A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial.

BACKGROUND: Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups. METHODS: This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing. RESULTS: There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P < 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02). CONCLUSIONS: This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing.

Clinical outcomes of prophylactic compression sutures for treatment of uterine atony during the cesarean delivery of twins.

BACKGROUND: Twin pregnancy has a high risk for developing uterine atony (UA). This study aimed to evaluate efficacy and clinical outcomes of prophylactic compression sutures to treat UA during twin cesarean section (CS). METHODS: All patient records of twin deliveries by CS after gestational age of 24 weeks in a large maternity hospital in South Korea between January 2013 and June 2018 were reviewed. Patients with monochorionic monoamniotic twins were excluded from data analysis. In total, 953 women were eligible for data analysis. RESULTS: Of the 953 patients, compression sutures were applied to 147 cases with postpartum bleeding that were refractory to uterine massage and uterotonics. Out of the 147, two patients (1.4%) proceeded to additional uterine artery ligation to achieve hemostasis, yielding a success rate of 98.6%. The rate of transfusion after the first 24 h of delivery in the suture group was not significantly different from that in the non-suture group, suggesting that both groups achieved hemostasis at an equal rate after the first 24 h of delivery. The difference in the operation time between the two groups was only 8.5 min. The rate of subsequent pregnancy among the patients who received compression sutures was 44.4%. CONCLUSIONS: Overall, our findings suggest that with early and fast implementation of compression sutures, UA can be treated in the setting of twin cesarean delivery without significantly increasing maternal morbidity.

Total Knee Arthroplasty Is Safe in Jehovah's Witness Patients-A 12-Year Perspective.

Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.

A randomized controlled trial of trigger finger release under digital anesthesia with (WALANT) and without adrenaline.

BACKGROUND: Trigger finger release utilizing wide-awake local anesthesia no tourniquet (WALANT) usage in extremity surgery is not widely used in our setting due to the possibility of necrosis. Usage of a tourniquet is generally acceptable for providing surgical field hemostasis. We evaluate hemostasis score, surgical field visibility, onset and duration of anesthesia, pain score, and the duration of surgery and potential side effects of WALANT. METHODS: Eighty-six patients scheduled for trigger finger release between July 2016 and December 2017 were randomized into a control group (1% lignocaine and 8.4% sodium bicarbonate with arm tourniquet; given 10 min prior to procedure) and an intervention group (1% lignocaine, 1:100,000 of adrenaline and 8.4% sodium bicarbonate; given 30 min prior to procedure), with a total of 4 ml of solution injected around the A1 pulley. The onset of anesthesia and pain score upon injection of the first 1 ml were recorded. After the procedure, the surgeon rated for the hemostasis score (1-10: 1 as no bleeding and 10 being profuse bleeding). Duration of surgery and return of sensation were recorded. RESULTS: Hemostasis score was grouped into visibility score as 1-3: good, 4-6: moderate, and 7-10: poor. The intervention group (with adrenaline) had a 74% of good surgical field visibility compared to 44% from the controlled group (without adrenaline; p < 0.05). Duration of anesthesia was longer in the intervention group (with adrenaline), with a 2.77-h difference. CONCLUSION: WALANT provides excellent surgical field visibility and is safe and on par with conventional methods but without the usage of a tourniquet and its associated discomfort.

Excessive postextraction bleeding associated with Cordyceps sinensis: a case report and review of select traditional medicines used by Vietnamese people living in the United States.

Many older people who have emigrated from Vietnam to the United States continue to use the traditional medicines that they used in their country of origin. Clinicians trained in the West may not be familiar with these products. We reviewed 6 Asian traditional medicines that are popular among older Vietnamese people living in the United States. Each medicine has significant side effects that can lead to complications in patients undergoing surgery. Here, we present the case of a patient who used Cordyceps sinensis daily as a tonic and experienced prolonged bleeding after dental surgery.

The effectiveness of the double B-lynch suture as a modification in the treatment of intractable postpartum haemorrhage.

