Bismuth Subgallate as a Local Hemostatic Agent

Background: Patients on clopidogrel increased bleeding risk after surgery. This drug prolonged bleeding time, increased bleeding volume and induced secondary bleeding because its active metabolite inhibited platelets aggregation and interfered with haemostatic plug stabilization. Conventional methods, such as pressing sterile gauze on the surgery site, showed less effective to stop bleeding in patients on clopidogrel. This research aims to prove the haemostatic effect of bismuth subgallate both on normal and delayed platelet aggregation due to clopidogrel.Methods: Twenty-eight Wistar rats were equally and randomly administered with clopidogrel (10 mg/kgBW) or NaCl 0.9% (saline) via oral gavage. After anesthetizing, we amputated transversely their tail 10 mm from the distal tip. Bleeding after amputation was controlled with pressing gauze soaked in saline or bismuth subgallate solution. After 60 seconds, bleeding assays (bleeding time, bleeding volume, and secondary bleeding) have been observed, recorded, and analysed both in normal and clopidogrel groups.Results: Clopidogrel groups had significantly longer bleeding time, greater bleeding volume, and had more secondary bleeding rather than saline groups (p <.05). Using bismuth subgallate as local haemostatic agent decreased bleeding time and bleeding volume significantly (p <.05) both in normal and clopidogrel groups. Conclusions: Bismuth subgallate has a haemostatic effect on both clopidogrel and normal rat tail bleeding models.

Evaluation of endoscopic assisted suction coagulation adenoidectomy versus traditional curettage technique

Background Adenoidal hypertrophy is a common condition in children and can cause symptoms such as mouth breathing, nasal discharge, snoring, sleep apnea, and hyponasal speech. The curettage adenoidectomy has some disadvantages, especially the intranasal extension of the adenoid tissue that makes this technique inadequate. This study is conducted to evaluate and compare between assisted suction coagulation adenoidectomy and traditional curettage techniques. Results One hundred twenty-two patients with symptomatic adenoid hypertrophy such as nasal obstruction, snoring, and mouth breathing were included in our study. Patients underwent adenoidectomy either traditional curettage adenoidectomy (60 patients as group A) or endoscopic assisted suction coagulation adenoidectomy (62 patients as group B). Patients were scheduled for follow-up visits with respect to operative time, operative and postoperative complications. The mean age of groups A and B were 6.57+2.8 and 7+2.8 ranging from 3 to12 years. There was a statistically significant difference between groups as regard intraoperative blood loss, trauma, postoperative complications as neck stiffness and bad odor plus postoperative endoscopic and radiological grading after the operation. Conclusions Suction coagulation diathermy adenoidectomy is alternative to cold adenoidectomy with significantly fewer intraoperative complications such as blood loss and trauma of prevertebral muscle plus post-operative complications such as primary or secondary bleeding and rhinolalia aperta.

