Haemorrhage from a radiosurgically treated arteriovenous malformation after its angiographically proven obliteration: a case report

Small lower-grade Spetzler-Martin arteriovenous malformations (AVMs) are mainly treated by microsurgical resection or stereotactic radiosurgery. The choice of treatment largely depends on the referring centre's preference and the patient's decision. We present here a patient with an AVM repeatedly treated at our Leksell Gamma Knife unit with radiographically confirmed obliteration of the AVM which subsequently began bleeding. This case demonstrates the possibility of late complications in radiosurgically treated AVMs even after their demonstrable obliteration. Meticulous histological examination was performed, proving patency of the AVM nidus. The risk of haemorrhagic complications of radiosurgically removed AVMs despite angiographic proof of their obliteration is, in our view, a cogent argument for preferring surgical resection if the AVM is accessible and for prolonged follow-up after radiosurgical treatment of an AVM.

[Endoscopy in diagnosis and treatment of complicated esophageal anastomoses]

The authors describe an experience with treatment of 115 patients with complicated course after esophagogastroanastomoses and esophagojejunoanastomoses using endoscopic techniques. The diagnostic manipulations and algorithm of treatment of patients with early and late complications in the area of nutritional anastomoses were developed. Thanks to high tech minimally invasive interventions (bougienage, balloon dilatation, stenting, endoscopic hemostasis, dissection of scar strictures) traumatic reoperations could be avoided.

Bleeding After Right Laparoscopic Adrenalectomy

This report describes a case of significant postoperative hemorrhage following clipless laparoscopic adrenalectomy.

The current standard of care for treating benign adrenal disease is laparoscopic adrenalectomy. Surgical tools, such as ultrasonic shears and vessel sealing systems, have increased in popularity and improved surgical outcomes. However, the safety profile of clipless and sutureless adrenalectomy has not been completely established. We report on a complicated 74-year-old male who underwent significant postoperative hemorrhage following laparoscopic adrenalectomy. Interventional radiology with renal artery stent insertion was successful for the management of postoperative bleeding in this high-risk patient.

Noninvasive monitoring of tissue hemoglobin using UV-VIS diffuse reflectance spectroscopy: a pilot study

We conducted a pilot study on 10 patients undergoing general surgery to test the feasibility of diffuse reflectance spectroscopy in the visible wavelength range as a noninvasive monitoring tool for blood loss during surgery. Ratios of raw diffuse reflectance at wavelength pairs were tested as a first-pass for estimating hemoglobin concentration. Ratios can be calculated easily and rapidly with limited post-processing, and so this can be considered a near real-time monitoring device. We found the best hemoglobin correlations were when ratios at isosbestic points of oxy- and deoxyhemoglobin were used, specifically 529/500 nm. Baseline subtraction improved correlations, specifically at 520/509 nm. These results demonstrate proof-of-concept for the ability of this noninvasive device to monitor hemoglobin concentration changes due to surgical blood loss. The 529/500 nm ratio also appears to account for variations in probe pressure, as determined from measurements on two volunteers.

Retrospective, matched case-control study comparing the oncologic outcomes between laparoscopic surgery and open surgery in patients with right-sided colon cancer

PURPOSE

The short- and long-term outcomes of laparoscopic surgery for right-sided colon cancer remain largely uninvestigated. This study was undertaken to compare the morbidity and mortality after either a laparoscopic right hemicolectomy (LRHC) or an open right hemicolectomy (ORHC) for this type of tumor.

METHODS

The study group included 100 patients who underwent an LRHC and 100 patients who underwent an ORHC for right-sided colon cancer from 1990 through 2004. The two groups were retrospectively well matched with respect to sex, age (+/-5 years), and pathological tumor-node-metastasis (TNM) stage.

RESULTS

The median follow-up period was 83 months in the LRHC group and 105 months in the ORHC group. The LRHC group had a lower volume of intraoperative bleeding (P < 0.001), a lower rate of wound infection (P = 0.019) or postoperative intestinal obstruction (P = 0.013), and a shorter hospital stay (P < 0.001) than the ORHC group. The rate of recurrence did not differ significantly between the LRHC group (19%) and the ORHC group (22%). In patients with TNM stage I or II, the disease-free survival (DFS) rate (94.9% vs 95.1%) and overall survival (OS) rate (95.8% vs 95.0%) did not differ significantly between the two groups. A similar tendency was observed in patients with stage III with the rates for DFS (71.3% vs 60.4%) and OS (73.6% vs 64.1%), respectively.

