Extra Peritoneal Packing for Exsanguinating Pelvic Hemorrhage: Should We Do It in the Emergency Department?

BACKGROUND: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage. OBJECTIVES: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR). METHODS: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008-2018. RESULTS: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038). CONCLUSIONS: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT.

Literature review of primary versus patching versus eversion as carotid endarterectomy closure.

BACKGROUND: Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure. METHODS: We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies. RESULTS: The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion). CONCLUSIONS: Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.

Short Durations of Radial Hemostatic Device After Diagnostic Transradial Cardiac Catheterization: The PRACTICAL-2 Randomized Trial.

BACKGROUND: Radial artery occlusion (RAO) is the most common complication following transradial approach (TRA) for cardiac catheterisation. Our aim was to assess if decreasing radial hemostatic device (RHD) time reduces the risk of RAO among individuals receiving small sheath sizes with no adjunctive heparin. METHODS: We randomised 450 individuals undergoing diagnostic cardiac catheterization via TRA to 3 durations of RHD time: 10, 20, or 30 minutes. After these time periods, the RHD was gradually released over 20 minutes. The primary efficacy end point was forearm hematoma grade ≥ 2 (5-10 cm) and the primary safety end point was RAO (as determined by Doppler ultrasound) 1 hour after RHD removal (before discharge). RESULTS: The mean age was 66 years and 64% were male. Five-French sheaths were used in all patients. Hematoma grade ≥ 2 occurred in only 1 patient, who was in the 20-minute group (P = 0.39). RAO occurred in 6.7% of patients in the 10-minute group, 10.7% in the 20-minute group and 6% in the 30-minute group (P = 0.26). CONCLUSIONS: Among patients receiving small-caliber sheaths without adjunctive heparin, the incidence of forearm hematoma and RAO are low. Shorter durations of RHD time did not further reduce the risk of these complications.

Circumcision in Hemophilia: A Multicenter Experience.

BACKGROUND: Hemophiliac patients and their families have social pressure to undergo circumcision, despite the potential complications. The objective of this study was to report our experience in the circumcision of hemophilia patients. MATERIALS AND METHODS: We included 35 patients with hemophilia who had circumcision in 3 centers from January 2010 to August 2019. Their age ranged between 0.3 months and 8 years. Hemophilia a was classified as mild (n=3), moderate (n=4), and severe (n=28). Patients received 2 doses of factor VIII concentrate 50µ/kg, 1 hour before the procedure and 12 hours after it. RESULTS: Four neonates were diagnosed with hemophilia after circumcision because of prolonged bleeding. Two patients with severe hemophilia A had bleeding after hospital discharge (6.5%). They received additional factor concentrate, and 1 patient had an extra stitch. Two patients had wound gaping (6.5%), and 1 patient had a wound infection (3.2%). CONCLUSION: Hemophilia is not an absolute contraindication for circumcision. Circumcision of hemophilic children should be performed under appropriate conditions in hemophilia centers. Bleeding is not frequent but could be serious.

Association between intraoperative application of microfibrillar collagen hemostat and anastomotic leakage after anterior resection for rectal cancer: A retrospective case-control study.

BACKGROUND: The purpose of the study was to evaluate the association between microfibrillar collagen hemostat and anastomotic leakage after anterior resection. METHOD: Between March 2015 and December 2019, a total of 203 consecutive rectal cancer patients who underwent elective anterior resection were included. Patient parameters were analyzed. The relevant risk factors were identified by univariate and multivariate analysis. Propensity score matching was performed to reduce the selection bias. RESULTS: In total, 26 (12.8%) of the 203 study patients developed clinical anastomotic leakage. The length of hospital stay was significantly prolonged by anastomotic leakage. In univariate analysis and multivariate analysis, male sex, low tumor location, and intraoperative application of microfibrillar collagen hemostat significantly increased the risk of anastomotic leakage. Furthermore, analysis after propensity score matching confirmed the independent role of microfibrillar collagen hemostat in anastomotic leakage. In addition, the median time of anastomotic leakage occurrence from the initial operation in patients with microfibrillar collagen hemostat was 9.00 days, which was significantly later than that in patients without microfibrillar collagen hemostat. CONCLUSION: In addition to male sex and low tumor location, intraoperative application of microfibrillar collagen hemostat was demonstrated to be a significant risk factor for anastomotic leakage. This finding suggested that surgeons should be fully aware of this potential risk in anterior resection. Because of the limitation of retrospective study, however, randomized controlled trials are needed to confirm this association in the future.

