompatibility assays of the above coated gauze was undertaken using NIH3T3 of which, the later showed optimum hemocompatibility with <6 % lysis of red blood cells. Potent antibacterial action on both gram positive and gram negative strains were obtained with significant zone of inhibition of 17 ± 0.34 mm and 16 ± 0.56 mm, respectively. Importantly, significant reduction of the clotting time (31.81 ± 0.12 % for P time and 33.3 ± 0.23 % for aPTT) compared to the control group, indicated activation of both intrinsic and extrinsic coagulation pathways. Scanning electron microscope (SEM) images exhibited an enhanced in vitro blood clot formation in case of AlBGscg in comparison to the control (uncoated surgical cotton gauze), visually. Additionally, a noticeable reduction of ∼30 % in the time required for the blood clot formation, in case of AlBGscg, was observed. The in vivo hemostatic potential of AlBGscg was evaluated in Wistar rats through femoral artery injury and was compared with commercially available surgical cotton gauze. The results demonstrated substantial reduction in the time required for hemostasis (approximately 50 % reduction), a lower amount of blood loss (7.33 % with AlBGscg compared to 22.31 % with surgical cotton gauze), and importantly, there were no incidents of re-bleeding observed with AlBGscg, highlighting its promise as a candidate for effective hemostasis.

Corona mortis: clinical evaluation of prevalence, anatomy, and relevance in anterior approaches to the pelvis and acetabulum

PurposeTo evaluate the clinical prevalence, characteristics, and relevance of the corona mortis (CM) in anterior approaches to the pelvis and acetabulum.MethodsRetrospective analysis of 185 theater reports from patients (73 females; mean age 62.8 ± 17.2 years) who underwent surgeries for pelvic ring injuries, acetabular fractures, or combined injuries using anterior approaches (Modified Stoppa or Pararectus) at our institution between 01/2008 to 12/2022. During procedures, the CM was routinely identified, evaluated, and occluded. Bilateral exposure of the superior pubic branch in 25 cases led to 210 hemipelvises analyzed. Exclusions: CM not mentioned in report and revisions via the initial approach.ResultsIn the 210 hemipelvises examined, the prevalence of any CM vessel was 81% (170/210). Venous anastomoses were found in 76% of hemipelvises (159/210), arterial in 22% (47/210). Sole venous anastomoses appeared in 59% (123/210), sole arterial in 5% (11/210). Both types coexisted in 17% (36/210), while 19% (40/210) had none. A single incidental CM injury occurred without significant bleeding. In ten cases, trauma had preoperatively ruptured the CM, but bleeding was readily managed. Females had a significantly higher CM prevalence than males (p = 0.001).ConclusionOur findings show a CM prevalence aligning more with anatomical studies than prior intraoperative series. Although we observed one incidental and ten trauma-related CM injuries, we did not encounter uncontrollable bleeding. Our data suggest that in anterior pelvic approaches, when the CM is actively identified and occluded, it is not associated with bleeding events, despite its high prevalence.

Progress in injectable hydrogels for the treatment of incompressible bleeding: an update.

Uncontrollable haemorrhage from deep, noncompressible wounds remains a persistent and intractable challenge, accounting for a very high proportion of deaths in both war and disaster situations. Recently, injectable hydrogels have been increasingly studied as potential haemostatic materials, highlighting their enormous potential for the management of noncompressible haemorrhages. In this review, we summarize haemostatic mechanisms, commonly used clinical haemostatic methods, and the research progress on injectable haemostatic hydrogels. We emphasize the current status of injectable hydrogels as haemostatic materials, including their physical and chemical properties, design strategy, haemostatic mechanisms, and application in various types of wounds. We discuss the advantages and disadvantages of injectable hydrogels as haemostatic materials, as well as the opportunities and challenges involved. Finally, we propose cutting-edge research avenues to address these challenges and opportunities, including the combination of injectable hydrogels with advanced materials and innovative strategies to increase their biocompatibility and tune their degradation profile. Surface modifications for promoting cell adhesion and proliferation, as well as the delivery of growth factors or other biologics for optimal wound healing, are also suggested. We believe that this paper will inform researchers about the current status of the use of injectable haemostatic hydrogels for noncompressible haemorrhage and spark new ideas for those striving to propel this field forward.

