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.

Diagnóstico diferencial del dolor torácico: un caso de síndrome aórtico agudo / Differential diagnosis of chest pain: a case of acute aortic syndrome

El dolor torácico es uno de los motivos de consulta más frecuentes en cualquier ámbito sanitario, no obstante sigue suponiendo un reto diagnóstico tanto en la consulta del médico de atención primaria como en el ámbito de los médicos que prestan atención en los servicios de urgencias. Describimos un caso de síndrome aórtico agudo que se presentó de forma insidiosa en forma de dolor torácico y síncope de repetición en el que el retraso en el diagnóstico y tratamiento pudo resultar fatal. Hacemos también un breve repaso en la definición, diagnóstico, tratamiento y pronóstico de esta entidad (AU)

Chest pain is one of the most frequent reasons for consulting in any healthcare setting, however its diagnosis remains a challenge for both Primary Care and Emergency Department physicians. We report a case of an Acute Aortic Syndrome which was diagnosed late after an insidious course of chest pain, repetitive syncope, and in which the delay in diagnosis and treatment could be fatal. We also describe the definition, diagnosis, treatment, and outcome of this condition (AU)

Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica / Simplified Renorrhaphy Using Self-retaining Barbed Suture During Laparoscopic Partial Nephrectomy

Introducción y objetivos: La nefrectomía parcial laparoscópica (NPL) es una intervención desafiante que requiere sutura intracorpórea rápida y efectiva, lo que limita su aplicación de forma extendida. Refinamientos de la cirugía han mejorado los tiempos de isquemia y facilitado la reconstrucción renal. Se presenta una técnica que simplifica al máximo la renorrafia empleando sutura barbada de auto-retención (SBAR) entrelazando dos hilos. Pacientes y métodos: A dos pacientes con carcinoma de riñón, de 3,4 y 1,5 cm respectivamente, se les realizó la NPL. La SBAR es un poligliconato absorbible con pequeños salientes a lo largo de su eje que se anclan en los tejidos, distribuyendo la tensión de la línea de sutura y eliminando la necesidad de nudos. La renorrafia se realizó con la SBAR mediante dos líneas de sutura continuas sin nudos, fijando los hilos con clips de Hem-o-lok® y ajustándolos con la técnica del «clip deslizante», sin colocación de bolsters dentro del defecto del parénquima renal. Resultados: El tiempo operatorio fue de 156 y 163 minutos, el sangrado intraoperatorio fue de 50 y 850 ml, el tiempo de isquemia caliente fue de 14,3 y 23 minutos y el tiempo de seguimiento fue de 7 y 3 meses, en el primer y segundo caso respectivamente. La estancia hospitalaria fue de 5 días y no hubo complicaciones postoperatorias. Conclusiones: La renorrafia simplificada empleando SBAR es efectiva, hemostática, facilita significativamente la reconstrucción renal y puede ayudar a disminuir los tiempos de isquemia (AU)

Introduction and objectives: Laparoscopic partial nephrectomy (LPN) is a challenging procedure that requires quick and effective intracorporeal suturing, that could limit wides preadadoption. Refinements of surgery have improved warm ischemia times and facilitated renal reconstruction. We present a technique that makes renorrhaphy easier using Self-Retaining Barbed Suture (SRBS) weaving two threads. Patients and methods: Two patients with carcinoma of the kidney, 3.4 and 1.5 cm respectively, were subjected to the LPN. The SRBS is an absorbable polygluconate with small projections along its axis which are anchored in the tissue, distributing the tension of the suture line and eliminating the need for knots. Renorrhaphy was performed using the SRBS by two continuous suture lines without knots, setting the sutures with clips of Hem-o-lok® and adjusting it with the technique of «sliding clip», without placing «bolsters» inside the renal parenchymal defect. Results: Operative time was 156 minutes and 163 minutes, intraoperative bleeding was 50 ml and 850 ml, the warm ischemia time was 14.3 minutes and 23 minutes and follow-up time was7 months and 3 months in the first and second cases respectively. The hospital stay was 5 days and there were no postoperative complications. Conclusions: Simplified renorrhaphy using SRBS is effective, hemostatic, facilitates the renal reconstruction, and can help reduce the warn ischemia time (AU)

