Frequency and Risk Factors of Severe Postoperative Bleeding After Proctological Surgery: A Retrospective Case-Control Study

Purpose

The aim of this study was to assess frequency and risk factors of severe bleeding after proctological surgery requiring hemostatic surgery observed after publication of the French guidelines for anticoagulant and platelet-inhibitor treatment.

Methods

All patients who underwent proctological surgery between January 2012 and March 2017 in a referral center were included. Delay, severity of bleeding, and need for blood transfusion were recorded. Patients with severe postoperative bleeding were matched to controls at a 2:1 ratio adjusted on the operator, and the type of surgery.

Results

Among the 8,890 operated patients, 65 (0.7%) needed a postoperative hemostatic procedure in an operating room. The risk of a hemostatic surgery was significantly increased after hemorrhoidal surgery compared with other procedures (1.9% vs. 0.5%, P<10-4) and was most frequent after Milligan-Morgan hemorrhoidectomy (2.5%). Mean bleeding time was 6.2 days and no bleeding occurred after day 15. Blood transfusion rate was 0.1%. Treatment with anticoagulants and platelet inhibitors were managed according to recommendations and did not increase the severity of bleeding. The risk of severe bleeding was significantly lower in active smokers vs. non-smokers in univariate (16.9% vs. 36.2%, P=0.007) and multivariate (odds ratio, 0.31; 95% confidence interval, 0.14-0.65) analysis whereas sex, age, and body mass were not significantly associated with bleeding.

Conclusion

Severe postoperative bleeding occurs in 0.7% of patients, but varies with type of procedure and is not affected by anticoagulant or antiplatelet treatment. These treatments given in accordance with the new guidelines do not increase the severity of postoperative bleeding.

Stapled haemorrhoidopexy: 6 years' experience of a referral centre

AIM

To prospectively evaluate the long-term results and assess patient satisfaction after stapled haemorrhoidopexy (HS).

METHOD

A total of 150 patients (121 male patients) with symptomatic grade II (n = 50) or III (n = 100) haemorrhoids underwent stapled HS. Patients were followed up during consultations at regular intervals, allowing prospective data collection. A final telephone follow up was also undertaken.

RESULTS

Follow up data were obtained for 130 of 150 patients (86.6%). After a median follow up of 39 months (range, 12-72), 90% of the patients were fully satisfied and 92% were free of haemorrhoidal symptoms. There were no intraoperative complications. Postoperative bleeding that required operation was observed in five patients (3.3%). Most late postoperative complications were benign and easily resolved: unexplained pain for over a month (n = 1), external haemorrhoidal thrombosis (n = 2), anal fissure (n = 6) one with hypertrophic papilla, anal fistula (n = 1), rectal stenosis (n = 1), anal incontinence for (n = 1). Eight patients needed rubber band ligation to treat persistent or recurrent symptomatic prolapse. Four patients (2.6%) were reoperated on during the follow up period but none for haemorrhoidal pathology.

CONCLUSION

Stapled HS procedure is effective and has low morbidity, high patient satisfaction and provided good long-term control of haemorrhoidal symptoms in the treatment of second and third-degree haemorrhoids.

Fibrin glue sealing in the treatment of a recto-urethral fistula in Crohn's disease: a case report

Recto-urethral fistulas in Crohn's disease are rare, and managing them is difficult. The various surgical techniques are not reliably effective and are associated with a significant risk of morbidity. The rectal mucosal transposition flap technique, which is used most frequently, requires the rectal mucosa to be in a healthy condition. We report here on a case where treatment was by injecting fibrin glue into a complex fistula with a single anorectal point of origin but combining a median recto-urethrocutaneous tract with two deep lateral rectoperineal tracts. The patient had presented with active rectal Crohn's disease. This treatment produced complete closure, verified by MRI, of all the fistula tracts, which was still maintained after three years, and with normal anal continence. When confronted with this type of fistula, and particularly when the condition of the rectal mucosa is poor, the specialist should be encouraged by this good result to consider the injection of fibrin glue, a technique without risk of morbidity, as a first course of action.

Triple therapy with ursodeoxycholic acid, budesonide and mycophenolate mofetil in patients with features of severe primary biliary cirrhosis not responding to ursodeoxycholic acid alone

BACKGROUND/AIMS

To assess the benefit of the UDCA-budesonide combination in association with mycophenolate mofetil (MMF) in patients with primary biliary cirrhosis (PBC) at high risk of developing cirrhosis or liver failure.

METHODS

Inclusion criteria for this three-year open study were: 1) suboptimal biochemical response to one-year UDCA therapy at 13-15 mg/kg/d; 2) significant interface hepatitis without cirrhosis at liver biopsy. Treatment regimen included UDCA (13-15 mg/kg/d), budesonide (6 mg/d) and MMF (1.5 g/d). All patients underwent a control biopsy at three years.

RESULTS

Fifteen patients fulfilled the inclusion criteria. Six patients (41%) normalized biochemistries and seven (47%) had a partial but significant biochemical response, as defined by a serum bilirubin less than 17 micromol/L, alanine aminotransferase less than 70 UI/L and alkaline phosphatase less than 250 UI/L. Histological activity and fibrosis were markedly improved. Side effects were minimal or absent.

CONCLUSIONS

Triple therapy with UDCA, budesonide and MMF may provide benefit in non-cirrhotic PBC patients with features of severe disease not responding to UDCA.

Biochemical response to ursodeoxycholic acid and long-term prognosis in primary biliary cirrhosis

Biochemical response to ursodeoxycholic acid (UDCA) in patients with primary biliary cirrhosis (PBC) is variable. It has been recently proposed that an alkaline phosphatase (ALP) decline of more than 40% in baseline value or a normal level after 1 year of UDCA treatment (Barcelona criteria) could serve as a good marker of long-term prognosis. Our aim was to define the best efficient set of biochemistries able to identify UDCA-treated patients at risk of death or liver transplantation (LT). The efficiency of several combinations of serum bilirubin, ALP, and aspartate aminotransferase (AST) threshold values to predict outcome was assessed after 1 year of treatment in 292 patients with PBC. Patients showing ALP <3 upper limit of normal (ULN), AST <2 ULN, and bilirubin </=1 mg/dL after 1 year of UDCA had a 10-year transplant-free survival rate of 90% (95% confidence interval, 81%-95%), compared to 51% (95% confidence interval, 38%-64%) for those who did not (P < 0.001). Patients were less well discriminated by the Barcelona criteria (79% versus 63%). Independent predictive factors of death or LT were baseline serum bilirubin level >1 mg/dL (relative risk [RR], 1.7), histologic stage >/=3 (RR, 1.5), interface hepatitis (RR, 1.9), and the absence of biochemical response (ALP >3 ULN or AST >2 ULN, or bilirubin >1 mg/dL) (RR, 2.3). Antinuclear antibodies against gp210 or Sp100 proteins were associated with death or LT in univariate but not in multivariate analysis.

CONCLUSION

This study defines the best efficient biochemical response to UDCA, which, independent of baseline predictive factors, identifies patients with PBC with a good long-term prognosis. Patients who fail to achieve this response and those with interface hepatitis or advanced histological stage should be targeted for further therapeutic research.