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Hemostatic procedures for controlling nasal bleeding in refractory diseases such as hereditary hemorrhagic telangiectasia (HHT) can be challenging. In this report, we present a novel technique for underwater endoscopic endonasal hemostatic surgery, which was performed on a 69-year-old man with HHT. The patient had been experiencing frequent episodes of nasal bleeding and had many telangiectasias in the nasal cavity, which were the cause of the bleeding. These telangiectasias were effectively treated using a coblation device in combination with an endoscope lens-cleaning system that supplied saline to create stable underwater conditions. There are several advantages to this technique, including provision of a stable and clear endoscopic field of view, allowing for better visualization of the surgical site. This makes it easier to identify bleeding points and ensure accurate hemostasis. Additionally, the hydrostatic pressure created by the underwater environment helps to reduce bleeding during the procedure. However, it is important to take careful precautions to prevent water from entering the lower airway. With this precautionary measure, this technique is particularly useful in managing bleeding in patients with HHT. [ABSTRACT FROM AUTHOR]

To analyze the impact of perioperative antithrombotic use on the bleeding outcomes following Aquablation. One hundred sixteen men with who underwent Aquablation as part of the WATER prospective trial (NCT02505919) were assigned to 2 groups based on perioperative antithrombotic status. Antithrombotic cessation and restart timing were based on the surgeon's discretion. Methods of achieving intraoperative hemostasis consisted of no-cautery balloon tamponade or cautery. Primary endpoints included immediate postoperative hematuria rates and changes in hemoglobin. Secondary endpoints included 90-day bleeding complications and nonbleeding postoperative adverse events. Forty-one men took antithrombotic medications in the perioperative period while 75 men had no antithrombotic medication. Preoperative hemoglobin levels were comparable between both groups. Postoperative hemoglobin change from baseline (drop of 1.8 ± 1.5 g/dL among the antithrombotic group vs 1.8 ± 1.7 g/dL among the antithrombotic-naïve group) did not differ between both groups (P =.896). In total, 4 (9.8%) men in the antithrombotic group and 4 (5.3%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 1 complication (P =.451) in the 3-month postoperative period. Eight (19.5%) patients in the antithrombotic group and 11 (14.7%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 2 complication (P =.601), none of which is associated with bleeding in both groups. No men in either group demonstrated de novo erectile dysfunction. One patient (2.4%) in the antithrombotic group and none in the antithrombotic-naïve group required blood products (P =.353). Aquablation demonstrates comparable postoperative bleeding outcomes and other adverse effects for men with benign prostatic hypertrophy who are on antithrombotic therapy. [ABSTRACT FROM AUTHOR]

Prevention of rebleeding events is crucial for patients with hemorrhagic moyamoya disease (MMD), as these increase the risk of mortality. Bypass surgery is effective in preventing subsequent hemorrhage, particularly in patients with posterior hemorrhage, but its efficacy in those with anterior hemorrhage remains unclear. We analyzed the effects of surgical intervention, stroke risk factors, and radiological features on rebleeding events. Patients with hemorrhagic-onset MMD who were followed at our institution between 2000 and 2022 were included (41 adult patients, 45 hemispheres). Baseline characteristics and radiological features (anterior or posterior hemorrhagic site, Suzuki grade, posterior cerebral artery involvement, and periventricular anastomosis) were thoroughly reviewed. Of the 45 hemispheres, hemorrhage developed in 9 (20%) hemispheres, with a median duration until rebleeding of 38 (range: 1–44) months. Rebleeding rates were significantly lower in the surgical group than in the nonsurgical group (odds ratio: 0.09; 95% confidence interval [CI]: 0.01–0.79; P = 0.011), and Kaplan–Meier analysis revealed a significantly longer interval between bleeding events in the surgical group (1.3%/y vs. 5.3%/y; P = 0.002), especially in the anterior hemorrhage group (1.3%/y vs. 5.1%/y; P = 0.019). The hazard ratio of surgical intervention for rebleeding with initial anterior hemorrhage was 0.11 (95% CI: 0.01–0.98; P = 0.048). In the nonsurgical group, the presence of hypertension shortened the time to subsequent hemorrhage (P = 0.004). Surgical intervention may decrease the risk of rebleeding in hemorrhagic onset MMD patients, even in those presenting with anterior hemorrhage. Hypertension was a significant risk factor for rebleeding in nonsurgical patients. [ABSTRACT FROM AUTHOR]

Brain tumor biopsies are essential for pathologic diagnosis. However, hemorrhagic complications after biopsies may occur, leading to suboptimal outcomes. This study aimed to evaluate the associated factors of hemorrhagic complications after brain tumor biopsies and propose countermeasures. We retrospectively collected data on 208 consecutive patients with brain tumors (malignant lymphoma or glioma) who underwent a biopsy from 2011–2020. We evaluated factors and microbleeds (MBs) in the tumor plus relative cerebral/tumoral blood flow (rCBF) at the biopsy site on preoperative magnetic resonance imaging (MRI). Postoperative all and symptomatic hemorrhage occurred in 21.6% and 9.6% of patients. In univariate analysis, a needle biopsy was significantly associated with the risk of all and symptomatic hemorrhages compared to techniques that allow adequate hemostatic manipulation (i.e., open and endoscopic biopsies). Multivariate analyses revealed that a needle biopsy and gliomas of World Health Organization (WHO) grade III/IV were significantly associated with postoperative all and symptomatic hemorrhages. Multiple lesions were also an independent risk factor for symptomatic hemorrhages. On preoperative MRI, abundant MBs in the tumor and MBs at the biopsy sites, in addition to high rCBF, were significantly associated with postoperative all and symptomatic hemorrhages. We recommend the following measures to prevent hemorrhagic complications: consider biopsy techniques that allow adequate hemostatic manipulation preferentially; perform more careful hemostasis in cases of suspected gliomas of WHO grade III/IV, multiple lesions, and abundant MBs in the tumors; and, if there are multiple candidate biopsy sites, select areas with lower rCBF and no MBs as a biopsy target. [ABSTRACT FROM AUTHOR]