A broader range of more effective compression techniques are needed in the patients who have an intractable postpartum haemorrhage due to uterine atony despite medical treatment and B-Lynch sutures. The aim of this study was to report the outcome of a series of patients with haemorrhage who were managed by double B-Lynch suture. Fourteen patients who were treated in a tertiary hospital between July 2010 and February 2015 were included in the study. The intractable haemorrhage rate was 0.35% over 5 years (14/4000 births). Bleeding was controlled in all the patients with a double B-Lynch suture. The mean age of the patients was 24 ± 3.4 years. The mean estimated blood loss was 1696 ± 272.075 mL, and the mean transfusion rate was 4.2 ± 2.5 units. Pregnancy was observed in five patients at follow up. The double B-Lynch suture seems to be an effective and reliable solution to an intractable postpartum haemorrhage resulting from uterine atony and has no unfavourable impacts on fertility. It should be considered before the use of any aggressive surgical techniques such as a hypogastric artery ligation or a hysterectomy. This the first study to investigate the effectiveness of the double B-Lynch suture, and we showed that the hysterectomy and/or hypogastric artery ligation rate can be decreased by adding a second B-Lynch suture in cases where the medical treatment or a single B-Lynch has failed. Impact statement What is already known on the subject? Uterine atony is the most common cause of a primary postpartum haemorrhage. When a simple massage of the uterus and medication failed to manage this condition, various surgical solutions have been sought, including uterine compression sutures, uterine artery ligation, devascularisation of the uterus, internal iliac artery ligation and, ultimately, a hysterectomy. The B-Lynch suturing technique is particularly useful because of its simplicity of application, life-saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. To-date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. However in the cases of when it falls, usually a hysterectomy or a hipogastric artery ligation is preferred. What does this study add? A 'double B-Lynch suture seems to be an effective and reliable method in an intractable postpartum haemorrhage due to a uterine atony and has no unfavourable impact on fertility'. What are the implications of these findings for clinical practice? The double B-Lynch suture seems to be an effective, reliable and technically easy method. With this aspect, it might be considered before any aggressive surgical techniques, such as a hypogastric artery ligation and hysterectomy in selected cases.

Topical blood stopper agents during adenoid surgery in young children; a prospective randomized controlled trial.

OBJECTIVE: To investigate the safety and efficacy of two topical blood stopper modulators; Ankaferd blood stopper (ABS) and feracrylum 1% solution (FS) during adenoid surgery. STUDY DESIGN: Prospective randomized trial. METHODS: Two hundred and twenty five consecutive pediatric adenoid patients aged from 9 months to 2 years old were studied. Patients were randomly allocated into two haemostatic groups; (ABS, FS) and normal saline (control group). RESULTS: ABS and FS groups showed a significantly less intra operative blood loss (16.4 ± 2.6/22 ± 6.2), operative time (9.31 ± 1.9/11.2 ± 1.6 min), use of cautery (10.6/25.3%), postoperative analgesics (3 ± 1.1/3.8 ± 1.2), duration to return normal diet (2.4 ± 1.2/3.9 ± 0.9) and operating theatre cost (233 ± 48$ and 279 ± 40$) than the control group. CONCLUSION: AFS and FS are easy, safe, and reliable topical haemostatic modulators that could be used in adenoid surgery.

Surgical approach to piles at risk of severe postoperative pain: tricks and tips.