A novel strategy of combining abdominal surgery and endoscopy for the quick hemostasis of acute duodenal ulcer bleeding: a case report.

Uncontrolled ulcer bleeding of duodenal ulcer (DU) after endoscopic therapy often needs surgery. At present, cutting the bottom of the ulcer with ligation and performing its excision-lesion are the common ways to achieve immediate efficacy in stopping bleeding. For the problem of its great trauma, we seek an easy and useful technical method to reach the same therapeutic effect to stop acute bleeding. We determined the distribution of the lesion and its innervated blood vessels under the guidance of the endoscopy and then performed suture and hemostasis on the external surface of the stomach and duodenum. An immediate efficacy in stopping bleeding was shown and the hemoglobin (Hb) level returned to normal after operation with no recurrence of bleeding. We created a successful and novel strategy for laparotomy-endoscopic assisted suture for DU emergency hemostasis without duodenectomy.

Endovascular technologies in the treatment of patients with blunt abdominal trauma

Trauma is one of the leading causes of disability and mortality in working-age population. Abdominal injuries comprise 20-30% of traumas. Uncontrolled bleeding is the main cause of death in 30-40% of patients. Among abdominal organs, spleen is most often damaged due to fragile structure and subcostal localization. In the last two decades, therapeutic management has become preferable in patients with abdominal trauma and stable hemodynamic parameters. In addition to clinical examination, standard laboratory tests and ultrasound, as well as contrast-enhanced CT of the abdomen should be included in diagnostic algorithm to identify all traumatic injuries and assess severity of abdominal damage. Development of interventional radiological technologies improved preservation of damaged organs. Endovascular embolization can be performed selectively according to indications (leakage, false aneurysm, arteriovenous anastomosis) and considered for severe damage to the liver and spleen, hemoperitoneum or severe polytrauma. Embolization is essential in complex treatment of traumatic vascular injuries of parenchymal abdominal organs. We reviewed modern principles and methods of intra-arterial embolization for the treatment of patients with traumatic injuries of the liver and spleen.

Treatment of penetrating injuries of the retrohepatic vena cava: systematic review protocol.

Injuries to the retrohepatic segment of the inferior vena cava require complex procedures, as exposure without prior vascular control can lead to uncontrollable and fatal bleeding. To achieve such control, the classic techniques of hepatic vascular exclusion and the implantation of an atriocaval shunt have been described, and more recently, endovascular strategies have been reported. However, there is no consensus in the literature regarding which of these strategies is associated with lower mortality. In order to determine which therapeutic strategy presents the lowest mortality and complication rates in the treatment of penetrating injuries to the retrohepatic segment of the inferior vena cava, a systematic review of the literature will be conducted, registered on the PROSPERO platform under the number CRD42023464133. The Cochrane Handbook for Systematic Reviews of Interventions will guide the process. Searches will be carried out in the MEDLINE/PubMed, LILACS, Embase, Scopus, and Web of Science databases. ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) will be consulted to detect ongoing or unpublished trials. Studies will be selected based on a predefined search strategy, the number of results will be filtered using the Rayyan app, and the studies included will be independently reviewed by two authors to reach a final consensus. The qualitative analysis of the studies will be conducted using the RoB 1.0 tool.

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding

Condom Uterine Tamponade A Revolutionary Invention to Control Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is the most challenging situation faced by obstetricians. It remains the primary cause of maternal mortality in low &amp; low-middle-income countries. In some South Asian countries, such as Bangladesh, many obstetrics patients were dying from excessive bleeding just after giving birth a few decades ago. Many of them had to undergo hysterectomy (a surgical procedure to remove the uterus), sacrificing the further opportunities of giving birth, just to prevent this uncontrolled bleeding. To overcome this situation, Dr. Sayeba Akhter invented a method of Condom Tamponade in 2000.

