Continuous postoperative pericardial flushing method versus standard care for wound drainage after adult cardiac surgery: A randomized controlled trial.

BACKGROUND: Excessive bleeding, incomplete wound drainage, and subsequent accumulation of blood and clots in the pericardium have been associated with a broad spectrum of bleeding-related complications after cardiac surgery. We developed and studied the continuous postoperative pericardial flushing (CPPF) method to improve wound drainage and reduce blood loss and bleeding-related complications. METHODS: We conducted a single-center, open-label, ITT, randomized controlled trial at the Academic Medical Center Amstserdam. Adults undergoing cardiac surgery for non-emergent valvular or congenital heart disease (CHD) were randomly assigned (1:1) to receive CPPF method or standard care. The primary outcome was actual blood loss after 12-hour stay in the intensive care unit (ICU). Secondary outcomes included bleeding-related complications and clinical outcome after six months follow-up. FINDINGS: Between May 2013 and February 2016, 170 patients were randomly allocated to CPPF method (study group; n = 80) or to standard care (control group; n = 90). CPPF significantly reduced blood loss after 12-hour stay in the ICU (-41%) when compared to standard care (median differences -155 ml, 95% confidence interval (CI) -310 to 0; p=≤0·001). Cardiac tamponade and reoperation for bleeding did not occur in the study group versus one and three in the control group, respectively. At discharge from hospital, patients in the study group were less likely to have pleural effusion in a surgically opened pleural cavity (22% vs. 36%; p = 0·043). INTERPRETATION: Our study results indicate that CPPF is a safe and effective method to improve chest tube patency and reduce blood loss after cardiac surgery. Larger trials are needed to draw final conclusions concerning the effectiveness of CPPF on clinically relevant outcomes.

Effects of the ratios of marrow cavity diameter to intramedullary nail diameter from different layers on blood loss during perioperative period for femoral intertrochanteric fractures.

The study aimed to investigate the effect of ratios of marrow cavity diameter to intramedullary nail diameter from different layers on hidden blood loss (HBL), overt blood loss (OBL) and total blood loss (TBL) during using proximal femoral nail antirotation-Asian version (PFNA)-II for femoral intertrochanteric fractures.We retrospectively studied 70 patients treated in our hospital recently. We recorded postoperative hematocrit (Hct) and OBL during operation. TBL and HBL were calculated using CROSS equation. The ratios of marrow cavity diameter to intramedullary nail diameter from different layers, including start of funnel, end of funnel and femoral isthmus, were measured. The mean of the ratio from frontal and lateral X-ray were designated as R. We classified all included participants into a high and a low matching group according to z-score of R within each layer. TBL, HBL, and OBL were compared between the 2 groups. We applied multiple linear regression analysis between the HBL as a dependent variable and gender, age, body mass index, fracture type, and R as independent variables.The present study indicated a significant reduction in the HBL and TBL in the high matching group compared to low matching group on three layers, whereas it showed no significant difference in OBL between the 2 groups on three layers. It showed that R values from start of funnel and end of funnel were significantly associated with HBL.Matching rate of PFNA II at the funnel might be an important factor for HBL and TBL postoperatively.

Two forms of one complication: Late erosive and nonerosive postpancreatectomy hemorrhage following laparoscopic pancreaticoduodenectomy.