Energy vessel sealant devices are associated with decreased risk of neck hematoma after thyroid surgery.

Postoperative neck hematomas following thyroidectomy occur in up to 6.5% of cases. It is unclear whether the use of energy vessel sealant devices effects the rate of PNH. We hypothesized use of an EVSD to be associated with decreased risk of PNH in patients undergoing thyroidectomy. The 2016-2017 American College of Surgeons Thyroidectomy database was queried for patients undergoing thyroidectomy with and without EVSDs. A multivariable logistic regression analysis was performed to evaluate for risk of PNH. From 11,355 patients undergoing thyroidectomy, an EVSD was used for 7460 (65.7%) patients. Age distribution was similar between the two groups (52 vs. 53-years old, p = 0.467). Compared to patients without EVSD used, patients with EVSD used had higher rates of comorbid hypertension (40.6% vs. 34.8%, p < 0.001) and diabetes (14.2% vs. 11.5%, p < 0.001); however, a lower rate of PNH (1.4% vs. 2.4%, p < 0.001). After adjusting for known risk factors for PNH including age, prior neck surgery, and comorbidities, EVSD use was associated with a decreased risk of PNH (OR 0.453, 95% CI 0.330-0.620, p < 0.001). The strongest associated risk factors for PNH were hypertension (OR 1.823, 95% CI 1.283-2.591, p = 0.001) and toxic goiter (OR 1.837, 95% CI 1.144-2.949, p = 0.012). When compared to standard vessel ligation, EVSD use was associated with a lower risk of PNH in patients undergoing thyroidectomy. The strongest associated risk factor for PNH was toxic goiter. Future prospective research is needed to confirm these findings and if corroborated, then increased use of an EVSD should be employed.

Treatment strategies and prognosis for initially unresectable ruptured hepatocellular carcinoma: a single-center experience in 94 patients.

PURPOSE: To identify the treatment options and prognostic factors for patients with initially unresectable ruptured hepatocellular carcinoma (HCC). METHODS: Between June 2012 to December 2016, 94 consecutive patients with initially unresectable ruptured HCC were analyzed retrospectively in this study. Patients were followed until December 2017. Predictors of short-term (≤30 days) and long-term (>30 days) survival were identified by using logistic regression model and Cox proportional hazard model, respectively. RESULTS: Of the 94 patients, initial hemostasis treatment was achieved by transarterial embolization (TAE) in 59 patients, surgical hemostasis in 14, and conservative treatment in 21. Twenty-five (26.6%) patients died within 30 d after tumor rupture. In the multivariate analysis, patients treated with aggressive initial treatment strategies (TAE or surgical hemostasis) (P < 0.001) or those with better Child-Pugh class (P = 0.003) and absence of shock on admission (P = 0.001) had a better chance of short-term survival. Of the 69 patients who survived more than 30 days after initial treatment, the median survival time was 268 d. In the multivariate analysis, among the 69 who survived, early modified LCSGJ stage (P = 0.003) and staged hepatectomy as definitive treatment (P < 0.001) were significant predictors of increased long-term survival. CONCLUSION: Short-term survival of patients with initially unresectable ruptured HCC could achieve with better Child-Pugh class, absence of shock and aggressive initial treatment strategies. After survived the emergency phase of tumor rupture, long-term survival was significantly increased with early modified LCSGJ stage and staged hepatectomy therapy.

Abdominal aortic and junctional tourniquet versus zone III resuscitative endovascular balloon occlusion of the aorta in a swine junctional hemorrhage model.