Meningiomas are rarely revealed by an intracranial hemorrhage (ICH). Rebleeding occurrence rate and time of onset are unknown. Here, we performed a systematic review of the literature of meningiomas revealed by ICH. We retrospectively collected all meningiomas revealed by spontaneous ICH published between January 1980 and December 2021. We reported clinicopathological features of meningiomas revealed by ICH. We also estimated rebleeding rate and time to onset. Ninety-two studies met all inclusion criteria, led to a total of 120 cases. The mean age was 56.3 years, with 66 (55%) female. Seventy-nine (66%) cases were conscious before surgery, 20 (17%) were in coma, and 17 (14%) were unconscious after deterioration. The most frequent bleeding type was subdural hemorrhage (N = 49, 41%) followed by intraparenchymal hemorrhage (IPH) (N = 44, 37%), subarachnoid hemorrhage (SAH) (N = 22, 18%), and intraventricular hemorrhage (IVH) (N = 5, 4%). IPH and hindbrain/ventricular locations are associated with poor outcomes (P = 0.031 and < 0.001, respectively). Among the 19 patients who did not undergo surgical resection of the meningioma, 14 (74%) experienced rebleeding with a median occurrence of 120 days (interquartile, [90; -]). Rebleeding occurs earlier if the type of bleeding is SAH or IVH and for hindbrain location (both P < 0.01). ICH is a rare presentation of meningiomas. Hindbrain and ventricular tumor location and IPH are associated with poor outcomes. Rebleeding rate is high and premature. It occurs earlier if the first bleeding was SAH or IVH and for hindbrain location. [ABSTRACT FROM AUTHOR]

Filifactor alocis , an anaerobic Gram-positive rod, has garnered interest from its association with periodontal disease. Extraoral infections by F. alocis are rare; only seven cases have been reported. We report the first case in which we identified F. alocis as one of the causative organisms of a deep neck abscess. A 71-year-old male on hemodialysis came to our hospital with a fever and left buccal pain. The patient's left neck was swollen, and contrast-enhanced computed tomography showed an abscess with gas extending from the left cheek to the deep neck. We diagnosed the patient with a deep neck abscess and performed an urgent neck drainage. We isolated F. alocis, Eggerthia catenaformis, Parvimonas micra , and Streptococcus constellatus in the abscess and identified them using matrix-assisted laser desorption ionization-time of flight mass spectrometry. Blood cultures were negative. We initiated treatment with piperacillin-tazobactam and vancomycin. The patient improved but developed a hemorrhagic duodenal ulcer on the third day of admission. We attempted endoscopic hemostasis, but the patient's bleeding continued. Ultimately, he died of the duodenal ulcer hemorrhage on the sixth day of admission. This is the first case of F. alocis detected in a deep neck abscess. [ABSTRACT FROM AUTHOR]

Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding. This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied. A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1–2), and the median volume of cyanoacrylate per session was 2 (1–2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding. In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session. Factors associated with rebleeding from gastric varices. [Display omitted] [ABSTRACT FROM AUTHOR]

Recently many different endoscopic techniques have been used in spontaneous intracerebral hemorrhage evacuation. However, most of these techniques require expensive special equipment or a well-coordinated assistant. We present a simple and effective binding technique for endoscopic hemorrhage evacuation, which is especially useful during emergency treatment and suitable for use in less-developed areas. Our goal was to achieve easy and accurate hemostasis when using an endoscopic technique in which a single surgeon could operate 3 instruments (endoscope, suction tube, and bipolar forceps) with both hands simultaneously in the transparent tubular retractor. This modification, which we called the binding technique, was achieved by bundling the endoscope and suction tube with a sterile rubber band. We performed the binding technique for endoscopic removal of hematoma in 6 patients, including 3 basal ganglia hemorrhages, 2 brain lobe hemorrhages, and 1 cerebellar hemorrhage. The mean operative time was 117.5 minutes (range, 96–155 minutes). One patient died of postoperative delayed brainstem infarction. The Glasgow Outcome Scale score at 3 months was 5 in 3 patients, 3 in 2 patients and 1 (death) in 1 patient. The modified Rankin Scale score at 3 months was 0 in 3 patients, 4 in 2 patients, and 6 (death) in 1 patient. The binding technique is a modification that allows a single surgeon to achieve easy and accurate hemostasis in endoscopic surgery of intracerebral hematomas. This technique is easy to learn and suitable for emergency surgery, especially in less developed areas. [ABSTRACT FROM AUTHOR]

This study investigated risk factors for bleeding in patients with acute necrotizing pancreatitis (ANP) undergoing endoscopic necrosectomy (EN) and the effect of endoscopic haemostasis. 145 patients with ANP who underwent EN were recruited from January 2014 to December 2018. Patients with and without bleeding were allocated to the bleeding and nonbleeding groups, respectively. Multivariable logistic regression models were used to assess independent risk factors for bleeding. 39 patients (26.9%) experienced bleeding. The body mass index and culture-confirmed infectious pancreatic necrosis (IPN), renal failure and continuous renal replacement therapy rates were significantly higher in the bleeding group (all P < 0.01). In addition, the number of debridement procedures was significantly higher in the bleeding group (P = 0.004), accompanied by a higher mortality rate and greater hospitalization costs (all P < 0.05). Most cases of bleeding during EN were successfully stopped by endoscopic haemostasis (94.1%), but this was difficult to achieve after EN. Multivariate analysis revealed that renal failure (odds ratio [OR]: 3.77, P = 0.02), culture-confirmed IPN (OR: 3.19, P = 0.02), and ≥3 debridement procedures (OR: 12.92, P = 0.001) were associated with an increased bleeding risk. Renal failure, culture-confirmed IPN, and multiple debridement procedures were independent risk factors for bleeding in patients with ANP who underwent EN. [ABSTRACT FROM AUTHOR]

Endoscopic venous harvest (EVH) has become widely adopted in routine elective coronary artery bypass graft operations given it reduces surgical-site infections and improves wound cosmesis. The conventional EVH involves a 'stab and grab' incision at the inguinal crease, which is a hard-to-reach area for routine wound care. This paper describes the steps of the uniportal EVH, which transects the venous conduit, omitting the need for a stab incision at the groin. [ABSTRACT FROM AUTHOR]

