Institutional trends over a decade in catheter-directed interventions for pulmonary embolism.

OBJECTIVE: Catheter-directed interventions (CDIs) are commonly performed for acute pulmonary embolism (PE). The evolving catheter types and treatment algorithms impact the use and outcomes of these interventions. This study aimed to investigate the changes in CDI practice and their impact on outcomes. METHODS: Patients who underwent CDIs for PE between 2010 and 2019 at a single institution were identified from a prospectively maintained database. A PE team was launched in 2012, and in 2014 was established as an official Pulmonary Embolism Response Team. CDI annual use trends and clinical failures were recorded. Clinical success was defined as physiologic improvement in the absence of major bleeding, perioperative stroke or other procedure-related adverse event, decompensation for submassive or persistent shock for massive PE, the need for surgical thromboembolectomy, or death. Major bleeding was defined as requiring a blood transfusion, a surgical intervention, or suffering from an intracranial hemorrhage. RESULTS: There were 372 patients who underwent a CDI for acute PE during the study period with a mean age of 58.9 ± 15.4 years; there were males 187 (50.3%) and 340 patients has a submassive PE (91.4%). CDI showed a steep increase in the early Pulmonary Embolism Response Team years, peaking in 2016 with a subsequent decrease. Ultrasound-assisted thrombolysis was the predominant CDI technique peaking at 84% of all CDI in 2014. Suction thrombectomy use peaked at 15.2% of CDI in 2019. The mean alteplase dose with catheter thrombolysis techniques decreased from 26.8 ± 12.5 mg in 2013 to 13.9 ± 7.5 mg in 2019 (P < .001). The mean lysis time decreased from 17.2 ± 8.3 hours in 2013 to 11.3 ± 8.2 hours in 2019 (P < .001). Clinical success for the massive and the submassive PE cohorts was 58.1% and 91.2%, respectively; the major bleed rates were 25.0% and 5.3%. There were two major clinical success peaks, one in 2015 mirroring our technical learning curve and one in 2019 mirroring our patient selection learning curve. The clinical success decrease in 2018 was primarily derived from blood transfusions owing to acute blood loss during suction thrombectomy. CONCLUSIONS: CDIs for acute PE have rapidly evolved with high success rates. Multidisciplinary approaches among centers with appropriate expertise are advisable for the safe and successful implementation of catheter interventions.

The surgical arrest of post-tonsillectomy haemorrhage: Hospital Episode Statistics 12 years on.

Introduction The risk of returning to theatre for arrest of haemorrhage following tonsillectomy can be determined from analysis of the Hospital Episode Statistics data provided by the Department of Health website. This method was employed previously for data between 1998-2002 and was repeated in this study to observe any changes over this time period. Materials and methods Hospital Episode Statistics data for England from 2010-2016 were used. The number of tonsillectomies and surgical arrest of post-tonsillectomy haemorrhage were considered for children and adults. Results Of 267,159 tonsillectomies performed over the six-year period, 5027 (1.88%) returned to theatre for control of bleeding. This was 3.5 times more likely in adults than children (P < 0.0001). Comparison with the previous study showed an increase in return to theatre rates following tonsillectomy of 1.06%, from 0.82% to 1.88%. Conclusion Adults are more likely than children to require and arrest of haemorrhage post-tonsillectomy. Return to theatre rates have increased since 2004 at an estimated additional cost to NHS England of £1,415,056 per annum. The causes of this observed increase have yet to be determined.

Dry-field maneuver for controlling the massive intraventricular bleeding during neuroendoscopic procedures.

PURPOSE: Massive hemorrhages pose a significant problem in intraventricular endoscopic surgeries. These hemorrhages have the potential to cause mortality and morbidity, particularly in excisional surgeries. Often, the bleeding can be controlled only by cauterization and liquid irrigation, due to the incongruity of the use of antihemorrhagic agents in the fluid. The final option to stop the massive bleeding is the dry-field maneuver. In this study, the effects and clinical results of the dry-field maneuver in bleeding control of a massive bleeding were investigated. METHODS: Dry-field maneuver was retrospectively studied in a patient population that had massive bleeding during intraventricular endoscopic procedures. RESULTS: Dry-field maneuver was used in seven patients. Four of these patients underwent some excisional surgery. The other two patients were operated for an endoscopic third ventriculostomy and one for intraventricular hemorrhage evacuation. It was observed that the hemorrhage in patients stopped rapidly after the dry-field maneuver. Moreover, there was no need for an antihemorrhagic material. CONCLUSION: Dry-field maneuver is an option for providing hemostasis, particularly, for a massive hemorrhage. It also has the potential to be used in elective surgeries because it improves the visual quality.

Imaging fibrin formation and platelet and endothelial cell activation in vivo.