BACKGROUND: Junctional hemorrhage is a leading contributor to battlefield mortality. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infrarenal (zone III) resuscitative endovascular balloon occlusion of the aorta (REBOA) are emerging strategies for controlling junctional hemorrhage, with AAJT currently available in select forward deployed settings and increasing interest in applying REBOA in the military prehospital environment. This study compared the hemostatic, hemodynamic, and metabolic effects of these devices used for junctional hemorrhage control. METHODS: Shock was induced in anesthetized, mechanically ventilated swine with a controlled hemorrhage (20 mL/kg) and closed femur fracture followed by uncontrolled hemorrhage from a partial femoral artery transection (40% total hemorrhage volume). Residual femoral hemorrhage was recorded during 60-minute AAJT (n = 10) or zone III REBOA (n = 10) deployment, and the arterial injury was repaired subsequently. Animals were resuscitated with 15 mL/kg autologous whole blood and observed for 6 hours. RESULTS: One animal in each group died during observation. Both devices achieved hemostasis with mean residual femoral blood loss in the AAJT and REBOA groups of 0.38 ± 0.59 mL/kg and 0.10 ± 0.07 mL/kg (p = 0.16), respectively, during the 60-minute intervention. The AAJT and REBOA augmented proximal blood pressure equally with AAJT allowing higher distal pressure than REBOA during intervention (p < 0.01). Following device deflation, AAJT animals had transiently lower mean arterial blood pressure than REBOA pigs (39 ± 6 vs. 54 ± 11 mm Hg p = 0.01). Both interventions resulted in similar degrees of lactic acidemia which resolved during observation. Similar cardiac and renal effects were observed between AAJT and REBOA. CONCLUSION: The AAJT and REBOA produced similar hemostatic, resuscitative, and metabolic effects in this model of severe shock with junctional hemorrhage. Both interventions may have utility in future military medical operations.

A Prospective, Single-Blind, Randomized, Phase III Study to Evaluate the Safety and Efficacy of Fibrin Sealant Grifols as an Adjunct to Hemostasis During Soft Tissue Open Surgery.

BACKGROUND/PURPOSE: Rapid hemostasis, an essential prerequisite of good surgical practice during surgical bleeding, including soft tissue open surgery, often requires adjunctive treatment. We evaluated the safety and hemostatic effectiveness of a human plasma-derived fibrin sealant (FS Grifols) in soft tissue open surgery. METHODS: Patients with moderate soft tissue bleeding during open, urologic, gynecologic or general surgery were studied. The trial consisted of a preliminary phase (to familiarize investigators with the technique for FS Grifols application and the intraoperative procedures required by the clinical protocol) and a primary phase: in both phases, patients were randomized 1:1 to FS Grifols or Surgicel®. The primary efficacy endpoint, based on analysis of subjects in the primary phase of the study, was to evaluate whether FS Grifols was non-inferior to Surgicel® in achieving hemostasis, based on the proportion of subjects in both treatment groups who achieved hemostasis at the target bleeding site (TBS) by 4 min (T4) following the start of treatment application. Safety assessments included adverse events (AEs), vital signs, physical assessments, common clinical laboratory tests, viral markers, and immunogenicity. RESULTS: A total of 224 subjects were randomized (primary phase): FS Grifols (N = 116), Surgicel® (N = 108). The 95% CI at T4 for the ratio of the proportion of patients achieving hemostasis in the two treatment groups was 1.064 (0.934, 1.213), indicating non-inferiority for FS Grifols vs. Surgicel®. The rate of hemostasis at the TBS by T4 in both phases of the study was higher in the FS Grifols treatment group (preliminary phase: 90.2%; primary phase: 82.8%) than in the Surgicel® treatment group (preliminary phase: 78.8%; primary phase: 77.8%). Overall, reported AEs were as expected in surgical patients and were similar between the two treatment groups. CONCLUSIONS: This study shows the non-inferiority in time to hemostasis of FS Grifols vs. Surgicel as an adjunct to hemostasis in patients undergoing soft tissue open surgery, and a similar rate of AEs.

Cecal Resection with Bipolar Sealing Devices in a Rat Model.