Intracerebral hemorrhage (ICH) is the most devastating form of stroke, with thalamic hemorrhages carrying the worst outcomes. Minimally invasive (MIS) endoscopic ICH evacuation is a promising new therapy for the condition. However, it remains unclear whether therapy success is location dependent. Here we present long-term functional outcomes after MIS evacuation of spontaneous thalamic hemorrhages. Patients presenting to a single urban health system with spontaneous ICH were triaged to a central hospital for management of ICH. Operative criteria for MIS evacuation included hemorrhage volume ≥15 mL, age ≥18, National Institutes of Health Stroke Scale ≥6, and baseline modified Rankin Score (mRS) ≤3. Demographic, radiographic, and clinical data were collected prospectively, and descriptive statistics were performed retrospectively. Functional outcomes were assessed using 6-month mRS scores. Endoscopic ICH evacuation was performed on 21 patients. Eleven patients had hemorrhage confined to the thalamus, whereas 10 patients had hemorrhages in the thalamus and surrounding structures. Eighteen patients (85.7%) had intraventricular extension. The average preoperative volume was 39.8 mL (standard deviation [SD]: 31.5 mL) and postoperative volume was 3.8 mL (SD: 6.1 mL), resulting in an average evacuation rate of 91.4% (SD: 11.1%). One month after hemorrhage, 2 patients (9.5%) had expired and all other patients remained functionally dependent (90.5%). At 6-month follow-up, 4 patients (19.0%) had improved to a favorable outcome (mRS ≤ 3). Among patients with ICH undergoing medical management, those with thalamic hemorrhages have especially poor outcomes. This study suggests that MIS evacuation can be safely performed in a thalamic population. It also presents long-term functional outcomes that can aid in planning randomization schemes or subgroup analyses in future MIS evacuation clinical trials. [ABSTRACT FROM AUTHOR]

Limited data exist on the safety of early nasogastric (NG) feeding in patients with cirrhosis after endotherapy for variceal bleeding (VB). We studied the impact of early NG tube feeding in these patients in this proof-of-concept open-label randomized controlled trial. Eligible patients with cirrhosis undergoing endotherapy for VB were randomized to receive either a liquid diet through a 14 Fr NG tube (commencing 1 h after endotherapy) (early feeding [EF] group) or sips of water and lemon water orally (standard-of-care [SOC] group) for total duration of 48 h. The primary outcome was 5-day rebleeding in both arms. Other outcomes included 5-day infection rate, hepatic encephalopathy during hospitalization, and 6-week mortality. Eighty patients (Mean age: 41 ± 11.5 years; males [82.5%]; alcohol etiology [55%]) were included. Baseline median Child-Pugh and MELD scores were similar (CTP: 8 [IQR: 8–9] vs 9 [8–9.25]; P = 0.47 and MELDNa: 13 [10.75–16.25] vs 15 [12–18.25]; P = 0.16). The 5-day rebleeding rates in EF and SOC groups were 2.5% and 5%, respectively (P = 0.55), and non-inferiority or superiority of either could not be demonstrated. The incidence of infection (2.5% [EF] vs 2.5% [SOC]; P = 1.00) and development of HE (5% [EF] vs 2.5% [SOC]; P = 0.36) during hospitalization were comparable. The average daily calorie and protein intake in the EF group during the 48 h was 1318 ± 240 Kcals and 43.4 ± 9.2 g of proteins. No patient in the EF group had feed intolerance. Early initiation of NG tube-based feeding after endotherapy in VB appears safe and well tolerated without the additional risk of rebleeding or encephalopathy. [ABSTRACT FROM AUTHOR]

Background and Aim: Several risk factors affecting post-operative recurrence in Crohn's disease patients have been studied, and of these, the role of the anastomosis remains contentious. We aimed to compare the risk of developing early post-operative endoscopic recurrence (EPER), in resections that had an end-to-end anastomosis (ETEA) to a side-to-side anastomosis (STSA). Methods: All Crohn's disease patients that underwent an ileocolic or small bowel resection between January 2012 and June 2017 at two tertiary IBD centres were reviewed retrospectively. Included patients had a minimum of 12-month clinical follow-up and a colonoscopy within 12 months of the resection or stoma reversal. Univariate and multivariate binary logistic regression analyses determined the independent risk factors for early post-operative endoscopic recurrence, defined as a Rutgeerts score of ≥ i2b. Results: Ninety-two resections associated with an ETEA or a STSA were included for analysis. The ETEA was the most common anastomosis, constructed in 55 patients (59.8%). Forty-nine operations (53.3%) resulted in a ≥ i2b recurrence at the first surveillance colonoscopy. The multivariate analysis showed that there was no difference between the ETEA and STSA in determining the odds ratio (OR) for developing EPER (OR = 2.41 (0.95–6.05), P = 0.06). In those that underwent a resection emergently however, the significant determinants of EPER were as follows: having an ETEA (OR = 38.12 (2.44–595.87), P = 0.01), failing to commence a biologic and/or an immunosuppressant early (OR = 24.21 (1.69, 347.81), P = 0.02), and active smoking (OR = 7.19 (1.12–46.21), P = 0.04). Conclusion: The ETEA is best avoided in those undergoing an emergency resection. The early commencement of a biologic and/or an immunosuppressant and smoking cessation is imperative this high-risk group of patients. [ABSTRACT FROM AUTHOR]

Objectives: This study investigated the feasibility and safety of transulnar access (TUA) and efficacy of novel TR band modification for dual site hemostasis in patients with failed ipsilateral transradial approach.Background: Failed transradial access requires cross over to alternative access site. There is paucity of data on feasibility and safety of ipsilateral TUA due to concern of potential risk of hand ischemia.Methods: We retrospectively reviewed ten patients who underwent coronary angiography and intervention via ulnar artery in the setting of failed ipsilateral transradial access. Patent hemostasis for both ulnar and radial arteries was achieved with novel modification of the TR band to compress both arteries at the same level of puncture sites.Results: TUA after failed ipsilateral transradial access was successful in all ten cases. All patients were followed within 7 days and there were no adverse complications such as ulnar artery occlusion, nerve injury, or hand ischemia.Conclusion: TUA maybe a safe and viable option when cross over is necessary from failed ipsilateral transradial access. Modification of the TR band for both radial and ulnar access site can achieve patent hemostasis effectively at the level of both puncture sites. [ABSTRACT FROM AUTHOR]