Postpancreatectomy hemorrhage (PPH) remains a rare but lethal complication following laparoscopic pancreaticoduodenectomy (LPD) in the modern era of advanced surgical techniques. The main reason for early PPH (within 24 hours following surgery) has been found to be a failure of hemostasis during the surgical procedure. The reasons for late PPH tend to be variate. Positive associations have been identified between late PPH and intraabdominal erosive factors such as postoperative pancreatic fistula, bile leakage, gastrointestinal fistula, and intraabdominal infection. Still, some patients suffer PPH who do not have these erosive factors. The severity of bleeding and clinical prognosis of erosive and nonerosive PPH following LPD is different.We analyzed the electronic clinical records of 33 consecutive patients undergoing LPD and experiencing one or more episodes of hemorrhage after postoperative day 1 in this study. All patients received an LPD with standard lymphadenectomy. The patient's hemorrhage-related information was extracted, such as interval from surgery to bleeding, presentation, bleeding site, severity, management, and clinical prognosis. Based on our clinical practice, we proposed a treatment strategy for these 2 forms of late PPH following LPD.Of these 33 patients, 8 patients (24.24%) developed nonerosive bleeding, and other 25 patients (75.76%) suffered from postoperative hemorrhage caused by various intraabdominal erosive factors. The median interval from the LPD surgery to postoperative hemorrhage for both groups was 11 days, and no significant differences were found (P = .387). For patients with erosive bleeding, most (60%) underwent their episodes of bleeding on postoperative days 5 to 14. For patients with nonerosive bleeding, most (75%) began postoperative hemorrhage 2 weeks after surgery, and 50% of these patients had bleeding between postoperative days 20 and 30. In the present study, 64% (16/25) of patients with erosive bleeding and 87.5% (7/8) of patients with nonerosive bleeding had internal bleeding. The fact that 90% (9/10) of all gastrointestinal bleeding patients had intraabdominal erosive factors indicated strong relationships between gastrointestinal hemorrhage and these erosive factors. The bleeding sites were detected in most patients, except for 4 patients who received conservative treatments. For patients with erosive bleeding, the most common bleeding site detected was the pancreatic remnant (43.48%); others included the hepatic artery (39.13%), splenic artery (13.04%), and left gastric artery (4.35%). For patients with nonerosive bleeding, the most common bleeding site was the hepatic artery (83.33%), and the 2nd most frequent site was the splenic artery (16.67%). No hemorrhage from pancreaticojejunal anastomosis occurred in the patients with nonerosive bleeding. Statistical significance was noted between these 2 groups in hemorrhage severity (P = .012), management strategies (P = .001), rebleeding occurrence (P = .031), and prognosis outcome (P = .010). The patients with intraabdominal erosive factors tended to have a higher risk of grade C bleeding (68.00%) than that of their nonerosive bleeding counterparts (12.50%). As for treatment strategy for postoperative bleeding, the favorable method to manage nonerosive bleeding was conservative and endovascular treatments if the patients' hemodynamics was stable. All these nonerosive bleeding patients survived. On the contrary, 22 patients (88.00%) in the erosive bleeding group had a 2nd surgical procedure, and the mortality was 56.00%. In this group, 2 patients received conservative therapy due to the demand of their family and expired. One patient underwent endovascular treatment and had another episode of hemorrhage, finally dying from multi-organ failure. No patients in the nonerosive bleeding group suffered from rebleeding after complete hemostasis, and 44.00% of patients with erosive bleeding underwent a 2nd episode of postoperative bleeding.Erosive and nonerosive PPH are 2 forms of this lethal complication following LPD. Their severity of bleeding, rebleeding rate, and treatment strategy are different. Patients with erosive factors tend to have a higher incidence of grade C bleeding, rebleeding, and mortality. Factors influencing treatment protocols for PPH include the existence of intraabdominal erosive factors, patient hemodynamics, possibility to detect the bleeding site during endovascular treatment, and surgeon's preference. The performance of endovascular treatment with stent repair for managing postoperative hemorrhage after LPD depends on the discovery of the bleeding site. Surgery should be reserved as an emergent and final choice to manage PPH.

The short-term effect analysis of intraoperative intraperitoneal perfusion chemotherapy with lobaplatin for colorectal cancer.

PURPOSE: To explore the safety and feasibility of intraoperative, intraperitoneal perfusion chemotherapy with lobaplatin for colorectal cancer (CRC). METHODS: From November 1, 2016 to January 15, 2017, a total of 100 patients with CRC in Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, who had undergone radical surgery, were randomized into two groups as follows: the lobaplatin group (50 patients) and the control group (50 patients). The time of recovery of postoperative intestinal functions, hematotoxicity, hepatic-renal toxicity, and postoperative complications were observed and analyzed, with the goal of exploring the safety and feasibility of the drug administration. RESULTS: The time to first gas exhaust in lobaplatin and the control group was 3.08 days and 3.20 days, respectively (p=0.392). The time of defecation in lobaplatin and the control group was 4.38 days and 4.50 days, respectively (p=0.524). There was no statistically significant difference between them in terms of the time of gas exhaust and defecation. One case with intra-abdominal hemorrhage, 1 case with anastomotic leakage, 3 cases with incision complication, 1 case with adhesive intestinal obstruction, and 1 case with pulmonary infection occurred in lobaplatin group compared to 1 case with anastomotic bleeding, 1 case with anastomotic leakage, 2 cases with incision complication, 2 cases with adhesive intestinal obstruction, 2 cases with pulmonary infection, and 1 case with lymphatic fistulas occurred in control group. There was no statistically significant difference between the groups in terms of the total incidence of postoperative complications (p=0.790). No statistically significant difference was observed between the groups in terms of leukocyte and platelet levels on the first, third, and fifth postoperative day. There was also no statistically significant difference in terms of platelet level 2 weeks after surgery. Both the lobaplatin and control group had 2 cases with postoperative abnormal hepatic-renal function. A total of 6 cases in the lobaplatin group and 7 cases in the control group developed gastrointestinal reactions, showing no statistically significant difference (p=0.766). CONCLUSION: Intraoperative intraperitoneal perfusion chemotherapy with lobaplatin showed no effect on short-term recovery in patients with CRC.