CONCLUSIONS

An LRHC for right-sided colon cancer has the advantage over an ORHC of better short-term outcomes, and both groups have similar long-term oncologic outcomes. An LRHC is thus an acceptable alternative to an ORHC for the treatment of this type cancer.

Ileal conduit stomal hemorrhage as the first presentation of end stage liver disease: case report and review of the literature

Hemorrhage from an ileal conduit is a rare and potentially life threatening event with only 17 cases reported in the medical literature. We present the unique case of an 83-year-old patient with acute stomal hemorrhage as the first sign of underlying liver disease and portal hypertension. Bleeding was controlled with conservative measures including balloon tamponade, betablockade, octreotide, and suture ligation. Our review of the literature revealed multiple management options for stomal hemorrhage with most authors advocating definitive management via portosystemic shunt creation, either surgically, or with transjugular intrahepatic portosystemic shunt (TIPS). In all cases the incidence of rebleeding associated with the procedure, and the ability of the patient to undergo invasive procedures, must be considered carefully.

A study on complication and monitoring of warfarin in post-valve surgery

INTRODUCTION

This study was carried out to determine the incidence of complication related to warfarin in patients with valve surgery and identify potential risk factors for complication and study its monitoring aspects.

METHODS

A combined retrospective and prospective observational study including a total of 185 patients who underwent mechanical valve replacement in Shahid Gangalal National Heart Centre. The study was conducted from 4 November 2006 till 1 February 2007.

RESULTS

There were a total of 141 episodes of bleeding. Among them significant bleeding occurred in 15.7% patients, major bleeding was 3.2 per 100 patient-years (3.8%) and minor bleeding was 11.8 per 100 patient-years (11.9%). Epistaxis (16.8%) was the most common bleeding complication. Menorrhagia was the most common bleeding complication in females with 20.5 per 100 patient-years (27.4%). Thromboembolic complications occurred at the rate of 2.3 per 100 patient-years. Patients on warfarin were outside the INR target range 67.8% of the time, with 21% INR values above range and 46.8% INR values below range. However, dose adjustment was done only 31.8% of times when INR was outside range.

CONCLUSIONS

There is high incidence of bleeding complication in patients on warfarin and hypertension is significantly associated with bleeding. Difficulty in tightly controlling INR probably is related to high incidence of bleeding. Better patient education, stricter adjustment of INR, frequent monitoring of INR at peripheral hospitals and standardization of the test at different hospitals are suggested to reduce the warfarin related complications.

[Heparin-induced thrombocytopenia and liver hemorrhage following polytrauma]

Up to 3% of patients receiving unfractioned heparin develop heparin-induced thrombocytopenia (HIT). We report on a polytrauma patient who developed severe HIT with bilateral pulmonary embolism. Lepirudin treatment resulted initially in rapid improvement. Ten days after discharge the patient complained of abdominal pain. A large subcapsular hepatic hematoma was diagnosed, requiring repeat surgery and ending in secondary sclerosing cholangitis. This process can potentially be avoided by regular tests of lepirudin concentration and coagulation.

[An attempt to evaluate the reliability of coagulation tests in postoperative haemorrhages in patients operated for tonsil disorders]

Postoperative haemorrhage is an important complication of surgical procedures performed on adenoids and tonsils. They occur rarely but they seriously endanger the patients. Determining risk factors of the postoperative haemorrhages might be very important. The aim of the study was to analyze values of coagulation tests' results obtained in the patients prior to the operations, to determine correlation between the values of the results and incidents of postoperative haemorrhages, and to answer the question whether performing the coagulation tests in these patients is cost-effective. Records of 249 patients aged from 2 to 60 (mean 10.1) years treated in our department between January 2007 and May 2008 were analysed retrospectively. Values of activated partial thromboplastin time (APTT), prothrombin/INR ratio and platelet count were analyzed. In 50 (20.1%) individuals coagulation tests' values were elevated, among them APTT results in 48 (19.3%) patients. In 36 (14.5%) of them the results exceeded the normal range by less than 10% and in the remaining 14 (5.6%)--by 10% or more. There were 16 (6,4%) cases of postoperative haemorrhage. 11 (4.4%) of them occurred in the first 24 postoperative hours. In only 3 (1.2%) individuals (with early haemorrhages) the values were elevated, in 2 (0,8%) less than by 10%, in one (0.4%) more than by 10%. No statistically significant correlation between frequency of haemorrhages and the obtained coagulation tests results in the groups of patients was established. Blood tests' performed prior to the operations on adenoids and tonsils have no relevance for the course of the operation and postoperative bleeding event, particularly in children. Blood tests should only be performed in patients with a relevant bleeding history.