Optimization of the approach to conducting tonsillectomy

Actuality: Recurrent tonsillitis considers to be one of the most common ENT diseases. Tonsillectomy as the method of recurrent tonsillitis’ treatment is being performed as usual as 20% of all surgeries in ENT departments. The critical criteria for the success of tonsillectomy for the surgeon are the frequency of perioperative complications, long-term results of treatment, and the patient's recovery time. For the patient, those criteria are the severity of pain, psychoemotional stress, the time spent in the hospital, and how fast he can return to his daily life routine. The factors that significantly affect the outcome of tonsillectomy are the choice of anesthetic management and perioperative medical hemostatic support. Aim: Our study aimed to optimize the approach to carry out tonsillectomy by preoperative application of the tranexamic acid 10% solution and optimize the approach to choosing between endotracheal anesthesia and local anesthesia. Materials and methods: Clinical studies were made among 212 patients with recurrent tonsillitis who went through a bilateral tonsillectomy. The patients were divided into three groups. The 1st group included 54 patients undergoing tonsillectomy using endotracheal anesthesia with the administration of tranexamic acid at the rate of 10 mg/kg of body weight. The 2nd group consisted of 97 patients undergoing tonsillectomy using local anesthesia. A 3rd (control) group included 61 patient undergoing tonsillectomy using endotracheal anesthesia. The first and control (3rd) groups of patients were compared to assess the efficacy of using tranexamic acid.Factors such as the duration of the surgery, the amount of blood loss, intraoperative events, the number of incidents of primary and secondary bleeding, and laboratory data were considered. The second and control (third) groups were compared to evaluate the impact of anesthetic management. We considered the factors such as duration of surgery, the amount of blood loss, intraoperative events, number of incidents of primary and secondary bleeding, assessment of pain syndrome, necessity of analgesics administration, length of hospital stay, and recovery period. Conclusions: tonsillectomy surgery using local anesthesia requires less time to perform, has less blood loss, fewer intraoperative events, and lessincidents of primary and secondary bleeding. The average level of pain is higher in patients using endotracheal anesthesia. The use of tranexamic acid 10% significantly reduces the amount of blood loss, helps to reduce intraoperative complications, and lower the emergence of postoperative bleeding and its intensity.

Endoscopic Procedures In Patients Taking Novel Oral Anticoagulants

The use of direct oral anticoagulants (DOAC) for the treatment of atrial fibrillation and prevention of strokes is encouraged by their superior properties compared to vitamin K antagonists: predictable anticoagulant effect, greater patient compliance, few drug interactions, low risk of intracranial hemorrhages. Although practicing gastroenterologists may never prescribe a DOAC, they are likely to encounter DOAC-related GI adverse events (gastrointestinal bleeding), and they will need to manage DOACs around the time of endoscopy. The present paper aims to present the management possibilities of the patient treated with DOAC undergoing endoscopy, most studies performed so far focusing on the risk of spontaneous bleeding in this category of subjects. The current guidelines provided by the British Society of Gastroenterology and the European Society of Gastrointestinal Endoscopy orientate us, but endoscopic maneuvers should be preceded by a detailed analysis of the risks of secondary bleeding and thrombosis associated with DOAC users.

ULSOSEAL Technique: A Unique Technique to Achieve Hemostasis Using ExoSeal in High-Risk Patients after Common Femoral Artery Puncture

This study aimed to assess the safety and feasibility of the ULtrasound-guided uSe Of exoSEAL technique (ULSOSEAL technique) in patients at a high risk of complications following the use of ExoSeal. ExoSeal is a novel, completely extravascular hemostatic device that can treat punctures of the common femoral artery; however, it is not preferable for use in cases that require hemostasis of complex puncture sites. From November 2019 to August 2020, the ULSOSEAL technique was performed in 35 patients with implanted stents (6 patients, 17%), severe calcification (32 patients, 91%), and plaque (7 patients, 20%) around the puncture site; the presence of these conditions is usually undesirable when using ExoSeal. The antegrade approach was used in 22 patients (71%). The size of the ExoSeal used was 5 Fr (13 patients, 37%), 6 Fr (21 patients, 60%), and 7 Fr (1 patient, 2%). Technical success was achieved in 34 patients (97%), while ExoSeal malfunction occurred in 1 patient. There was no incidence of vessel occlusion, pseudoaneurysm, arteriovenous fistula, infection, and secondary bleeding. One patient developed a hematoma (>5 cm in size); however, it occurred before the use of ExoSeal due to side leakage from the inserted sheath. The ULSOSEAL technique was safe and feasible for hemostasis in patients who were considered unsuitable for the ExoSeal device.

Mild Traumatic Brain Injury in Older Adults: Are Routine Second cCT Scans Necessary?