Background: Bipolar sealing devices are routinely used to seal blood vessels. The aim of the study is to evaluate the feasibility and safety of colonic sealing with the use of the bipolar energy devices in rats as model for experimental appendectomy. Methods: Seventy-five male Wistar rats underwent a cecal resection with four different bipolar sealing devices or a linear stapler. The harvesting procedure was performed immediately or at postoperative day (POD) 7. The sealing front bursting pressure (BP) was measured in both groups. At POD7, the resection line was clinically examined and the hydroxyproline (HDP) levels were determined. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the sealing front as well. Results: There was no mortality and no insufficiency. The BPs between the bipolar sealing devices showed no statistical differences. The early phase of the seal (POD 0) provides a low BP with an 30.8% increase until POD 7. The BPs in the stapler group showed significant better values. The hydroxyproline levels did not differ statistically between the groups. Histopathologically, there were more signs of ischemic necrosis in the stapler group than in the sealing devices groups. Conclusion: The resection and sealing of the cecum as an experimental appendectomy model with the use of bipolar energy devices proved feasible and safe in rats. The different energy devices in this study produce comparable results. To justify clinical practice in humans, several studies on the underlying mechanisms of early stage wound healing are needed.

Spontaneous renal hemorrhage: critical analysis of different lines of management in non-traumatic patients: a single tertiary center experience.

PURPOSE: To assess clinical presentation and outcomes of different treatment strategies in cases of spontaneous renal hemorrhage (SRH). METHODS: A retrospective analysis of patients with SRH between 2000 and 2018 was performed. Patients' demographics, clinical presentation, laboratory and radiological investigations, and different lines of treatment were retrieved. The primary outcome was to assess the predictors of the success of conservative treatment. The secondary outcome was to assess the long-term renal function outcome comparing serum creatinine, e GFF, and CT-assessed renal volume at last follow-up with baseline values. RESULTS: The study included 42 (23 males and 19 women) patients with mean ± SD age was 48.1 ± 17.8 years. Conservative management was successful in 19 (46%) patients. Trans-arterial embolization (TAE) was performed in 13 patients (30%) to control active bleeding. Ten patients (25%) required surgical exploration and nephrectomy. Lower serum creatinine (P = 0.003), higher prothrombin concentration (P = 0.04), lower hematoma size (P = 0.02), and non-AML lesions (P = 0.03) were independent predictors of conservative management success. Unlike the TAE-treated group, serum creatinine increased significantly (P = 0.04) with a significant decrease in e-GFR (P = 0.02) and renal volume (P < 0.001) of affected kidneys at last follow-up after conservative treatment. CONCLUSION: Although SRH is a life-threatening condition, conservative treatment is successful in a certain subset of patients. However, it is associated with significant deterioration of the affected kidney function as well as renal volume.

Cytotoxicity and effect on wound re-epithelialization after topical administration of tranexamic acid.

Background: Topical administration of tranexamic acid (TXA) reduces bleeding from surgical wounds similarly to intravenous use, but with negligible risk of adverse systemic events. Topical use is expanding, but is off-label. Surgeons lack guidelines regarding safe topical dosages and modes of administration. The effects of topical TXA on skin cells and wound healing are unknown. This study investigated whether topical TXA might be cytotoxic or affect wound re-epithelialization. Methods: Human keratinocytes and fibroblast cell cultures and an ex vivo human skin wound model were subjected to both short (limited) and long (chronic) exposure to various clinically relevant concentrations of TXA to mimic different modalities of topical administration. Cytotoxicity and effects on wound re-epithelialization were evaluated. Results: In cell culture, toxicity from chronic exposure was associated with increasing concentration and exposure time. Limited exposure to TXA did not cause significant cytotoxicity even at high concentrations. Re-epithelialization was completely absent in wounds chronically exposed to TXA concentrations of 25 mg/ml or above, and 50-100 mg/ml induced epidermolysis of normal epithelium, possibly by a non-toxic mechanism. Wound re-epithelialization was slightly delayed, but not impaired, by limited exposure to 100 mg/ml or chronic exposure to 6·25 mg/ml. Conclusion: Although short exposure to even high concentrations of topical TXA seems well tolerated in vitro, prolonged exposure can be cytotoxic and may affect wound re-epithelialization. Surgeons should adjust the TXA concentration to the planned mode of topical administration in clinical practice.