AIM: Aim of the present study is to propose a clinic-therapeutic course for the treatment of hemorrhoidal disease able to combine radical anatomic surgery with a painless postoperative path. MATERIAL OF STUDY: The present study is based on the evaluation of 20 selected patients who underwent radical hemorrhoidectomy for very high grade hemorrhoidal disease. The clinical course was characterized by careful bowel cleansing, hemorrhoidectomy according to Milligan-Morgan using LigaSure, intraoperative perianal infiltration of Ropivacaine and postoperative use of analgesic drugs. DISCUSSION: A low postoperative pain may descend from a scheduled timing of clinical procedures. Preoperative bowel cleansing delays the first postoperative evacuation, thus avoiding the perianal nerve stimulation. The use of LigaSure allows to perform surgical excision in a perfect way: lack of hemostatic stitches, less tissue trauma, very low early morbidity. A rational and scheduled intra and postoperative drug administration offers a highly significant contribution to the pain control. The intra and postoperative use of drugs makes it possible to perform the so-called "preventive anesthesia with activation of the pain memory" and postoperative evacuations with low pain perception. All patients, in fact, reported low and well tolerated pain, satisfaction and return to normal activities in a short period. CONCLUSIONS: Radical hemorrhoidectomy with LigaSure and attention to pre, intra and postoperative protocol makes the procedure painless, safe and with low morbidity. KEY WORDS: Hemorrhoidectomy, LigaSure, Painless procedure.

Reassessment of Rebleeding Risk of Forrest IB (Oozing) Peptic Ulcer Bleeding in a Large International Randomized Trial.

OBJECTIVES: Our aims were to assess risks of early rebleeding after successful endoscopic hemostasis for Forrest oozing (FIB) peptic ulcer bleeding (PUBs) compared with other stigmata of recent hemorrhage (SRH). METHODS: These were post hoc multivariable analyses of a large, international, double-blind study (NCT00251979) of patients randomized to high-dose intravenous (IV) esomeprazole (PPI) or placebo for 72 h. Rebleeding rates of patients with PUB SRH treated with either PPI or placebo after successful endoscopic hemostasis were also compared. RESULTS: For patients treated with placebo for 72 h after successful endoscopic hemostasis, rebleed rates by SRH were spurting arterial bleeding (FIA) 22.5%, adherent clot (FIIB) 17.6%, non-bleeding visible vessel (FIIA) 11.3%, and oozing bleeding (FIB) 4.9%. Compared with FIB patients, FIA, FIIB, and FIIA had significantly greater risks of rebleeding with odds ratios (95% CI's) from 2.61 (1.05, 6.52) for FIIA to 6.66 (2.19, 20.26) for FIA. After hemostasis, PUB rebleeding rates for FIB patients at 72 h were similar with esomeprazole (5.4%) and placebo (4.9%), whereas rebleed rates for all other major SRH (FIA, FIIA, FIIB) were lower for PPI than placebo, but the treatment by SRH interaction test was not statistically significant. CONCLUSIONS: After successful endoscopic hemostasis, FIB patients had very low PUB rebleeding rates irrespective of PPI or placebo treatment. This implies that after successful endoscopic hemostasis the prognostic classification of FIB ulcers as a high-risk SRH and the recommendation to treat these with high-dose IV PPI's should be re-evaluated.

Garlic-Induced Surgical Bleeding: How Much Is Too Much?

A patient underwent C2-T2 decompression and fusion with excessive intraoperative bleeding and no clear source. The patient denied the use of blood-thinning medications, but had consumed the equivalent of 12 g garlic daily in the days leading up to the surgery. He was treated with desmopressin acetate (DDAVP) and cryoprecipitate with adequate control of bleeding. Garlic is known to have an antiplatelet effect, although the dose range necessary to create a bleeding abnormality has not yet been well described nor has the effect of taking garlic with sertraline or other agents with an established or potential effect on coagulation.

How I do it: Same day discharge for transurethral resection of prostate using Olympus PlasmaButton and PlasmaLoop.

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting older men. Transurethral resection of the prostate (TURP) has widely been considered the gold standard in surgical treatment for BPH. However, this procedure remains largely an inpatient procedure. Inpatient admission ultimately adds to healthcare cost and patient morbidity. In this article, we present an alternative methodology to treat BPH using combination Olympus PlasmaButton and Olympus PlasmaLoop therapy. Preliminary results from our experience suggest improved hemostasis with adequate resection, allowing a majority of our patients to be discharged the same day of the procedure. We describe our novel technique as a safe and effective way to possibly treat BPH in an outpatient setting.

Blood-Sparing Techniques in Head and Neck Surgery.