Background: No consensus has been achieved on optimal perioperative strategies for patients undergoing endoscopic submucosal dissection (ESD). The aim of this study was to investigate the effects of an intravenous (IV) proton pump inhibitor (PPI) given during the fasting period after ESD on delayed bleeding following ESD.Methods: This study was designed as a prospective, randomized, double-blind, placebo-controlled trial in a single center. A total of 235 patients who underwent ESD for adenoma and early gastric cancer between March 2016 and September 2018 were randomized into a PPI group and placebo group. Patients were administrated intravenous pantoprazole 40 mg daily (PPI group) or placebo (placebo group) during the fasting period 48 h after ESD (from the day of ESD to the following day, 48 h). After oral feeding (48 h after ESD), oral PPI was given to both groups for 8 weeks.Results: Among 235 patients in the intention-to-treat (ITT) and 195 in the per-protocol (PP) analysis, there was no significant difference between the PPI and control groups in major bleeding (PPI vs. placebo; 3.3% vs. 1.7%, p = 0.27) or minor bleeding (PPI vs. placebo; 7.6% vs. 4.3%, p = 0.41) after ESD. There was no significant difference in age (p = 0.28), histology (p = 0.75), tumor size (p = 0.48), or procedure time (p = 0.49) between the two groups. The only independent risk factor for major delayed bleeding was the combined use of aspirin and antiplatelet agent (OR; 12.25, 95% CI; 1.06-141.19, p = 0.04).Conclusions: Administration of routine IV PPI during the fasting period 48 h after ESD does not reduce delayed post-ESD bleeding. [ABSTRACT FROM AUTHOR]

Although surgeries for intracerebral hemorrhage remain controversial, endoscopic surgery is considered a promising surgical treatment. The most fatal type of thalamic hemorrhage is the medial type, which is always combined with expansion of the hematoma into the third ventricle. The current endoscopic approach to this lesion involves injury to the mediodorsal nucleus of the thalamus (MDT). We report 5 cases of medial thalamic hemorrhage with third intraventricular involvement treated by an endoscopic-assisted translateral ventricular transchoroidal fissure approach. The preoperative average volume of the parenchymal hematomas was 9.63 mL, while the preoperative average volume of the intraventricular hematomas was 23.35 mL. The average surgical duration was 80.6 minutes. No intraoperative MDT incision was needed in any patient. The evacuation rates of parenchymal and intraventricular hematomas were 74.21%−98.84% and 85.89%–99.51%, respectively. Three months after the surgery, the average Glasgow Coma Scale scores improved to 13.8 from 7.2 preoperatively. No ventriculoperitoneal shunt was needed in any patient. The endoscopic-assisted translateral ventricular transchoroidal fissure approach is a safe and effective approach for evacuation of a medial thalamic hemorrhage with third intraventricular involvement. This approach allows parenchymal hematoma evacuation through the rupture of the third ventricle without incising the MDT in the lateral ventricle. [ABSTRACT FROM AUTHOR]

To analyze the outcomes of balloon occluded retrograde transvenous obliteration (BRTO) as salvage therapy in cirrhotic patients with gastric variceal bleed (GVB) after failed endotherapy or very early rebleeds. We assessed for technical/clinical success of BRTO and transplantation-free survival. Patients with GVB who underwent BRTO as salvage therapy (between 2011 and 2017) were analyzed. Rebleed rate, Child Pugh score (CTP), Model for end-stage liver disease (MELD) values were calculated at 1,6,12, and 24 months follow-up. Fifty-two patients who underwent BRTO as salvage therapy were assessed for rebleed rate and transplantation-free survival. Technical success was 100% with rebleed rate being 1.9% (n = 1) and clinical success rate of 92.3% (n = 48) at 12-months follow-up and transplantation-free one-year survival of 90.4% (n = 47). Five patients (9.6%) failed to achieve one-year transplantation-free survival. Four patients died within 30 days; one rebleed, 3 (all Child C) progressive liver and multiorgan failure and one required liver transplantation (day 88) after BRTO. Thus, a total of 4 of 9 (44.4%) Child C patients failed to achieve one-year transplantation-free survival. Improvement in liver functions was noted in the rest with improved CTP, MELD scores, and albumin levels in the 12-month follow-up. Six of 52 (11.5%) developed new onset medically manageable ascites, whereas 7 of 52 (13.5%) had progression of esophageal varices at 12-months follow-up requiring prophylactic band ligation in follow-up. Salvage BRTO is a safe and effective procedure for patients with acute GVB with failure to control bleed with endotherapy or very early rebleed after endotherapy. Salvage BRTO has good short/long-term outcomes with lower rebleed, higher survival, and improved liver disease severity. [ABSTRACT FROM AUTHOR]

Intracranial aneurysms (IAs) located in the midline region represent formidable challenge owing to their deep location. The objective of this study was to assess feasibility and identify the limitations of endoscopic endonasal clipping of IAs. We further aimed to describe the locations and characteristics of aneurysms that may be amenable for endoscopic endonasal clipping; thus outlining the indications of these approaches. Fifteen latex-injected cadaveric heads were used for endoscopic endonasal exposure of anterior and posterior cerebral circulations. An aneurysm simulator model with 2 different sizes was used at the common sites for IAs to emulate a real surgery. Key measured parameters included "exposure of vessels and their respective perforators," "ability to gain proximal/distal control," and "possibility of clip placement" according to the size, direction, and location of the aneurysm model. Maneuverability of instruments and the need for pituitary gland transposition were assessed and recorded as well. Exposure of the anterior communicating artery complex and the common sites of posterior circulation aneurysms were feasible. The size, location, and direction of the aneurysm model had an impact on obtaining proximal and/or distal control, and the ability of clip placement. Clipping of midline aneurysms of the posterior circulation is feasible via endoscopic endonasal approach. Small-sized ventrally and medially directed aneurysm models carried a better probability of getting proximal and/or distal control, as well as better overall ability to place a clip. The endonasal route seems to provide a limited condition for proper management of anterior circulation aneurysms. [ABSTRACT FROM AUTHOR]