Antecedentes: La administración tópica de ácido tranexámico (tranexamic acid, TXA) reduce la hemorragia de las heridas quirúrgicas de forma equivalente a su uso endovenoso, pero con un riesgo insignificante de eventos adversos sistémicos. El uso tópico se está expandiendo, pero se realiza fuera de indicación. Los cirujanos no disponen de directrices sobre las dosis para uso tópico seguras y las formas de administración. Se desconocen los efectos del TXA tópico sobre las células de la piel y sobre la curación de las heridas. Nos propusimos investigar si el TXA tópico puede ser citotóxico o afectar la reepitelización de la herida. Métodos: Los cultivos de queratinocitos humanos y fibroblastos y un modelo ex vivo humano de herida en la piel se sometieron a una exposición corta (limitada) y larga (crónica) de varias concentraciones clínicamente relevantes de TXA para simular diferentes modalidades de administración tópica. Se evaluaron la citotoxicidad y los efectos sobre la reepitelización de la herida. Resultados: En los cultivos celulares, la toxicidad de la exposición crónica se correlacionó con el incremento de la concentración y el tiempo de exposición. La exposición limitada al TXA no causó toxicidad significativa incluso a elevadas concentraciones. No se observó reepitelización en heridas expuestas de forma crónica a concentraciones de TXA de 25 mg/ml o superiores, y 50­100 mg/ml provocó epidermólisis del epitelio normal, posiblemente por un mecanismo no tóxico. La reepitelización de la herida se retrasó ligeramente, pero no se deterioró por una exposición limitada de 100 mg/ml o exposición crónica de 6,25 mg/ml. Conclusión: Mientras que la exposición corta, incluso hasta concentraciones elevadas, de TXA tópico parecen ser bien toleradas in vitro, la exposición prolongada al TXA tópico puede ser citotóxica y afectar la reepitelización de la herida. Los cirujanos deben ajustar la concentración de TXA al modo previsto de administración tópica en la práctica clínica.

Trans-tract electrocoagulation can decrease the need for postoperative nephrostomy tube after endoscopic combined intrarenal surgery.

AIM: To assess the efficacy and safety of trans-tract electrocoagulation at the end of endoscopic combined intrarenal surgery for renal or ureteral stones. METHODS: The present study included patients who underwent endoscopic combined intrarenal surgery from May 2010 to March 2018. After June 2013, the trans-tract electrocoagulation procedure, to coagulate bleeding from the access tract using a resectscope was carried out at the end of the operation. We compared the patients' background and surgical outcomes between patients with and without trans-tract electrocoagulation. RESULTS: Between the trans-tract electrocoagulation (n = 225) and non-trans-tract electrocoagulation (n = 72) groups, the stone number was significantly smaller (1:2:3 or more, 126:72:27 vs 59:10:3, P = 0.001) and the initial stone-free rates were significantly higher (80% vs 72%, P = 0.006) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group. Patients experienced a higher nephrostomy tube-free rate (67% vs 26%, P < 0.0001), shorter postoperative catheterization time (2.8 ± 3.8 vs 5.4 ± 5.0 days, P = 0.002) and shorter hospital stay (6.5 ± 3.6 vs 8.8 ± 5.0 days, P = 0.0001) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group. CONCLUSIONS: Trans-tract electrocoagulation in endoscopic combined intrarenal surgery is a safe and efficient procedure that decreases the need for nephrostomy tube placement after surgery.

A comparison in an experimental rat model of the effects on adhesion formation of different hemostatic methods used in abdominopelvic surgery.