Functional hemostatic hydrogels: design based on procoagulant principles.

Uncontrolled hemorrhage results in various complications and is currently the leading cause of death in the general population. Traditional hemostatic methods have drawbacks that may lead to ineffective hemostasis and even the risk of secondary injury. Therefore, there is an urgent need for more effective hemostatic techniques. Polymeric hemostatic materials, particularly hydrogels, are ideal due to their biocompatibility, flexibility, absorption, and versatility. Functional hemostatic hydrogels can enhance hemostasis by creating physical circumstances conducive to hemostasis or by directly interfering with the physiological processes of hemostasis. The procoagulant principles include increasing the concentration of localized hemostatic substances or establishing a physical barrier at the physical level and intervention in blood cells or the coagulation cascade at the physiological level. Moreover, synergistic hemostasis can combine these functions. However, some hydrogels are ineffective in promoting hemostasis or have a limited application scope. These defects have impeded the advancement of hemostatic hydrogels. To provide inspiration and resources for new designs, this review provides an overview of the procoagulant principles of hemostatic hydrogels. We also discuss the challenges in developing effective hemostatic hydrogels and provide viewpoints.

Purely Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region in Pediatric Population.

Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.

Factors influencing in-hospital mortality for salvage percutaneous transjugular intrahepatic portosystemic shunting in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention

Background. Endoscopic therapy is the first-line treatment of choice for control of acute variceal bleeding (AVB). In high-risk patients with persistent AVB despite pharmacological treatment and endoscopic intervention, percutaneous transjugular intrahepatic portosystemic shunting (TIPS) provides a minimally invasive salvage method to reduce portal pressure and control bleeding. Objectives. To evaluate factors influencing in-hospital mortality after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding despite medical treatment and endoscopic intervention. Methods. Clinical and laboratory data were analysed in all patients treated with sTIPS following failed endoscopic therapy for AVB between August 1991 and November 2020. Factors associated with and predictors of death were determined using bivariate analysis and univariate logistic regression analysis. Results. Thirty-four patients (29 men, 5 women), mean age 52 years (range 31 - 80), received sTIPS for uncontrolled (n=11) or refractory (n=23) AVB. The causes of portal hypertension were alcohol-related (n=24) and non-alcohol-related cirrhosis. Salvage TIPS controlled bleeding in 32 patients, with recurrence in 1. Ten patients died in hospital (mean 4.8 days, range 1 - 10) of liver failure (n=4), multiorgan failure (n=3), alcoholic cardiomyopathy (n=2) and uncontrolled gastric variceal bleeding (n=1). On bivariate analysis, factors associated with death were Child-Pugh (C-P) score ≥10 (p=0.006), sodium Model for End-stage Liver Disease (MELD-Na) score ≥22 (p&lt;0.001), ≥8 units of blood transfused (p&lt;0.001), Sengstaken-Blakemore balloon tube placement (p&lt;0.001), endotracheal intubation (p&lt;0.001), inotropic support (p&lt;0.001) and endoscopically uncontrolled bleeding (p&lt;0.001). Univariate logistic regression analysis showed that the most significant predictors of mortality were inotrope dependency (odds ratio (OR) 134; p&lt;0.001), endotracheal intubation (OR 99; p&lt;0.001), endoscopically uncontrolled bleeding (OR 28; p=0.001), grade 3 ascites (OR 20.9; p=0.012) and C-P grade C (OR 8.8; p=0.011). Conclusion. Salvage TIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy with 29% in-hospital mortality. The most significant predictors of mortality were C-P grade C, grade 3 ascites, inotrope requirement, endotracheal intubation and endoscopically uncontrolled bleeding.