Ensuring hemostasis during invasive procedures is a challenge in patients with severe hemophilia A. This analysis evaluated efficacy and safety of BAY 94-9027, an extended-half-life recombinant factor VIII (FVIII), in the surgical setting. Patients participating in an open-label BAY 94-9027 clinical trial who underwent major surgery were included in the analysis. Investigator/surgeon assessment of hemostasis during surgery was the primary outcome. In addition, information about FVIII use, FVIII levels during perioperative period, bleeding complications and FVIII inhibitor development were collected. Data were analyzed for 26 major surgeries (orthopedic, n = 21) in 20 patients aged 13–61 years. BAY 94-9027 provided effective hemostasis during all procedures. FVIII levels 6–8 h post preoperative infusion and prior to the first follow-up infusion were in the range expected to maintain protection in the major surgery setting. The median time from preoperative infusion to the first follow-up infusion (the first infusion administered after the preoperative infusion) was 12.33 (3.6–49.9) h. No intraoperative bleeding complications occurred, and no new inhibitors developed following any surgery. The results of the study demonstrate that BAY 94-9027 was efficacious and well tolerated in the treatment of patients undergoing major surgeries. Advantages of BAY 94-9027 include the potential for less frequent infusion and reduced factor consumption, which should simplify the management of patients during major surgery. • Largest hemophilia A surgery cohort reported receiving extended-half-life treatment. • Procedures predominantly orthopedic, typical of those needed by hemophilia patients. • Hemostasis with BAY 94-9027 was excellent/good for major surgery bleed prevention. • Frequent and/or continuous infusion was not needed during the perioperative period. [ABSTRACT FROM AUTHOR]

Background: Pancreatoduodenectomy is considered to be a very invasive treatment for early superficial duodenal tumors (SDTs), which have a lower risk of lymph node metastasis. Partial resection of the duodenum with endoscopic submucosal dissection for SDT resection is an attractive technique but it is associated with a high risk of complications. We describe our technique for SDT resection.Method: It includes the following elements: freeing the transverse mesocolon, exposing and mobilizing the second part of the duodenum and the head of the pancreas (Kocher maneuver), confirming the location of the ulcer bed for endoscopic submucosal dissection, and laparoscopic suturing by hand in the seromuscular layer of the duodenum. We performed this technique in 10 patients between March 2015 and March 2017.Results: The median tumor diameter and resected tissue diameter were 36 (20-54) and 41 (25-60) mm, respectively. Curative resection (R0) with negative margins was achieved for all patients. There were no conversions to open surgery in this series. No postoperative complications were above grade 2 in the Clavien-Dindo classification system. No recurrences were observed during the medium-term follow-up period.Conclusion: This technique is safe and feasible and can be an option for surgical SDT resection. [ABSTRACT FROM AUTHOR]

Background: The radial artery is the access of choice in many catheterization labs around the world due to its proven benefits over the femoral artery access. There has been growing interest in the left radial artery. We sought to evaluate the feasibility, safety and complication rates of the left distal radial artery (ldTRA) access for cardiac catheterization.Methods: This is a single arm retrospective study evaluating the feasibility and safety of performing cardiac catheterization through ldTRA. The procedure was completed using standard diagnostic and guiding catheters. Hemostasis was achieved with a radial band. Feasibility was the ability to cannulate the distal left radial artery as well as completing the procedure without requiring an additional arterial access. The safety point included hematoma, bleeding or neuropathy.Results: ldTRA was attempted in 61 patients. 59 patients had successful completion of the procedure through ldTRA. Conversion occurred in 1 patient (1.7%), requiring an additional arterial access to complete the procedure. 34 patients (55.7%) required percutaneous coronary intervention (PCI). There was no access site bleeds post procedure, no hematomas, with 100% successful hemostasis with a radial hemostatic band. There were 2 cases requiring reaccess of the distal left radial artery access for repeat revascularization, with procedure success and good left radial artery patency.Conclusion: ldTRA is a safe and feasible arterial access in a radial experienced catheterization lab. ldTRA provides improved operator ergonomics and patient's comfort, in addition to the advantage of being able to cannulate the bypass grafts and with a very low risk of vascular complications. [ABSTRACT FROM AUTHOR]

• A higher International normalized ratio is a risk factor for 30-day mortality. • A lower Charlson Comobidity Index and Rockall score are associated with longer overall survival. • Early rebleeding is associated with lower overall survival. • Type of embolic does not seem to be a prognostic factor for clinical outcome. Long-term outcome and prognostic factors of transcatheter embolization for gastroduodenal peptic ulcer bleeding are unknown. This study was conducted to evaluate the clinical outcome and factors associated with early recurrent bleeding and 30-day mortality of transcatheter arterial embolization (TAE) for severe, upper gastroduodenal hemorrhage associated with peptic ulcer and refractory to medical and endoscopic therapy. A monocenter, retrospective study from 2005 to 2020 including 76 consecutive patients who underwent TAE as first-line therapy for bleeding gastroduodenal peptic ulcers refractory to endoscopic therapy. Patient demographics, endoscopy findings, co-morbidities and interventional procedure findings were recorded. The outcome measures were technical and clinical success, procedure related complications, recurrent bleeding, length of hospital stay, 30-day mortality and overall survival. The technical success rate was 96% and the clinical success rate was 65,8%. The rebleeding and 30-day mortality rate were 30,7% and 22,4% respectively. A higher international normalized ratio (INR) was a statistically significant risk factor for 30-day mortality (OR, 7.15; 95% CI, 1.67–30.70; p = 0.008). The mean overall survival was 3.76 years (1.16–––5.09; 95% CI); a lower Charlson Comorbidity Index (CCI) and a lower Rockall score were significantly associated with a longer overall survival (HR, 1.24; 95% CI, 1.14–1.35; p = 0.0001; HR, 1.32; 95% CI, 1.10–1.59; p = 0.003) respectively. Early rebleeding was significantly associated with a lower overall survival (HR, 2.72; 95% CI, 1.57–4.71; p = 0.0004). A higher INR was a significant risk factor with a higher 30-day mortality. A lower CCI, a lower Rockall score and the absence of early rebleeding were significantly associated with a longer overall survival. [ABSTRACT FROM AUTHOR]