Over the past six decades research employing in vitro assays has identified enzymes, cofactors, cell receptors and associated ligands important to the haemostatic process and its regulation. These studies have greatly advanced our understanding of the molecular and cellular bases of haemostasis and thrombosis. However, in vitro assays cannot simultaneously reproduce the interactions of all of the components of the haemostatic process that occur in vivo nor do they reflect the importance of haemodynamic factors resulting from blood flow. To overcome these limitations investigators have increasingly turned to animal models of haemostasis and thrombosis. In this article we describe some advances in the visualisation of platelet and endothelial cell activation and blood coagulation in vivo and review what we have learned from our intravital microscopy experiments using primarily the laser-induced injury model for thrombosis.

[Further improvement of apparatuses for the hemostasis, processing and treatment of the infected wounds using high-temperature stream].

The bleeding stoppage and the wound sanitation constitute an important problem of modern surgery. There is information presented concerning the apparatuses elaboration for the bleeding stoppage, processing of the soft living tissues wounds, including the infected, during surgical operations conduction, using high-temperature stream of air. The data adduced about the apparatuses trial and preclinical investigations of the method, realized with their help, had confirmed a high efficacy of hemostasis and sanation effects as well as significant reduction of the wounds processing time.

Advances in absorbable biomaterials and nasal packing.

Absorbable biomaterials are commonly used after endoscopic sinus surgery, both for hemostatic and wound healing considerations. Although removable nasal packing is the traditional method of controlling ongoing bleeding and modulating wound healing, it is uncomfortable for patients and associated with several complications. Currently available absorbable agents frequently incite an inflammatory reaction and have been shown in animal and human trials to adversely affect the wound healing process. Newer agents offer distinct advantages because of their unique composition and rapid clearance profiles. The selection of packing material used in any given sinus procedure should be based on surgeon preference and the details of the specific case.

The academic challenge of teaching psychomotor skills for hemostasis of solid organ injury.

BACKGROUND: This study highlights the inherent challenges of achieving psychomotor skills in an era of nonoperative therapy for solid organ injuries. Technical procedures on the liver, the most frequent intra-abdominal solid organ injured, were assessed in five decades. METHODS: Guided by prospective assessment and registry data, all patients with liver injury seen during 24 months in five consecutive decades were reviewed. Initially (1960s), all injuries were explored; currently (2000s), most injuries are observed. The number of patients was 235 (1960s), 228 (1970s), 79 (1980s), 116 (1990s), and 64 (2000s). The greater number in the 1990s reflects the diagnosis of minor, clinically insignificant, blunt injuries after abdominal CAT scan became available. Each injury was categorized by cause, severity (Abbreviated Injury Scale), associated shock, and primary therapy (observe [OBS], operation alone [OR], hepatorrhaphy [SUT], tractotomy [TRACT] with intraparenchymal hemostasis, hepatic dearterialization [HAL], and resection [RESECT]). Packing, used in each decade, was placed in one of the above primary treatment groups. RESULTS: The primary techniques for hemostasis are shown in the text table.Shock and Abbreviated Injury Scale correlated with mortality averaged 16%; 40 of 116 deaths (34%) exsanguinated from hepatic injury. During training, a resident performed an average of 12.0, 12.0, 2.4, 4.0, and 1.3 procedures for hemostasis. CONCLUSIONS: Reduced incidence and decreased therapeutic laparotomies for liver injury have created a training vacuum for future trauma surgeons. Surgical residents will need to supplement their clinical experience with solid organ hemostasis by practice on appropriate animal models of injury and cadaver dissections.

Cesarean delivery in the interventional radiology suite: a novel approach to obstetric hemostasis.

BACKGROUND: The adjunctive use of interventional radiology procedures to minimize and control bleeding at the time of cesarean delivery has become increasingly common. These procedures require modern imaging equipment and supplies not available in traditional operating rooms. METHODS: We describe three women who strongly desired continued reproductive function in clinical circumstances where postpartum hemorrhage and hysterectomy were likely. RESULTS: Cesarean delivery was performed in the interventional radiology suite after selective uterine artery balloon placement and/or embolotherapy, which successfully minimized blood loss during delivery. CONCLUSION: We propose that this novel surgical location is feasible, and may offer advantages in select patients.

[Ulcer surgery - what remains?]. / Ulkuschirurgie - was bleibt?