Hidden blood loss and its risk factors in patients undergoing laparoscopy and laparotomy for cervical cancer management.

PURPOSE: Laparoscopy and laparotomy are the two most common surgical options used to treat women with early-stage cervical cancer. This study aimed to examine the volume of hidden blood loss (HBL) between laparoscopy and laparotomy for cervical cancer and to identify its risk factors. METHODS: Sixty-one patients treated with laparotomy and 50 patients treated with laparoscopy were enrolled in this study. Their medical data were collected to calculate the HBL according to the Nadler and Gross formula, and its risk factors were identified by multiple linear regression analysis. RESULTS: The visible blood loss was 574.9 ± 271.6 mL in the laparotomy surgery; however, the HBL was 345.2 ± 258.6 mL, accounting for 38.3 ± 21.4% of true TBL. The visible blood loss in the laparoscopy group was 168.9 ± 121.9 mL, and the HBL was 185.1 ± 130.5 mL (52.3 ± 28.1% of true TBL). The HBL blood loss in laparotomy was more than laparoscopy (p < 0.01). Multiple linear regression analysis suggested that patient age (p = 0.012), surgical time (p = 0.037) and pathological tumour type (p = 0.014) were independent risk factors contributing to HBL in laparotomy. Meanwhile, the following risk factors were positively correlated with HBL in laparoscopy: pre-operative value of Hb (p = 0.002), pre-operative value of Hct (p = 0.003), surgical time (p = 0.035), pathological tumour type (p = 0.036) and diabetes mellitus (p = 0.022). Ten and eight patients had pre-operative anaemia in the laparotomy group and the laparoscopy group, respectively, and 54 and 29 post-operatively. CONCLUSIONS: HBL is seriously underestimated, and accounts for a large percentage of total blood loss both in laparotomy and laparoscopy for cervical cancer. Additionally, age, pathological tumour type, pre-operative value of Hb and Hct, surgical time and diabetes mellitus have the potential to increase HBL. A correct understanding of HBL can ensure patient safety and improve post-operative rehabilitation.

An autopsy report of basilar artery aneurysm flow diversion complicated by postoperative day 3 hemorrhage from vessel rupture.

A middle-aged patient presented with posterior circulation symptoms attributable to a large eccentric basilar trunk aneurysm. The planned treatment was flow diversion with loose coil packing which was successfully performed using a Pipeline Flex device deployed from the basilar to the left posterior cerebral artery. The complete procedure including live biplane fluoroscopy was digitally recorded. The patient had symptomatic improvement postoperatively and was discharged on day 1. The patient suffered a cardiac arrest on postoperative day 3 secondary to massive intraventricular and subarachnoid hemorrhage. An aneurysm rupture was suspected; however, postmortem examination showed an intact aneurysm sac. The hemorrhage was attributed to a small focal rent in the distal basilar artery next to an atheromatous plaque. The Pipeline device was visible through the rent. This is an autopsy report documenting an injury to the parent artery and not the aneurysm as a source of fatal delayed subarachnoid hemorrhage following flow diversion.

Late postoperative bleeding after Roux-en-Y gastric bypass: management and review of literature.

Gastrointestinal (GI) bleeding is a catastrophic complication of gastric bypass. Bleeding can occur during the early or late phase after the operation. Though bleeding after gastric bypass is infrequent, late bleeding is exceedingly rare. We present two patients with late bleeding following Roux-en-Y gastric bypass (RYGB). The first patient, a 65-year-old woman, presented with life-threatening upper GI bleeding almost 5 years after laparoscopic RYGB. The second patient, a 62-year-old woman, presented with upper GI bleeding after almost 14 years following RYGB. Both, due to an eroding marginal ulcer. We discuss here the management of a rare and catastrophic complication of late GI bleeding and review the various reports in the literature describing the late bleeding as a complication of gastric bypass. Late GI bleeding after RYGB presents a diagnostic and interventional challenge. High index of suspicion and adequate management strategies may lessen morbidity and mortality.