Local hemostatic agents have been used in the neurosurgical field for many years; it is safe and efficient with no fatal complication reported in the literature. We routinely used a gelatin-thrombin hemostatic agent (FloSeal Hemostatic Matrix) for hemostasis in minimally invasive endoscopic-assisted surgery for more than 500 patients with intracerebral hemorrhage. However, 2 cases with sterile cyst formation were encountered. We reported 2 cases with sterile cyst formation after the use of a gelatin-thrombin hemostatic agent. Both of them had intracerebral hemorrhage. One received endoscopic hematoma evacuation, and the other had traditional craniotomy. They all received drainage of the cyst due to progressive enlargement and the mass effect they exert. These sterile cysts were very close to the ventricle wall on images. We hypothesized that cyst wall may be formed not only by hemostatic agent-related fibrosis and inflammation according to the previous literature review but also by the presence of the check valve mechanism between the cyst and the ventricle, which caused further dilation of the cyst. [ABSTRACT FROM AUTHOR]

Purpose: Over the last 3 decades, laparoscopic procedures have emerged as the standard treatment for many elective and emergency surgical conditions. Despite the increased use of laparoscopic surgery, the role of laparoscopic repair for perforated peptic ulcer remains controversial among general surgeons. The aim of this study was to compare the outcomes of laparoscopic versus open repair for perforated peptic ulcer.Methods: A systemic literature review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database of all randomised controlled trials (RCT) that compared laparoscopic (LR) with open repair (OR) for perforated peptic ulcer (PPU). Data was extracted using a standardised form and subsequently analysed.Results: The meta-analysis using data from 7 RCT showed that LR for PPU has decreased overall post-operative morbidity (LR = 8.9% vs. OR = 17.0%) (OR = 0.54, 95% CI 0.37 to 0.79, p < 0.01), wound infections, (LR = 2.2% vs. OR = 6.3%) (OR = 0.3, 95% CI 0.16 to 0.5, p < 0.01) and shorter duration of hospital stay (6.6 days vs. 8.2 days, p = 0.01). There were no significant differences in length of operation, leakage rate, incidence of intra-abdominal abscess, post-operative sepsis, respiratory complications, re-operation rate or mortality. There was no publication bias and the quality of the studies ranged from poor to good.Conclusion: These results demonstrate that laparoscopic repair for perforated peptic ulcer has a reduced morbidity and total hospital stay compared with open approach. There are no significant differences in mortality, post-operative sepsis, abscess and re-operation rates. LR should be the preferred treatment option for patients with perforated peptic ulcer disease. [ABSTRACT FROM AUTHOR]

Background: Asymptomatic radial artery occlusion (RAO) is a major limitation of transradial catheterization (TRC). Two radial compression hemostatic devices are compared for their respective effects on RAO.Methods: In a prospective, randomized, single center, blinded trial, 320 patients were randomly treated with a TR band (Terumo Corporation) or Safeguard Radial (Merit Medical). Institution wide protocols consisting of anticoagulation, patent hemostasis, duration of compression, and use of 6 French slender sheaths (Terumo Corporation) were observed. Patient discomfort related to the device was recorded using the universal pain scale. Radial artery patency was evaluated by reverse Barbeau's test prior to discharge (1-hour post-diagnostic catheterization or 6-24 hour post-intervention) and at 30-days.Results: Of the 320 patients, 155 were randomized to the TR group (TRG) and 159 to the Safeguard group (SGG). 6 patients were excluded due to the inability to insert 6 Fr slender sheaths or patient withdrawing consent. Demographic and procedural characteristics were similar with the exception of the type of coronary procedure performed. Both bands were equally effective in achieving patent hemostasis. Despite having a higher rate of post-procedure hematoma (1.29% TRG vs. 3.1% SGG, p = 0.04) and acute RAO (3.8% TRG vs. 6.28% SGG, p = 0.05) with the Safeguard band, at 30 days RAO was similar in both groups (1.9% TRG vs. 2.5% SGG; p = 0.21). Patients in the SGG reported significantly less band discomfort and were found to require less air to achieve patent hemostasis.Conclusion: Evidence-based contemporary TRC protocols of using smaller diameter access, anticoagulation, and use of just enough pressure for the shortest duration of time to achieve hemostasis is associated with very low RAO rate at 30 days irrespective of the radial compression device used. [ABSTRACT FROM AUTHOR]

Background Brainstem cavernous malformations represent around 8%–22% of all intracranial cavernous malformations but exhibit a higher annual incidence of hemorrhage (2%–3%) compared with other cavernous angiomas and tend to be more symptomatic given their proximity to critical nuclei and fiber tracts. Recently, endoscopic endonasal techniques have been used for the removal of ventral skull base lesions, with significant improvement in operative morbidity and mortality compared with open approaches. Here we demonstrate the utility and feasibility of the endoscopic transclival approach for ventrally located pontine cavernomas in carefully selected patients. Case Description Consent was provided by the patient before the writing of this report. Institutional review board approval was not necessary because there was no other patient data accessed. A 21-year-old man presented to the emergency department with right-sided hemiparesis. Magnetic resonance imaging demonstrated evidence of hemorrhage from a ventrally located pontine cavernoma. Given the ventral location of the lesion and the desire for early control of an associated developmental venous anomaly (DVA), an endoscopic endonasal transclival approach was chosen. Gross total resection was achieved, and the patient did well postoperatively with no new neurologic deficits or cerebrospinal fluid leak. He is currently routinely followed and is neurologically well. Conclusions This approach provided direct visualization of the lesion and the associated DVA allowing for a gross total resection without injury to the DVA. The transclival approach may be considered as an alternative to open lateral and dorsolateral neurosurgical approaches for ventral brainstem cavernomas in carefully selected patients. Highlights • BSCMs have a higher incidence of rebleeding, with surgical management reserved for superficial lesions. • Presence of associated DVA complicates the surgery and should be taken into account when planning the approach. • Endoscopic transclival routes to the ventral brainstem allow for increased visualization of critical structures. • Main drawbacks to the transclival approach are the steep learning curve and gaining proximal control in arterial injury. • Transclival approach is a formidable tool and should be considered in select patients with symptomatic superficial BSCMs. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to evaluate the efficacy and safety of distal radial (DR) versus traditional radial (TR) approach during coronary angiography.Methods: Two hundred patients scheduled to undergo transradial coronary angiography were randomized between the two approaches. Primary endpoint of the study was switching to another access site due to inability of successful target artery cannulation. Secondary endpoints were time to cannulation, total procedure duration, number of attempts, number of skin punctures and duration of manual hemostasis. Secondary safety endpoints were the rate of moderate or severe spasm, arm hematoma EASY class III or more and radial artery occlusion at discharge. Quality of life endpoint was the patient's preference of cannulation method at 30 days.Results: The primary endpoint was met in 30 patients (30%) from the DR group and 2 patients (2%) from the TR group (p < 0.001). The time of cannulation was longer in the DR group compared to the TR group (269 ± 251 s vs 140 ± 161 s, p < 0.001), but this did not affect the total procedural duration (925 ± 896 s vs 831 ± 424 s, p = 0.494). The number of attempts and the number of skin punctures were more in the DR group compared to the TR group (6.8 ± 6.2 vs 3.4 ± 4.5, p < 0.001 and 2.4 ± 1.7 vs 1.6 ± 1.2, p < 0.001, respectively). However, DR treated patients had faster manual hemostasis time compared to TR treated patients (568 ± 462 s vs 841 ± 574 s, p = 0.002). There were no differences recorded in the safety endpoints of moderate or severe spasm, EASY grade III or more radial hematomas or the incidence of radial artery occlusion after the procedure. Patients' preference to the randomized puncture sites was the same (79% vs 85%, p = 0.358).Conclusion: Distal radial approach is associated with lower successful cannulation rates and shorter manual hemostasis time compared to the traditional radial approach. [ABSTRACT FROM AUTHOR]