[Clinical analysis of post pancreatoduodenectomy hemorrhage]

OBJECTIVE

To explore the factors of post pancreatoduodenectomy hemorrhage.

METHODS

The clinical data of 263 cases between January 1998 and April 2008 underwent pancreatoduodenectomy were analyzed prospectively.

RESULTS

The overall mortality rate was 4.94% (13/263). Postoperative bleeding occurred in 23 patients (8.75%), with 8 episodes ending fatally (34.8%). The tumor size, Child classification, caput total resection and pancreatic leakage were identified as significant risk factors for post pancreatoduodenectomy hemorrhage by means of univariate analysis. The multivariate Logistic regression analysis revealed that all of the five factors turned out to be the independent risk factors.

CONCLUSIONS

The prevention of these bleeding complications depends in the first place on meticulous hemostatic technique. The pancreatic leakage is also one of the most important factors due to postoperative bleeding. The prophylactic use of somatostatin is not necessary.

Use of oxidized regenerated cellulose to stop bleeding after a facelift procedure

A 52-year-old woman came to our department about correcting a severe soft-tissue laxity after a weight loss of 67 kg. We performed a deep-plane face lift under sedation with local anesthesia. Three hours after the operation the patient had significant and diffuse bleeding, which was controlled by a local hemostatic agent made of oxidized regenerated cellulose (Tabotamp). In the weeks after the operation no local pain or skin damage was observed. We believe that oxidized regenerated cellulose could be a good ancillary therapy for controlling local bleeding associated with this kind of surgery.

Hemorrhagic complications from glaucoma surgery in patients on anticoagulation therapy or antiplatelet therapy

PURPOSE

To determine the incidence of and risk factors for hemorrhagic complications in patients on anticoagulation (ACT) or antiplatelet therapy (APT) having glaucoma surgery.

DESIGN

Retrospective case-control study.

METHODS

Medical records of patients who had glaucoma surgery between July 1, 1998 and March 31, 2005 were reviewed. Patients who either used ACT/APT continuously throughout the perioperative period or discontinued its use prior to surgery were compared to case-matched control patients who were not on such therapies. Patients on ACT/APT who experienced postoperative hemorrhagic complications were compared to those who did not. Outcome measures included hemorrhagic complications and thromboembolic events.

RESULTS

Three hundred and forty-seven patients (eyes) who were on ACT or APT prior to glaucoma surgery had a higher rate of hemorrhagic complications than 347 control patients (10.1% vs 3.7%, respectively, P = .002). Patients on ACT had a higher rate of hemorrhagic complications than patients on APT (22.9% vs 8.0%, respectively, P = .003). Patients who continued ACT during glaucoma surgery had the highest rate of hemorrhagic complications (31.8%) when compared to patients who discontinued ACT prior to surgery or patients who used APT alone (P = .001). Hemorrhagic complications following glaucoma surgery were more frequently associated with preoperative ACT, arrhythmia, and higher preoperative and postoperative intraocular pressures (IOP).

CONCLUSION

Chronic ACT/APT was associated with a statistically significant increase in the rate of hemorrhagic complications, and perioperative ACT and a high preoperative IOP are potential risk factors for hemorrhagic complications in patients undergoing glaucoma surgery.

Could Parkinsonism complicate craniotomy and excision of convexity meningioma? A case report

Parkinsonism is a neurodegenerative clinical disorder characterized by varying combinations and degrees of rest tremor, rigidity, slowing of voluntary movements and postural instability. Amongst the aetiologic factors, massive post-craniotormy haematoma has not been previously considered. This report is to arouse the suspicion that vascular displacement in the midbrain resulting from a massive unilateral intracranial haematoma could lead to the unusual complication of Parkinsonism. This is the report of a 55-year old retired male banker, without any previously identifiable risk factor except for his age, who developed Parkinsonism following a huge acute extradural haematoma that complicated a craniotomy for the excision of a haemorrhagic convexity meningioma. The patient was placed on medical treatment resulting in a slow but progressive neurological improvement. Reports of Parkinsonism following post-tumour excision are probably, very rare. We, hereby, report a case of Parkinsonism complicating a gross total excision of a convexity meningioma.

Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign

INTRODUCTION

Delayed massive hemorrhage induced by pancreatic fistula after pancreaticoduodenectomy is a rare but life-threatening complication. The purpose of this study was to analyze the clinical course of patients with late hemorrhage, with or without sentinel bleeding, to better define treatment options in the future.

MATERIAL AND METHODS

From April 1998 to December 2006, 189 pancreaticoduodenectomies were performed. Eleven patients, including two patients referred from other hospitals, were treated with delayed massive hemorrhage occurring 5 days or more after pancreaticoduodenectomy. Sentinel bleeding was defined as minor blood loss via surgical drains or the gastrointestinal tract with an asymptomatic interval until development of hemorrhagic shock. The clinical data of patients with bleeding episodes were analyzed retrospectively.

RESULTS

Eight of the 11 patients had sentinel bleeding, and seven of them had it at least 6 h before acute deterioration. Seven out of 11 patients died, five out of eight with sentinel bleeding. No differences could be detected between patients with or without sentinel bleeding before delayed massive hemorrhage. The only difference found was that non-surviving patients were significantly older than surviving patients. Delayed massive hemorrhage is a common cause of death after pancreaticoduodenostomy complicated by pancreatic fistula formation. The observation of sentinel bleeding should lead to emergency angiography and dependent from the result to emergency relaparotomy to increase the likelihood of survival.

[Endoscopic diagnostics and management of postoperative gastrointestinal bleedings]

The features of clinical course, the frequency and the pattern of gastrointestinal bleedings after diverse abdominal operations were studied over a period of time from 1993 to 2006. Postoperative gastrointestinal bleedings were observed at 503 patients. The frequency of postoperative gastrointestinal bleedings amounted 0.5% after operations on account of purulent diseases with different localization, 0.6% after abdominal and cardiovascular operations, 0.8% after lung operations, 1.5% after operations on the account of burn disease, 6.1% after hepatopancreatobiliary operations. In accordance with the stages of postoperative period, distinctions in endoscopic picture and the tactics of treatment early and late bleedings were distinguished during the investigation. It has been established, that blood supply disturbance in portal vein, manifested by transient portal hypertension is, one of the most important pathogenetic factors of development of bleeding after hepatopancreatobiliary operations along with acute erosive (ulcerous) affection, caused by stress or trauma, and multiple organ failure. The features of clinical course of postoperative bleedings were studied in different groups of surgical patients. The comparative evaluation of efficacy of endoscopic methods of hemostasis (injection,various endoclips, hydrothermocoagulation, argon-plasma coagulation) was carried out. It was shown that the application of new methods of endoscopic sanation and investigation of the upper gastrointestinal tract had resulted in increase of frequency of exposure of gastrointestinal bleeding source from 69.8% to 88.4% at primary urgent esophagogastroscopy. The efficacy of hemostasis at postoperative gastrointestinal bleeding raised from 70.3% to 92.4%.

Preoperative Fibrinogen Levels as a Predictor of Postoperative Bleeding after Open Heart Surgery

BACKGROUND

Open heart surgery still involving major bleeding continues to be a major challenge after cardiac surgery and is also a significant cause of morbidity and mortality. Most hemostatic factors are intercorrelated with postoperative bleeding, and fibrinogen seems the most fundamental hemostatic risk factor for open heart surgery.

METHODS

The study included 97 patients who underwent elective coronary artery surgery (78 men and 19 women; mean age, 60.9 +/- 10.3). Preoperative blood samples were obtained and preoprative quantitative determination of plasma fibrinogen levels were measured by the clotting method of Clauss using the fibrinogen kit. Patients were operated on by the same team and the same technique. The total amount of drainage blood from chest tubes was recorded after termination of operation.

RESULTS

There were statistical significance between the fibrinogen levels and the drainage (r = -0.897, P < .001). Chest drainage was a mean of 972 mL (range, 240-2445 mL) in the first 48 hours after sternotomy closure. Fibrinogen level and relation to age was statistically significant (P = .015). There was no statistical significance between fibrinogen levels and gender (male gender = 400.7 +/- 123.0 versus female gender = 395.6 +/- 148.1; P = .877) and between drainage and gender (male gender = 968.2 +/- 538.5 versus female gender = 990.0 +/- 554.7; P = .876). Two patients (2%) died early after the surgery. There were no significant differences between the postoperative bleeding and cardiopulmonary bypass time (P = .648) or cross-clamp time (P = .974).