Early postoperative controlling nutritional status (CONUT) score is associated with complication III-V after hepatectomy in hepatocellular carcinoma: A retrospective cohort study of 1,334 patients.

Postoperative complication III-V is closely related with hepatectomy-related mortality for hepatocellular carcinoma (HCC) patients. The aim of the study was to investigate the relationship between CONUTS and postoperative complication III-V. 1334 HCC patients who underwent hepatectomy were divided into two groups: high CONUTS group (early postoperative CONUTS ≥ 8, n = 659) and low CONUTS group (early postoperative CONUTS < 8, n = 675). The characteristics and clinical outcomes were compared and analyzed. Risk factors for postoperative complication III-V were evaluated by univariate and multivariate analysis. early postoperative CONUTS showed a good prediction ability for postoperative complication III-V (AUROC = 0.653, P < 0.001), with the cut-off value of 8. The high CONUTS group had higher incidence of postoperative pulmonary complications (12.0% vs 7.9%, P = 0.011), bile leakage (2.6% vs 0.9%, P = 0.018), intra-abdominal hemorrhage (4.9% vs 1.6%, P = 0.001), postoperative liver failure Grade C (3.6% vs 1.0%, P = 0.002), complication III-V (15.6% vs 6.2%, P < 0.001), length of ICU stay > 48 hours (9.4% vs 4.1%, P < 0.001) and mortality in 90 days (2.6% vs 0.4%, P = 0.001), longer period of postoperative hospitalization (10 (8-13) vs 9 (7-11) days, P < 0.001). Multivariable analysis revealed that early postoperative CONUTS ≥ 8 (OR = 2.054, 95%CI = 1.371-3.078, P < 0.001) was independently associated with postoperative complication III-V. Early postoperative CONUTS ≥ 8 was identified as a novel risk factor for postoperative complication III-V, and should be further evaluated as a predictive marker for who are to undergo liver resection.

Bleeding from Wharton's duct after fine-needle aspiration biopsy on submandibular gland.

The case of a fine-needle aspiration biopsy (FNAB) of the patient's salivary gland lesions is considered a rapid, simple, reliable, minimal invasive procedure with markedly rare complications. Herein, we report a case of bleeding from the region of the Wharton's duct after a procedure of a FNAB on the patient's submandibular gland. To our knowledge, this is the first case of bleeding from a salivary duct after a FNAB. For this reason, it is important to recognize that bleeding from the salivary duct after a FNAB can be a rare occurrence.

Combination of aptamer and drug for reversible anticoagulation in cardiopulmonary bypass.

Unfractionated heparin (UFH), the standard anticoagulant for cardiopulmonary bypass (CPB) surgery, carries a risk of post-operative bleeding and is potentially harmful in patients with heparin-induced thrombocytopenia-associated antibodies. To improve the activity of an alternative anticoagulant, the RNA aptamer 11F7t, we solved X-ray crystal structures of the aptamer bound to factor Xa (FXa). The finding that 11F7t did not bind the catalytic site suggested that it could complement small-molecule FXa inhibitors. We demonstrate that combinations of 11F7t and catalytic-site FXa inhibitors enhance anticoagulation in purified reaction mixtures and plasma. Aptamer-drug combinations prevented clot formation as effectively as UFH in human blood circulated in an extracorporeal oxygenator circuit that mimicked CPB, while avoiding side effects of UFH. An antidote could promptly neutralize the anticoagulant effects of both FXa inhibitors. Our results suggest that drugs and aptamers with shared targets can be combined to exert more specific and potent effects than either agent alone.

Impact of Ultrasonic Scalpels for Liver Parenchymal Transection on Postoperative Bleeding and Bile Leakage.