Given the risks and potential complications of allogenic blood transfusion (ABT), as well as the expanding population of patients for whom ABT may not be an option, it is important for the treating physician, anesthesiologist, and surgeon to be well-versed in various alternatives. A good grasp of the concepts discussed in this article will help to customize a treatment plan that is specific to each patient's underlying disease and personal preferences without compromising appropriate medical care.

Angioleiomioma cutáneo / Cutaneous angioleiomyoma

No disponible

Hemostasis Plug for an Electromagnetic Thermotherapy and Its Application for Liver Laceration.

Accident-induced liver trauma is a significant human health concern, as this organ is readily injured during periods at which the abdominal region is compromised. In this work, electromagnetic thermotherapy was successfully developed and employed in vitro and in vivo to treat livers that had been lacerated. Briefly, a new hemostasis plug was integrated with an electromagnetic thermotherapy system (ETS) to perform surgery on lacerated livers. The high-frequency, alternating electromagnetic field (EMF) was generated by the ETS and was shown to induce a pre-set temperature increase within the hemostasis plug embedded in the target tissue. In order to prevent overheating and maintain a constant hemostasis temperature, a temperature feedback control system was utilized. The effect of the intensity of the EMF on the heating capacity of the ETS-hemostasis system was first explored. Furthermore, the relationship between the coagulation zone and operating temperature were investigated in vitro. By utilizing the temperature feedback control system, the hemostasis plug could be heated to a specific temperature for efficient hemostasis. With this approach, the optimal treatment temperature and time were investigated for liver laceration. Lacerated livers from New Zealand white rabbits were successfully treated with the hemostasis plug and ETS within a short period of time. When compared with the traditional perihepatic packing approach, the volume of blood loss from liver laceration surgeries treated by ETS has been dramatically reduced by 83%, suggesting a high therapeutic potential for this system.

Comparison of polyurethane with cyanoacrylate in hemostasis of vascular injury in guinea pigs.

OBJECTIVE: To evaluate the behavior of castor oil-derived polyurethane as a hemostatic agent and tissue response after abdominal aortic injury and to compare it with 2-octyl-cyanoacrylate. METHODS: Twenty-four Guinea Pigs were randomly divided into three groups of eight animals (I, II, and III). The infrarenal abdominal aorta was dissected, clamped proximally and distally to the vascular puncture site. In group I (control), hemostasis was achieved with digital pressure; in group II (polyurethane) castor oil-derived polyurethane was applied, and in group III (cyanoacrylate), 2-octyl-cyanoacrylate was used. Group II was subdivided into IIA and IIB according to the time of preparation of the hemostatic agent. RESULTS: Mean blood loss in groups IIA, IIB and III was 0.002 grams (g), 0.008 g, and 0.170 g, with standard deviation of 0.005 g, 0.005 g, and 0.424 g, respectively (P=0.069). The drying time for cyanoacrylate averaged 81.5 seconds (s) (standard deviation: 51.5 seconds) and 126.1 s (standard deviation: 23.0 s) for polyurethane B (P=0.046). However, there was a trend (P=0.069) for cyanoacrylate to dry more slowly than polyurethane A (mean: 40.5 s; SD: 8.6 s). Furthermore, polyurethane A had a shorter drying time than polyurethane B (P=0.003), mean IIA of 40.5 s (standard deviation: 8.6 s). In group III, 100% of the animals had mild/severe fibrosis, while in group II only 12.5% showed this degree of fibrosis (P=0.001). CONCLUSION: Polyurethane derived from castor oil showed similar hemostatic behavior to octyl-2-cyanoacrylate. There was less perivascular tissue response with polyurethane when compared with cyanoacrylate.

Transsylvian-transinsular approach to large lateral thalamus hemorrhages.