CONCLUSION

The results of this study suggested that low preoperative fibrinogen level appears to be a useful diagnostic marker to assess the activity of the coagulation system, and that its preoperative level may serve as a potential risk factor for postoperative bleeding after coronary artery bypass surgery.

Idiopathic thrombocytopenic purpura presenting as post-extraction hemorrhage

AIM

The aim of this article is to present a case of idiopathic thrombocytopenic purpura (ITP) in order to emphasize the importance of the clinical exam since the anamnesis leads to a diagnostic hypothesis of ITP.

BACKGROUND

Acute ITP is considered an autoimmune disease characterized by the production of antibodies against platelets, antigens produced by a viral infection, or a platelet sparing drug combination. These antibodies adhere to platelets and are recognized and destroyed by the reticulo-endothelial system. Consequently, the platelet count gradually diminishes and is insufficient for the maintenance of primary hemostasis.

REPORT

A 77-year-old woman presented with post-extraction intermittent bleeding. The physical examination revealed discoloration of the skin, multiple petechiae, hematomas, ecchymosis of the upper lip, bruises all over the body, gingiva that bled spontaneously, and a malformed blood clot at the extraction site of tooth #44. The hematological exams confirmed the hypothesis of ITP. The patient was immediately hospitalized in the Hematology Department of a local hospital and received platelet replacement, hydration, medication, and general care. After the spontaneous bleeding stopped, the malformed clot was removed using alveolar curettage along with a thorough cleaning of the extraction site with a 0.9% saline solution before suturing the wound and prescribing medication. After the sixth day of hospitalization, the patient presented with the following results: Hb: 12.3 mg/dL, Ht: 36.1%, and PC: 87,000 mm3. The patient was then discharged and was placed under outpatient follow-up care.

SUMMARY

The importance of the clinical exam must be emphasized since the anamnesis leads to a diagnostic hypothesis of ITP and provides the dental surgeon with an opportunity to make important systemic alterations to improve the prognosis of a patient with ITP.

Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections

BACKGROUND

To analyze clinical courses and outcome of postpancreatectomy hemorrhage (PPH) after major pancreatic surgery.

SUMMARY BACKGROUND DATA

Although PPH is the most life-threatening complication following pancreatic surgery, standardized rules for its management do not exist.

METHODS

Between 1992 and 2006, 1524 patients operated on for pancreatic diseases were included in a prospective database. A risk stratification of PPH according to the following parameters was performed: severity of PPH classified as mild (drop of hemoglobin concentration <3 g/dL) or severe (>3 g/dL), time of PPH occurrence (early, first to fifth postoperative day; late, after sixth day), coincident pancreatic fistula, intraluminal or extraluminal bleeding manifestation, and presence of "complex" vascular pathologies (erosions, pseudoaneurysms). Success rates of interventional endoscopy and angiography in preventing relaparotomy were analyzed as well as PPH-related overall outcome.

RESULTS

Prevalence of PPH was 5.7% (n = 87) distributed almost equally among patients suffering from malignancies, borderline tumors, and focal pancreatitis (n = 47) and from chronic pancreatitis (n = 40). PPH-related overall mortality of 16% (n = 14) was closely associated with 1) the occurrence of pancreatic fistula (13 of 14); 2) vascular pathologies, ie, erosions and pseudoaneurysms (12 of 14); 3) delayed PPH occurrence (14 of 14); and 4) underlying disease with lethal PPH found only in patients with soft texture of the pancreatic remnant, while no patient with chronic pancreatitis died. Conversely, primary severity of PPH (mild vs. severe) and the kind of index operation (Whipple resection, pylorus-preserving partial pancreaticoduodenectomy, organ-preserving procedures) had no influence on outcome of PPH. Endoscopy was successful in 3 from 15 patients (20%), who had intraluminal PPH within the first or second postoperative day. "True," early extraluminal PPH had uniformly to be treated by relaparotomy. Seventeen patients had "false," early extraluminal PPH due to primarily intraluminal bleeding site from the pancreaticoenteric anastomosis with secondary disruption of the anastomosis. From 43 patients subjected to angiography, 25 underwent interventional coiling with a success rate of 80% (n = 20). Overall, relaparotomy was performed in 60 patients among whom 33 underwent surgery as first-line treatment, while 27 were relaparotomied as rescue treatment after failure of interventional endoscopy or radiology.

CONCLUSION

Prognosis of PPH depends mainly on the presence of preceding pancreatic fistula. Decision making as to the indication for nonsurgical interventions should consider time of onset, presence of pancreatic fistula, vascular pathologies, and the underlying disease.