Background/Aims Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding. Methods Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV. Results Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7–47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3–51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months. Conclusion ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable. [ABSTRACT FROM AUTHOR]

Life-long anticoagulation is required for patients following pulmonary thromboendarterectomy (PTE). Warfarin is the default anticoagulant; however, many patients request direct oral anticoagulants (DOACs) as they do not require monitoring or dietary changes. There is limited data on the safety and efficacy of DOACs following PTE, and the aim of this study is to better understand the bleeding and clotting risks in patients taking the two classes of medications after PTE in a non-trial setting. To better understand real-world anticoagulation prescribing patterns and their potential implications following PTE, we retrospectively identified all patients who underwent PTE at our institution since July 2011 and determined their post-discharge anticoagulation regimen and the occurrence of complications using a standardized telephone questionnaire. Comparisons were made using Fisher's exact text. 246 patients underwent a PTE at our institution after July 2011; our hospital electronic medical record indicated 33 (13%) died since their index operation. Of the 213 remaining, 72 (34%) patients were successfully contacted and 51 (23%) agreed to participate in the questionnaire for a response rate of 24%. The mean time from the index PTE for these 51 patients was 5.2 years +/- 3.2 years. Table 1 displays the results of the questionnaire. Nine patients (18%) who were discharged on warfarin switched to a DOAC. Notably, all 3 patients with a recurrent pulmonary embolism (PE) after PTE had been switched from warfarin to a DOAC prior to the PE (P = 0.04). Each required hospitalization (P = 0.04). There was no difference in bleeding complications between the groups. Patients transitioned from warfarin to DOACs were more likely to experience recurrent PE and require in-hospital PE treatment. Larger studies assessing the use of DOACs in this population are needed to determine effectiveness and safety. [ABSTRACT FROM AUTHOR]

Background Gastric varices (GV) are found in patients with portal hypertension. Incidence of bleeding from GV is relatively low, but is severe, and associated with higher mortality. Aims and objectives To compare the types of GV in cirrhosis vs. extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N -butyl-2-cyanoacrylate (NBC, glue) injection. Methods Four hundred and fifty-four patients undergone glue injection of GV for primary prophylaxis or control of bleeding for first episode of bleeding from GV between August 2010 and August 2015 were analyzed. Results Of 454 patients, 64% ( n = 292) were cirrhotics and 36% ( n = 162) had EHPVO. Types of GV were GOV1 in 16.4% ( n = 48) of cirrhotics vs. 7.4% ( n = 12) of EHPVO, GOV2 in 76.7% ( n = 224) of cirrhotics vs. 53.1% ( n = 86) of EHPVO, Isolated gastric Varices (IGV1) in 39.5% ( n = 64) of patients with EHPVO vs. 6.8% ( n = 20) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 2.89 ± 1.59 ml over a median of 1 session (range: 1–7). The total volume of glue required was lower in cirrhotics (2.44 ± 1.17 ml vs. 3.69 ± 1.91 ml, P < 0.05) than in EHPVO patients. One hundred and seventeen (40.1%) of cirrhotics required >1 sessions of glue injection as compared to 102 (63%) of EHPVO patients. Over mean follow up of 14.7 ± 6.46 months, rebleeding (10% vs. 13%) was similar in patients with cirrhosis and EHPVO and mortality (15.4% vs. 2.5%) was higher in cirrhotics than EHPVO. Conclusion In patients with bleeding from GV, GOV2 are more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for GV obturation. [ABSTRACT FROM AUTHOR]

Background: The over-the-scope clip (OTSC) is a novel endoscopic tool that enables non-surgical management of gastrointestinal (GI) defects. The aim of this study was to report our experience with OTSC for patients with GI defects.Methods: A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC from 2012 to 2015. Primary outcome was the clinical success of the OTSC for the individual indication. Secondary outcome was the number of additional procedures needed following OTSC.Results: Fifty-one patients were treated with OTSC: upper GI (UGI) 30 and lower GI (LGI) 21. GI leak (n = 24; UGI = 12, LGI = 12) and fistulae (n = 17; UGI = 8, LGI = 9) were the most common indications. Overall success rate for the treatment of leaks was 59 % [UGI 66 % vs. LGI 33 % (p = 0.1)]. A lower success rate (35 %) was noted for fistulae [UGI 62 % vs. LGI 0 % (p = 0.001)]. Success rates for UGI perforation, bleeding, and stent anchoring indications were 75, 75, and 50 %, respectively. Additional endoscopic or surgical interventions following OTSC were indicated in 68.6 % of the patients.Conclusions: OTSC appears to have additional value in treating UGI defects. However, lower success rates for LGI defects were noted, specifically for fistulae. Most patients require an additional endoscopic or surgical procedure after one OTSC application. [ABSTRACT FROM AUTHOR]