BACKGROUND/AIM: Novel techniques for liver parenchymal transection have emerged and they are available to the hepatobiliary surgeon. The aim of our study was to compare two types of ultrasonic scalpels (Lotus and Harmonic) and examine how they perform either alone or in combination with the SonaStar ultrasonic surgical aspiration system regarding postoperative bleeding and bile leakage. PATIENTS AND METHODS: Our prospectively maintained database of patients who underwent liver resections in our Department was reviewed. One hundred and two patients with solid liver lesions underwent liver resection by a senior hepatobiliary surgeon in our department during a period of 51 months. They were divided into four groups according to the devices that were used for liver parenchymal transection. RESULTS: Patients were divided into the following groups: group 1: Lotus, 32 patients (31.4%); group 2: Lotus+SonaStar, 27 patients (26.5%); group 3: Harmonic, 27 patients (26.5%); group 4: Harmonic+SonaStar, 16 patients (15.7%). There were 5 cases of postoperative bleeding and 9 cases of postoperative bile leakage. No significant difference was found concerning postoperative bleeding (group 1: 2/32; 6.3%, group 2: 2/27; 7.4%, group 3: 0/27; 0%, group 4: 1/16; 6.3%) (p=0.577). Furthermore, no actual difference was detected in terms of postoperative bile leakage (group 1: 2/32; 6.3%, group 2: 3/27; 11.1%, group 3: 3/27; 11.1%, group 4: 1/16; 6.3%) (p=0.866). CONCLUSION: Both Lotus and Harmonic ultrasonic scalpels provide adequate and similar results concerning postoperative hemorrhage and cholorrhea.

Extensive Submacular Hemorrhage After Trabeculectomy With Mitomycin C.

PURPOSE: We report the occurrence of an extensive submacular hemorrhage after trabeculectomy with mitomycin C in a patient with an occult choroidal neovascular membrane (CNVM). PATIENTS AND METHODS: A 66-year-old man had a 3-year history of primary open-angle glaucoma in the left eye, which had been treated with topical antiglaucoma medication. The patient had age-related macular degeneration with an occult CNVM, for which he had received 5 intravitreal injections of ranibizumab and 5 intravitreal injections of bevacizumab in the left eye over a 3-year period. As intraocular pressure was not under control in the left eye over a 2-month period, trabeculectomy with mitomycin C was performed. RESULTS: On the first postoperative day, intraocular pressure was 8 mm Hg with a well-formed bleb in the left eye. However, extensive subretinal hemorrhage was observed, and the patient underwent pneumatic displacement and pars plana vitrectomy to remove the hemorrhage. After 7 months, extensive subretinal fibrosis was observed and visual acuity was low (hand movement only). CONCLUSIONS: To our knowledge, this is the first report of an extensive submacular hemorrhage after trabeculectomy with mitomycin C in a patient with an occult CNVM.

First Safety and Performance Evaluation of T45K, a Self-Assembling Peptide Barrier Hemostatic Device, After Skin Lesion Excision.

BACKGROUND: The self-assembling peptide barrier T45K (SAPB-T45K) is an oligopeptide that rapidly forms a biocompatible hemostatic barrier when applied to wounds. OBJECTIVE: Evaluate safety and performance of SAPB-T45K in cutaneous surgery. MATERIALS AND METHODS: In this single-blind study, after sequential shave excision of 2 lesions, wounds were randomized (intrapatient) to SAPB-T45K or control treatment. Safety was assessed at treatment, Day 7, and Day 30. Performance was evaluated using time to hemostasis (TTH) and ASEPSIS wound scores, with a subgroup analysis for patients with or without antiplatelet therapy. RESULTS: Each of 46 patients (10 [22%] with antiplatelet therapy) received randomized SAPB-T45K or control treatment for 2 wounds. Safety assessments were similar, and ASEPSIS scores reflected normal healing in both wound groups. SAPB-T45K demonstrated significantly faster median TTH (24.5 [range, 7-165] seconds) compared with control (44 [10-387] seconds), for a 41% median TTH reduction (18 [95% confidence interval, 7-35] seconds, p < .001). SAPB-T45K provided an identical median TTH of 24 seconds, regardless of antiplatelet therapy. Control median TTH was 90 and 40 seconds for patients taking or not taking antiplatelet therapy, respectively. CONCLUSIONS: SAPB-T45K provided significantly faster median TTH versus control, especially with antiplatelet therapy, and safety profiles were similar.

Risk factors for postoperative haemorrhage after total thyroidectomy: clinical results based on 2,678 patients.