Ulcer surgery today concentrates on the complications of chronic ulcer disease, especially ulcer perforation and endoscopically uncontrollable ulcer bleeding. In this case the laparoscopic or open closure of the gastroduodenal defect or local hemostasis of the bleeding ulcer by laparotomy are the main aims of surgery. Elective operations due to recurrent gastric or duodenal ulcers have become rare. An indication for gastric ulcer resistant to conservative therapy could be persisting suspicion of malignancy whereas in duodenal ulcer gastric outlet obstruction represents a reason for surgery. If these indications are confirmed the classic procedures of gastric resection like Billroth I and Billroth II are performed whereas vagotomy is no longer used. Altogether ulcer surgery has become very safe although it is practiced quite rarely.

Influence of new technologies on thyroid surgery: state of the art.

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. In general, the essential objectives for thyroidectomy are conservation of the parathyroid glands, avoidance of injury to the recurrent laryngeal nerve, an accurate hemostasis and an excellent cosmesis. In the last 20 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia and intraoperative neuro-monitoring.

Overview of clinical efficacy and safety of pharmacologic strategies for blood conservation.

PURPOSE: The pharmacologic management of hemostasis in patients undergoing surgery with cardiopulmonary bypass is discussed. SUMMARY: Nearly 45 studies involving 7,000 patients have reported efficacy of aprotinin in blood conservation. Both in primary coronary artery bypass graft (CABG) surgeries and in repeat surgeries, aprotinin treatment significantly reduces the incidence of blood transfusions and the number of units of blood transfused. These effects have been observed for red blood cell, platelet, and other blood products. The safety of aprotinin treatment has been extensively evaluated in randomized clinical trials, in postmarketing databases, and in systematic reviews of the literature. Overall, data do not indicate that aprotinin treatment increases mortality, myocardial infarction, or renal failure. These findings are supported by the results of a recent meta-analysis of 35 studies in patients undergoing CABG surgery. In addition, the meta-analysis suggests that aprotinin treatment was associated with a reduced incidence of stroke and a trend toward a reduced incidence of atrial fibrillation. Although lysine analogs, desmopressin, and recombinant factor VIIa are sometimes used to reduce bleeding, only aprotinin is indicated for use during CABG surgery. CONCLUSION: The future of cardiac surgery will be marked by an increasingly complex, high-risk group of patients and a greater need for multiple pharmacologic options for reducing bleeding. Pharmacologic approaches that attenuate the activation of the hemostatic system and inflammation need to be employed to decrease coagulopathies and the need for allogeneic blood administration.

[History of haemostasis in surgery]. / Storia dell'emostasi in chirurgia.

Haemostasis is an essential act in surgical procedures. Technical, physical and chemical devices' improvement in haemostasis is joined to the historical evolution of surgery. In ancient times haemostasis had also a magic and religious value. Simple but effective manoeuvres developed by medicine-men and barber-surgeons are used to control bleeding. Often their original intuitions anticipated scientific discoveries. Ancient haemostatic instruments and the way to use them represent the heritage of old and famous surgeons; some of these procedures are still used in operating rooms.

Upbeat advances in cardiac and emergency care.

From biphasic breakthroughs to simplified programming mechanisms, review the latest technology options.

[The change in laser usage in gastroenterology--the status in 1997]. / Wandel der Laseranwendung in der Gastroenterologie--Stand 1997.

Since the establishing of laser technology in gastroenterology there has been a change in the indications for laser therapy and numerous new laser systems have been introduced in basic and clinical research. First the argon laser and later on the Nd:YAG laser were used mainly for bleeding peptic lesions, today emphasis is on palliative desobliteration of advanced esophageal and rectosigmoidal carcinoma. Moreover, in selected cases it is used for curative ablation of early carcinoma and dysplasia. A new field of application is photocoagulation of the "watermelon stomach". Despite of promising ablation results the erbium:YAG and holmium:YAG laser became not yet established in gastroenterology. Also the KTP laser is rarely used e.g. for treatment of telangiectasia. Difficult bile duct stones can be highly effective fragmented intracorporally by means of laser lithotripsy; an automatic stone-tissue discrimination system avoids uncontrolled injury of the bile ducts. The hitherto experimental interstitial laser therapy of primary and secondary liver malignancies shows excellent results, but online monitoring of the expansion of the necrosis is still a problem. Thermal probes, MRT technology and duplex sonography are under current evaluation. Photodynamic therapy (PDT) is now, after numerous pilot studies, investigated with larger numbers of patients. First results show a marked effectiveness in ablation of dysplasia and mucosal carcinoma. The photosensitizer 5-aminolaevulinic acid seems to be particularly effective for ablation of Barrett's mucosa and m-THPC for treatment of local carcinoma. Palliative PDT of bile duct cancer may help to avoid repeated endoprosthetic treatment. The possibilities and limitations of light induced fluorescence diagnostics of severe dysplasia and carcinoma in situ is now being evaluated intensively. This method might in future facilitate the endoscopic diagnosis of dysplasia in Barrett's esophagus and chronic inflammatory bowel disease.