OBJECTIVES: To evaluate the effects of different hemostasis methods used in abdominal surgery on the development ofabdominal adhesion. MATERIAL AND METHODS: A total of 48 Wistar albino female rats were separated into six groups; Group 1 - Control group,Group 2 - Hemorrhage group, Group 3 - Electrocoautery group, Group 4 - Gel Spon-P®, Group 5 - PAHACEL®, andGroup 6 - Ankaferd-Blood Stopper®. Adhesions that developed were scored according to the Knightly classification andthe prevalence of adhesions according to the Linsky classification. The total adhesion score was calculated as the total ofthe severity and prevalence scores. RESULTS: The lowest total adhesion values were determined in Group 1 (control) and the highest adhesion values were inGroup 2 (hemorrhage) group in terms of all parameters. The adhesion values in Group 3, where the rats were administeredhemostasis with electrocautery were similar to those of Group 2 (hemorrhage). When the alternative methods were evaluated,the lowest adhesion scores were in Group 6 (Ankaferd-Blood Stopper®). CONCLUSIONS: In cases of minor pelvic or abdominal bleeding, not providing hemostasis or applying hemostasis withelectrocautery can increase the development of intra-abdominal adhesions. The use of alternative hemostatic materialsinstead of electrocautery for hemostasis may reduce the formation of adhesions.

Transition from abdominal aortic and junctional tourniquet to zone 3 resuscitative endovascular balloon occlusion of the aorta is feasible with hemodynamic support after porcine class IV hemorrhage.

BACKGROUND: Traumatic hemorrhage remains a major cause of death in rural civilian and combat environments. Potential interventions to control hemorrhage from the pelvis and lower junctional regions include the abdominal aortic and junctional tourniquet (AAJT) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT requires low technical skills and may thus be used by nonmedical professionals, but is associated with time-dependent ischemic complications. In combination with delayed patient evacuation, it may therefore be deleterious. Transition to zone 3 REBOA in higher levels of care may be a possibility to maintain hemostasis, mitigate adverse effects and enable surgery in patients resuscitated with the AAJT. It is possible that a transition between the interventions could lead to hemodynamic penalties. Therefore, we investigated the feasibility of replacing the AAJT with zone 3 REBOA in a porcine model of uncontrolled femoral hemorrhage. METHODS: Domestic pigs (n = 12) averaging 57 kg were exposed to a class IV uncontrolled hemorrhage from the common femoral artery. The animals were randomized to 60-minute AAJT (n = 6) or 30-minute AAJT with transition to 30-minute zone 3 REBOA. Hemodynamic and metabolic parameters and ultrasonographic measurements of the common femoral artery were collected. RESULTS: Transition from AAJT to zone 3 REBOA caused a significant decrease in mean arterial pressure (25 mm Hg). Hemostasis was maintained. The common femoral artery diameter decreased by 1.8 mm (38%) after hemorrhage and further 0.7 mm (23%) after aortic occlusion. CONCLUSION: Transition from AAJT to zone 3 REBOA after a class IV bleeding is feasible with hemodynamic support. Vascular access to the femoral artery for REBOA insertion poses a technical challenge after hemorrhage and AAJT application. LEVEL OF EVIDENCE: Laboratory animal study, level IV.

Impact of Intermittent Pringle Maneuver on Long-Term Survival After Hepatectomy for Hepatocellular Carcinoma: Result from Two Combined Randomized Controlled Trials.

BACKGROUND: Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes. METHODS: Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated. RESULTS: There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16-30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival. CONCLUSION: IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16-30 min. TRIAL REGISTRATION: NCT00730743 and NCT01759901 ( http://www.clinicaltrials.gov ).

Coagulation and anticoagulation in the intraoperative setting.

Adequate function of the coagulation system is vital for an uncomplicated outcome of surgery. Clinically relevant perioperative bleeding complications may occur when surgical hemostasis is inadequate, but can also be caused by insufficient activity of the hemostatic system. Optimal surgical hemostasis and a satisfactory function of the coagulation system are complementary. In this article current insights on normal function and dysfunction of the coagulation system are reviewed as well as drugs that may affect a proper hemostatic response. We discuss coagulation disorders resulting in increased perioperative blood loss and conditions that may enhance the threat of postoperative thrombosis.