El tratamiento preoperatorio con aspirina a dosis bajas no aumenta la hemorragia quirúrgica ni la tasa transfusional en la prótesis total de rodilla / Low-doses aspirin doesn’t increase surgical bleedind nor transfusion rate in total knee arthroplasty

Objetivos. Analizar la hemorragia quirúrgica, índice transfusional y complicaciones cardiovasculares en pacientes en tratamiento crónico con aspirina y sometidos a artroplastia total primaria unilateral de rodilla. Pacientes y métodos. Se estudió retrospectivamente a 117 pacientes programados entre 2005 y 2006 para cirugía electiva de artroplastia de rodilla y en tratamiento preoperatorio con aspirina (100mg/día). La medicación fue mantenida o interrumpida preoperatoriamente a criterio médico. Se analizaron las características biológicas, clínicas, anestésicas, técnicas de ahorro de sangre, hemorragia quirúrgica, transfusión alogénica, complicaciones cardiocirculatorias (isquemia miocárdica, cerebral o periférica), estancia y mortalidad hospitalarias. Se compararon con 190 pacientes (grupo control) intervenidos de la misma operación en el mismo intervalo de tiempo, pero sin tratamiento crónico con aspirina. Resultados. El grupo tratado con aspirina era significativamente de mayor edad, peso y con más enfermedades asociadas (mayor incidencia de cardiopatía isquémica, isquemia cerebral y diabetes). La hemorragia quirúrgica externa, oculta y total fue similar en ambos grupos, así como la transfusión alogénica. La hemorragia y tasa transfusional fueron independientes del tiempo de interrupción de la aspirina. La mortalidad hospitalaria fue nula en los 2 grupos. Dos pacientes en los que se interrumpió el tratamiento tuvieron un infarto agudo de miocardio y un accidente vascular cerebral transitorio, respectivamente. Conclusiones. El tratamiento preoperatorio con aspirina no incrementa la hemorragia quirúrgica ni el índice transfusional en la artroplastia total de rodilla. La interrupción preoperatoria puede ocasionar complicaciones cardiocirculatorias graves(AU)

Objectives. Surgical bleeding. transfusion rate and cardiovascular complications were analized in patients undergoing chronic treatment with low-doses aspirin and scheduled to unilateral primary knee arthroplasty. Patients and methods. We retrospectively studied 117 patients between 2005 and 2006 scheduled for elective knee replacement that received antiplatelet therapy with aspirin (100mg/day). Aspirin medication was maintained or discontinued preoperatively according to medical criteria. We analyzed the biological, clinical and anesthetic data, blood-saving techniques used, surgical bleeding, allogeneic blood transfusion rate, cardiocirculatory complications (myocardial, cerebral or peripheral ischemia), hospital stay and mortality. This population was compared with 190 patients (control group) who underwent the same operation at the same time interval but did not receive aspirin therapy. Results. The aspirin-treated group was significantly older, with higher weight and poorer health state (higher incidence of ischemic heart disease, cerebral ischemia and diabetes). The hidden and external surgical bleeding and transfusion rate were similar if the aspirin were interrupted or not, preoperatively. Bleeding and transfusion rates were independent of time of interruption of the aspirin. Hospital mortality was zero in the 2 groups. A acute myocardial infarction and a transient stroke happened in two patients wich aspirin treatment was discontinued. Conclusions. Preoperative treatment with low doses of aspirin does not increase surgical bleeding and transfusion rate in total knee arthroplasty. Preoperative discontinuation can cause severe cardiocirculatory complications(AU)

Indicaciones y usos del complejo protrombínico en cirugía cardiaca / Indications and use of prothrombin complex in cardiac surgery

En cirugía cardiaca una de las complicaciones más comunes y graves es el sangrado postoperatorio. Según la mayoría de los estudios, entre el 10 y el 92% de los pacientes sometidos a cirugía cardiaca programada requieren transfusiones de componentes sanguíneos y hemoderivados. Las transfusiones y reintervenciones se asocian a estancias más largas en las unidades de cuidados críticos y a una disminución de las tasas de supervivencia. En los últimos años, el tratamiento de las alteraciones de la hemostasia y la hemorragia posquirúrgica ha sufrido importantes cambios debido a la introducción en la práctica clínica de protocolos de actuación avalados por guías clínicas y por la existencia de nuevos fármacos. Nuestro objetivo en este trabajo es describir las principales características y actualizar el uso de los complejos protrombínicos que actualmente están disponibles en nuestro país, haciendo especial hincapié en su uso en cirugía cardiaca(AU)