The aim of this study was to analyse postoperative haemorrhage (POH) after a total thyroidectomy and explore the possible risk factors. Records of patients receiving a total thyroidectomy were reviewed and analysed for risk factors of POH. From the 2,678 patients in this study, a total of 39 patients had POH, representing an incidence of 1.5%. The majority (59.0%) of POH events occurred within four hours after surgery. Arterial haemorrhage was the primary cause of POH and was identifiable prior to venous bleeding, making it the first sign of POH. A univariate analysis revealed an association between POH, certain disease factors and BMI, but only a BMI greater than 30 was found to significantly increase the risk of POH (almost 6-fold). At the first sign of POH, all patients showed an obvious red drainage, and 92.3% of the patients had neck swelling. In summary, arterial bleeding is the main cause and first sign of postoperative haemorrhage, as it starts earlier than venous bleeding. A BMI greater than 30 significantly increases the risk of neck haematoma.

[Erbium laser application for oral surgery in patients with platelet hemostatic disorders]. / Primenenie érbievogo lazera pri khirurgicheskom stomatologicheskom lechenii patsientov s narusheniiami trombotsitarnogo gemostaza.

Hemostatic disorders are typically associated with prolonged bleeding after or during surgical procedures. The aim of the study was to increase the efficiency of oral surgery in these patients using erbium laser. Selected 46 patients receiving oral surgery were randomly divided in 2 groups: 43 patients with thrombocytopenia, trombocytemia and other platelet disorders treated with erbium laser and a control group of 43 patients without concomitant pathology determined for conventional surgical treatment. No postoperative bleeding was seen in group 1. Conventional procedures were associated with significantly more postoperative pain and epithelization took 1-3 days longer. Erbium laser radiation is an up-to-date method which can be successfully used for oral surgery in patients with hemostatic disorders.

Effect of Body Mass Index on Posttonsillectomy Hemorrhage.

OBJECTIVE: Obesity affects adverse outcomes in patients undergoing various surgeries. Tonsillectomy is one of the most common surgical procedures and posttonsillectomy hemorrhage (PTH) is the major complication in patients with tonsillectomy. However, the effect of body mass index (BMI) on posttonsillectomy bleeding episodes is not well known. This study aimed to assess the clinical association between obesity and PTH. METHODS: A total of 98 tonsillectomies were retrospectively reviewed. Patient charts were analyzed regarding demographic data and the indication for surgery. Patients with PTH were compared with uneventful cases. Patients were divided into three groups based on BMI: normal weight (BMI < 25 kg/m2), overweight (BMI ≥ 25 and <30 kg/m2), and obese (≥30 kg/m2). RESULTS: PTH occurred in 13% of patients with normal weight, in 23.5% of patients with overweight, and in 50% patients with obesity. The occurrence of PTH was significantly higher in patients with obesity than in those with normal weight and overweight (p = 0.008). Multivariate analysis showed that obesity was a significant factor affecting the incidence of PTH after adjusting for confounding factors. CONCLUSIONS: Our findings suggest that the obese condition is independently associated with the incidence of PTH.

Fatal bleeding from an aortocoronary bypass.

Coronary bypass grafting is a routine procedure in heart surgery, which can now also be performed using a minimally invasive technique on the beating heart. In the presented case, a 55-year-old man died two days after bypass surgery. His condition had deteriorated post-operatively over 2 days until he finally died from multi-organ failure and cardiogenic shock. Autopsy revealed a fatal haemorrhage into the chest cavities from a small tear in the bypass and acute myocardial infarction. The haemorrhage had not been noticed in the hospital. Postoperative haemorrhage is a common complication after this type of surgery, which occurs in about 1-2 % of cases.

Improvement in symptoms of obstructive sleep apnoea in children following tonsillectomy versus tonsillotomy: a systematic review and meta-analysis.