Here, we aimed to evaluate the experience of transsylvian-transinsular microsurgical approach (TTH) to the huge lateral thalamic hemorrhages (THs). A total of 37 patients with huge lateral TH (hematoma volumes between 30 and 90 cm) who underwent surgical treatment through middle or distal TTH at the Bayi Brain Hospital from January 2007 to May 2012 were included in this series. By using TTH, near-complete (99%) evacuation was achieved in 29 patients (78.4%). Glasgow Coma Scale (GOS) scores were significantly improved at discharge compared with admission scores (P < 0.001). The overall survival rate at 3 months was 81.08% (30/37), including 51.35% (19/37) with good function (GOS, 4-5), 13.51% (5/37) with disability (GOS, 3), and 16.22% (6/37) in a vegetative state (GOS, 2). The mortality rate (GOS, 1) was 18.92% (7/37). Our series showed that, according to the extension direction of hematomas, to select middle or distal TTH is effective and safe for TH.

Hemostatic effect of hot saline irrigation during functional endoscopic sinus surgery: a randomized controlled trial.

BACKGROUND: The endoscopically magnified operative field in functional endoscopic sinus surgery (FESS) makes even a small amount of bleeding a potentially significant hindrance. It is thought that irrigation with hot saline during surgery may improve surgical field of view by producing a hemostatic effect. Our objective was to assess the effectiveness of hot saline irrigation (HSI) compared to room temperature saline irrigation (RTSI) in the control of intraoperative bleeding during FESS. METHODS: Sixty-two chronic rhinosinusitis (CRS) patients undergoing FESS were randomized to 2 treatment arms in an equal ratio. Subjects received either HSI (49°C) or RTSI (18°C), 20 mL every 10 minutes, for the duration of FESS. The Boezaart endoscopic field of view grading system was the primary outcome measure. Boezaart score, heart rate, and mean arterial blood pressure (MABP) were recorded at 10-minute intervals between irrigations. RESULTS: Mean endoscopic surgical field of view (Boezaart score) did not significantly differ between the HSI and RTSI groups (1.5 ± 0.6 vs 1.3 ± 0.5; p = 0.23). However, when FESS was longer than 2 hours in duration, the Boezaart scores were significantly better in the HSI group (1.6 ± 0.6 vs 1.2 ± 0.4; p = 0.04). We found that blood loss per minute was significantly reduced (p = 0.02) in all cases in which HSI was used (2.3 ± 1.0) compared to RTSI (1.7 ± 1.1). Despite this, heart rate (p = 0.32) and MABP (p = 0.14) did not significantly differ between treatment groups. CONCLUSION: HSI may be beneficial in improving surgical field of view in FESS after 2 hours of operating time. A significant reduction in rate of blood loss may be attained with HSI.

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate.

OBJECTIVE: To evaluate the safety and feasibility of N-butyl cyanoacrylate (N-BCA) embolization of percutaneous transhepatic portal venous access tract and to establish an appropriate technique. METHODS: 40 consecutive patients underwent percutaneous transhepatic portal venous intervention for various reasons. Embolization of percutaneous transhepatic portal venous access tract was performed after the procedure in all of the patients using N-BCA and Lipiodol® (Lipiodol Ultra Fluide; Laboratoire Guerbet, Aulnay-sous-Bois, France) mixture. Immediate ultrasonography and fluoroscopy were performed to evaluate perihepatic haematoma formation and unintended embolization of more than one segmental portal vein. Follow-up CT was performed, and haemoglobin and haematocrit levels were checked to evaluate the presence of bleeding. RESULTS: Immediate haemostasis was achieved in all of the patients, without development of perihepatic haematoma or unintended embolization of more than one segmental portal vein. Complete embolization of percutaneous access tract was confirmed in 39 out of 40 patients by CT. Seven patients showed decreased haemoglobin and haematocrit levels. Other complications included mild pain at the site of embolization and mild fever, which resolved after conservative management. 16 patients died during the follow-up period owing to progression of the underlying disease. CONCLUSION: Embolization of percutaneous transhepatic portal vein access tract with N-BCA is feasible and technically safe. With the appropriate technique, N-BCA can be safely used as an alternate embolic material since it is easy to use and inexpensive compared with other embolic materials. ADVANCES IN KNOWLEDGE: This is the first study to investigate the efficacy of N-BCA for percutaneous transhepatic portal venous access tract embolization.