On of the most common, and serious, complications in cardiac surgery is postoperative bleeding. According to the majority of studies, between 10% and 92% of patients subjected to elective surgery require transfusions of blood products and blood derivatives. Transfusions and reinterventions are associated with longer stays in critical care units and a decrease in survival rates. There have been some important changes in the treatment of changes in haemostasis and post-surgical bleeding in the last few years, particularly with the introduction into clinical practice of working procedures backed up by clinical guidelines, as well as the appearance of new drugs. The aim of this work is to describe the main characteristics and update the use of prothrombin complexes that are currently available in Spain, with special emphasis on their use in cardiac surgery(AU)

Sistemas de hemostasia en cirugía tiroidea y complicaciones / Hemostatic systems in thyroid surgery and complications

Introducción: Los avances tecnológicos en hemostasia permiten el sellado vascular con mayor precisión y seguridad que la tradicional ligadura asociada a la electrocoagulación mono o bipolar. Objetivo: Comparar las complicaciones en tiroidectomía total mediante técnicas tradicionales (ligadura, electrocoagulación, incluido Ligasure), frente al uso exclusivo de Harmonic Ultracision que realiza disección, corte y hemostasia simultáneamente. Métodos: Estudio retrospectivo, descriptivo, comparativo, no aleatorio en 887 pacientes sometidos a tiroidectomía total por el mismo cirujano. Se distribuyen en grupo A (técnicas tradicionales en 468 pacientes, enero de 1997 a septiembre de 2006) y grupo B (Harmonic Ultracision en 419 pacientes, octubre de 2006 a mayo de 2010).Resultados: En el grupo B se produjeron significativamente menos complicaciones (incidencia global de 0,95 frente al 4,06 en el grupo A): hemorragia (0,24 frente a 1,92% en grupo A), traqueotomía (0 frente a 1,28%) y estancia en UCI (0 frente a 4,06%). Hubo mejora de los parámetros de actividad: menor tiempo quirúrgico (60 frente a 180 minutos), menor estancia hospitalaria (4,62 frente a 8,5 estancias), incremento del número de intervenciones mensuales (9,63 frente a 4 intervenciones). Las secuelas persistentes en el grupo B (parálisis recurrencial-0,48%- e hipoparatiroidismo -0,47%-) disminuyeron pero sin diferencia estadísticamente significativa respecto al grupo A. El coste por paciente es inferior en el grupo B. Conclusiones: El sistema Harmonic Ultracision es la técnica de elección en cirugía tiroidea (AU)

Introduction: There have been significant technological advances for hemostasis in thyroid surgery, which allow more precise and safer vascular sealing than the traditional bond associated with mono- or bipolar electrocoagulation. Objective: To compare the complications in total thyroidectomy using traditional techniques (ligation and electrocoagulation, including Liga Sure) compared to the exclusive use of the Ultracision Harmonic scalpel, performing dissection, cutting and hemostasis simultaneously. Methods: Retrospective descriptive non-randomized comparative study with 887 patients who underwent total thyroidectomy by the same surgeon. They were distributed into Group A (traditional techniques in 468 patients, January 1997 to September 2006) and Group B (Harmonic Ultracision in 419 patients, October 2006 to May 2010).Results: There was a statistically-significant lower incidence of complications in Group B (0.95% versus 4.06% in group A): bleeding (0.24% versus 1.92% in group A), tracheostomy (0% versus 1.28%) and intensive care unit stay (0% versus 4.06%). Improvement of surgical activity parameters was also significant for Group B: shorter operation time (60 minutes versus 180 minutes), fewer hospital stays (4.62 versus 8.5 stays) and increase in operations per month (9.63 versus 4 interventions). Persistent sequelae (recurrent paralysis [0.48%] and hypoparathyroidism [0.47%]) decreased in the second group but the difference was not statistically significant compared to Group A. The cost per patient was lower in Group B Conclusions: The Ultracision Harmonic scalpel system is the technique of choice for thyroid surgery (AU)

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.