BACKGROUND: Tonsillotomy (or intracapsular tonsillectomy) is a modern technique which is seen by some as potentially superior to traditional (extracapsular) tonsillectomy for the removal of tonsillar tissue to treat obstructive sleep apnoea in children. It has been suggested that peri-operative pain and haemorrhage and postoperative haemorrhage are reduced with the tonsillotomy technique. However, no systematic reviews have been carried out to assess its efficacy in treating obstructive sleep apnoea compared to tonsillectomy. OBJECTIVE OF REVIEW: To assess whether subjective improvement in symptoms of obstructive sleep apnoea following tonsillotomy is comparable to that following tonsillectomy, measured using a standardised questionnaire, the Obstructive sleep apnoea-18 (OSA-18) tool. TYPE OF REVIEW: Systematic review of the literature and meta-analysis. SEARCH STRATEGY: PubMed (MEDLINE), followed by Ovid (MEDLINE), Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and the British Medical Journal were searched for articles published in English between 1995 and 2015 inclusive. EVALUATION METHOD: Literature search, systematic review and meta-analysis. Studies examining improvement in mean OSA-18 score following tonsillotomy, improvement in mean OSA-18 score following tonsillectomy, and examining both were selected, examined and used for meta-analysis. Studies with and without concurrent adenoidectomy were included. RESULTS: Four studies examining tonsillotomy and 16 studies examining tonsillectomy were included in the analysis. Using a random effects model, the pooled improvement in OSA-18 score for tonsillotomy was 2.46 (95% CI 1.92-2.99), and for tonsillectomy, it was 2.10 (95% CI 1.91-2.30). There was no significant difference between the methods. CONCLUSION: That there is no significant difference in subjective outcome between tonsillotomy and tonsillectomy may support wider use of tonsillotomy over tonsillectomy for the treatment of obstructive sleep apnoea in children.

Comparison Between Minimally Invasive Surgery and Conventional Open Surgery for Patients With Spinal Metastasis: A Prospective Propensity Score-Matched Study.

STUDY DESIGN: Prospective propensity score-matched study. OBJECTIVE: To compare the outcomes of minimal invasive surgery (MIS) and conventional open surgery for spinal metastasis patients. SUMMARY OF BACKGROUND DATA: There is lack of knowledge on whether MIS is comparable to conventional open surgery in treating spinal metastasis. METHODS: Patients with spinal metastasis requiring surgery from January 2008 to December 2010 in two spine centers were recruited. The demographic, preoperative, operative, perioperative and postoperative data were collected and analyzed. Thirty MIS patients were matched with 30 open surgery patients using propensity score matching technique with a match tolerance of 0.02 based on the covariate age, tumor type, Tokuhashi score, and Tomita score. RESULTS: Both groups had significant improvements in Eastern Cooperative Oncology Group (ECOG), Karnofsky scores, visual analogue scale (VAS) for pain and neurological status postoperatively. However, the difference comparing the MIS and open surgery group was not statistically significant. MIS group had significantly longer instrumented segments (5.5 ±â€Š3.1) compared with open group (3.8 ±â€Š1.7). Open group had significantly longer decompressed segment (1.8 ±â€Š0.8) than MIS group (1.0 ±â€Š1.0). Open group had significantly more blood loss (2062.1 ±â€Š1148.0 mL) compared with MIS group (1156.0 ±â€Š572.3 mL). More patients in the open group (76.7%) needed blood transfusions (with higher average units of blood transfused) compared with MIS group (40.0%). Fluoroscopy time was significantly longer in MIS group (116.1 ±â€Š63.3 s) compared with open group (69.9 ±â€Š42.6 s). Open group required longer hospitalization (21.1 ±â€Š10.8 days) compared with MIS group (11.0 ±â€Š5.0 days). CONCLUSION: This study demonstrated that MIS resulted in comparable outcome to open surgery for patients with spinal metastasis but has the advantage of less blood loss, blood transfusions, and shorter hospital stay. LEVEL OF EVIDENCE: 3.

Life-threatening hemorrhage after zygomatic bone surgery. About 2 posttraumatic cases.

INTRODUCTION: Management of zygomatic bone fractures is still debated. Method and delay for intervention has to be chosen considering respective issues of operative or conservative treatments, especially hemorrhagic complications. The maxillofacial surgeon must be able to determine life-threatening situations and to react appropriately. CASES REPORT: We report 2 cases of external carotid branches pseudoaneurysm leading to massive hemorrhage after early or delayed zygomatic fracture surgery. The first patient underwent open reduction of fracture by intraoral approach. An active bleeding occurred in the immediate postoperative time. In the second case, a zygomatic osteotomy was performed 1 year after fracture. Bleeding occurred 2 weeks after surgery. In both cases, angiography demonstrated a pseudoaneurysm developed from the external carotid branches. Embolisation led to rapid bleeding control. DISCUSSION: Severe hemorrhage resulting from maxillofacial trauma may be life-threatening. Once the "damage control" principles applied, selective embolisation of external carotid branches is an efficient alternative to surgery for the control of bleeding resulting from ruptured pseudoaneurysm.