Abstract: Hemospray is a haemostatic agent licensed for endoscopic haemostasis of non-variceal upper gastrointestinal bleeding (NVUGIB) in Europe and Canada. Hemospray has been shown to be safe and effective in achieving haemostasis in bleeding peptic ulcers in a prospective clinical study and several further case series have described the use of hemospray in other non-variceal causes of gastrointestinal bleeding. Portal hypertensive gastropathy and colopathy are common in patients with portal hypertension. As hemospray is an easy to apply, non-contact method, which can cover large areas of mucosa, it may be of benefit in acute non-variceal portal hypertensive bleeding. We present data from the first four consecutive patients presenting to our institution with acute haemorrhage secondary to non-variceal diffuse portal hypertensive bleeding treated with hemospray. [Copyright &y& Elsevier]

Abstract: Background: The pre-endoscopic Rockall Score (RS) and the Glasgow-Blatchford Scores (GBS) can help risk stratify patients with upper gastrointestinal bleed who are seen in the Emergency Department (ED). The RS and GBS have yet to be validated in a United States patient population for their ability to discriminate which ED patients with upper gastrointestinal bleed do not need endoscopic hemostasis. Objective: We sought to determine whether patients who received a score of zero on either score (the lowest risk) in the ED still required upper endoscopic hemostasis during hospitalization. Methods: Retrospective electronic medical record chart review was performed during a 3-year period (2007–2009) to identify patients with suspected upper gastrointestinal bleed by ED final diagnosis of gastrointestinal hemorrhage and related terms at a single urban academic ED. The RS and GBS were calculated from ED chart abstraction and the hospital records of admitted patients were queried for subsequent endoscopic hemostasis. Results: Six hundred and ninety patients with gastrointestinal bleed were identified and 86% were admitted to the hospital. One hundred and twenty-two patients had an RS equal to zero; 67 (55%; 95% confidence interval [CI] 46–63%) of these patients were admitted to the hospital and 11 (16%; 95% CI 9–27%) received endoscopic hemostasis. Sixty-three patients had a GBS equal to zero; 15 (24%; 95% CI 15–36%) were admitted to the hospital and 2 (13%; 95% CI 4–38%) received endoscopic hemostasis. Conclusions: Some patients who were identified as lowest risk by the GBS or RS still received endoscopic hemostasis during hospital admission. These clinical decision rules may be insufficiently sensitive to predict which patients do not require endoscopic hemostasis. [Copyright &y& Elsevier]

Aim: The clinical features of postoperative bleeding from the ileal pouch-anal anastomosis(IPAA) vary and its management can be difficult. There is no published literature regarding pouch bleeding and its treatment.Materials and Methods: Pouch bleeding was defined as the passage of blood or clots transanally or into the ileostomy bag with or without hypotension or a drop in hemoglobin within 30 days after surgery. Patients were identified from a prospectively maintained pouch database.Results: Pouch bleeding developed in 47 (1.5%) patients out of 3,194 patients undergoing IPAA since 1983. Forty-two patients had inflammatory bowel disease, four had familial adenomatous polyposis, and one had colonic inertia. Sixty-six percent of bleeding occurred within 7 days postoperatively and 59.6% required transfusion; 72.3% patients developed transanal bleeding, nine from ileostomy and two from both. After initial fluid resuscitation, five patients were observed while 28 patients had pouch endoscopy and clot evacuation followed by cauterization or epinephrine(1:100,000) enemas, 27 of these had cessation within 24 h. Epinephrine enema was used as initial treatment in the remaining 12 patients. Overall success rate of epinephrine enema was 96%.Conclusion: Postoperative pouch bleeding after IPAA is uncommon, and it usually requires nonsurgical intervention. Epinephrine enema appears to be successful in managing this complication. [ABSTRACT FROM AUTHOR]

Median time for hemostasis in 30 cases was 33 second (range 18-150 second),In 25 cases, SLiC-WOC method was applied after incomplete hemostasis by using saline-linked electrocautery alone. B Conclusion: b For the bleeding which is difficult to control by electrocautery alone, saline-linked electrocautery combined with wet oxidized cellulose method is effective and time-efficient. [Extracted from the article]

Background: Thrombin-based formulations have been used for topical hemostasis in surgery for decades. However, the number of randomized clinical trials comparing bovine vs human thrombin is limited.Study Design: A randomized, double-blind, non-inferiority phase II study evaluated the hemostatic efficacy and safety of plasma-derived topical thrombin (human) Grifols (TTH-Grifols; Instituto Grifols SA) vs bovine THROMBIN JMI (BT-JMI; GenTrac Inc) (2:1 ratio) in vascular, hepatic, soft tissue, and spinal operations. The primary efficacy end point was the percentage of patients achieving hemostasis at target bleeding sites with mild to moderate bleeding (response) within 5 minutes (T5) of treatment application. Non-inferiority was met if the lower limit of the 95% CI of the response ratio of TTH-Grifols relative to BT-JMI by T5 exceeded 0.8. Secondary efficacy variables were the cumulative response by 3 and 4 minutes (T3 and T4), and the number of treatment failures. Safety parameters were assessed.Results: Randomized patients in TTH-Grifols and BT-JMI groups were n = 137 and n = 68, respectively. In modified intention-to-treat population, rates of hemostasis by T5 were 78.3% (94 of 120) in TTH-Grifols and 80.3% (49 of 61) in BT-JMI (response ratio: 0.973; 95% CI 0.833 to 1.135). Rates of hemostasis in vascular, hepatic, soft tissue, and spinal operations ranged from 75.0% to 82.5% for TTH-Grifols and from 54.5% to 91.7% for BT-JMI. No significant differences in adverse events were observed between treatment groups. Antibodies to bovine factor V antigen were detected in 2 patients exposed to BT-JMI and in none exposed to TTH-Grifols.Conclusions: The TTH-Grifols was safe and well tolerated as a local hemostatic agent and was non-inferior to BT-JMI. No antibodies to thrombin developed in TTH-Grifols-treated patients. [ABSTRACT FROM AUTHOR]