Management of hemophilia in colon and rectal surgery. Report of a patient with factor VIII inhibitors and review of the literature

Recurrent bleeding after rubber band ligation diagnosed as mild hemophilia B: a case report and literature review

Background

Hemophilia is a recessive hemorrhagic disease relevant to X chromosome. In mild hemophilia cases, spontaneous bleeding is rare and the blood clotting function is normal, but severe bleeding may occur after trauma or surgery. Therefore, missed diagnosis of hemophilia before operation may contribute to bleeding after hemorrhoid operation.

Case presentation

A 21-year-old male was hospitalized in the anorectal department because of repeated bleeding after hemorrhoid surgery. Despite several suture hemostasis procedures, the patient still suffered from recurrent bleeding. He had no family history of hemophilia or bleeding tendency, and had not been diagnosed with hemophilia before this admission. The diagnosis of mild hemophilia B was made after further examination of coagulation indexes. By using frozen plasma and coagulation factor complex to supplement coagulation factors, the patient’s bleeding was stopped and he was discharged after 23 days in hospital. During the follow-up, lower-than-normal coagulation factors were still found in him, but no bleeding occurred again.

Conclusions

The undiagnosed patient with mild hemophilia B has an increased risk of bleeding after hemorrhoid surgery because of the consumption of coagulation factors. This case report aims to address the importance of hemophilia screening before operation and reduce the risk of postoperative bleeding. For patients with recurrent bleeding after hemorrhoid surgery, hemophilia should be further excluded. Wound bleeding may recur in hemophilia patients after suture hemostasis. Therefore, prompt supplementation of coagulation factors is needed to help stop bleeding once the diagnosis of hemophilia is made.

Intestinal surgery with activated recombinant factor VII prophylaxis in patients with haemophilia A and high responding inhibitors

Five patients with severe haemophilia A and high responding inhibitors underwent laparoscopic or open surgery on the digestive tract (appendicectomy, cholecystectomy, partial colectomy, or haemorrhoidectomy) with recombinant activated factor VII (rFVIIa) prophylaxis. rFVIIa was administered at a dose of 92-127 mug/kg prior to surgery and then every 2 h for 18-56 h before increasing the dosing interval. One patient was switched to a continuous infusion after 48 h of rFVIIa boluses. rFVIIa treatment lasted between 5 and 14 days in four patients, with good or excellent efficacy (total dose, 3.13-9.28 mg/kg). The fifth patient, who underwent surgery for prolapsed haemorrhoids, bled on day 6 and day 10 after the procedure, despite a satisfactory prothrombin time and factor VII coagulant level. The rFVIIa dose regimen was increased after the second bleeding episode, then the bleeding rapidly ceased after this modification to the treatment regimen. The total dose of rFVIIa used was 12.65 mg/kg, and treatment lasted 17 days. Antifibrinolytic treatment was used concomitantly in all five patients. Clinical and biological tolerability was excellent, and no increase in the anti-factor VIII inhibitor titre was observed. These results suggest that rFVIIa prophylaxis is effective in haemophilia A patients with factor VIII inhibitors who are undergoing elective or emergency intestinal surgery. Further studies are required to optimize the dose regimen and treatment period according to the surgical indication and technique.

First-time development of FVIII inhibitor in haemophilia patients during the postoperative period

Development of inhibitor to FVIII in haemophilia patients is well-known and is not uncommon. However, their development for the first time during the postoperative period has hardly been reported. In a developing country such as India, where resources are limited, development of such an eventuality may prove disastrous. However, as many of our patients are sparingly treated, therefore, even if they test negative for the inhibitor preoperatively, they may get the requisite FVIII antigenic stimulation during the preoperative and immediate postoperative period, leading to the development of inhibitors during this critical time of wound healing. We describe here six patients who developed such an inhibitor, from a group of 35 patients with haemophilia A who underwent various surgical procedures (19%). We stress that such an eventuality may not remain rare in developing countries as more patients of severe haemophilia undergo surgery and are therefore challenged for the first time in their life with large amounts of FVIII concentrate during their preoperative period.