Fall-related hospitalizations among older adults have been increasing in recent decades. One of the most common reasons for this is minimal or mild traumatic brain injury (mTBI) in older individuals taking anticoagulant medication. In this study, we analyzed all inpatient stays from January 2017 to December 2019 of patients aged > 75 years with a mTBI on anticoagulant therapy who received at least two cranial computer tomography (cCT) scans. Of 1477 inpatient stays, 39 had primary cranial bleeding, and in 1438 the results of initial scans were negative for cranial bleeding. Of these 1438 cases, 6 suffered secondary bleeding from the control cCT scan. There was no significance for bleeding related to the type of anticoagulation. We conclude that geriatric patients under anticoagulant medication don’t need a second cCT scan if the primary cCT was negative for intracranial bleeding and the patient shows no clinical signs of bleeding. These patients can be dismissed but require an evaluation for need of home care or protective measures to prevent recurrent falls. The type of anticoagulant medication does not affect the risk of bleeding.

A novel electrosurgical divider: performance in a self-controlled tonsillectomy study

Purpose Tonsillectomies are among the most common surgeries in otorhinolaryngology. A novel electrosurgical temperature-controlled instrument (device) promises rapid tonsillectomies and might reduce postoperative pain, but comparative studies to assess performance are warranted. Methods This randomized self-controlled clinical trial was conducted from October 2019 to October 2020 at the Department of Otorhinolaryngology, Head and Neck Surgery of the Medical University of Vienna. Forty-eight patients underwent a tonsillectomy with the device on one side and using cold-steel with localized bipolar cauterization on the other side (control). Main outcomes were the time for tonsil removal (per side) and the time to stop bleeding (per side). Secondary measurements were postoperative pain, assessed once on day 0 and five times on days 1, 3, 5, 7, and 10. Postoperative bleeding episodes and consequences were recorded. Results Device tonsillectomies were performed significantly faster than controls; the mean surgical time difference was 209 s (p < 0.001, 95% CI 129; 288). Intraoperative blood loss was significantly lower on the device side (all p < 0.05). Postoperative measurements of pain and bleeding were similar for both sides. Two return-to-theatre secondary bleeding events were recorded for the control side. Conclusion The novel electrosurgical temperature-controlled divider reduced the tonsillectomy surgical time and intraoperative blood loss, with no apparent negative effects on postoperative pain or bleeding, compared to a cold-steel tonsillectomy with localized bipolar cauterization. In time-restricted settings, the device could be beneficial, particularly after familiarization with device handling. Trial registration ClinicalTrials.gov Identifier: < Blinded for review >

Jejunal Hemolymphangioma in a Patient Presenting with Gastrointestinal Bleeding

Background: Hemolymphangioma is rarely found in the small intestine. There have only been eight reports of hemolymphangiomas arising in the small intestine to date. The first patient was reported by Fang et al.in 2012. A small intestinal hemolymphangioma may lead to anemia and gastrointestinal bleeding. Case Presentation: We report a case of jejunal hemolymphangioma in a 49-year-old man. The patient presented with melena and anemia. He underwent double-balloon enteroscopy (DBE) via the antegrade approach, which demonstrated a 3.0 cm segment of jejunum with nearly 75% of the circumferential lesion with blood remnant. The raised soft lesion was in the middle of the jejunum with white patches on the surface of the mucosa. Endoscopic biopsy was not performed to avoid secondary bleeding. The patient underwent laparotomy, and partial small intestine resection was performed. A 5.0cm segment of jejunum was resected with primary anastomosis. The patient had an uneventful postoperative recovery. Macroscopic pathological examination showed a cavernous, soft and compressible tumor. Microscopic examination showed a tumor that was composed of blood and lymphatic vessels mainly located in the submucosa. The definitive histological diagnosis was jejunal hemolymphangioma. During a follow-up of 2 years, there was no further gastrointestinal bleeding. Conclusion: Small intestinal hemolymphangioma is a rare benign tumor of which clinical manifestations are nonspecific, and accurate preoperative diagnosis is challenging. Endoscopic biopsy is not recommended for hemolymphangioma of the gastrointestinal tract due to the risk of severe bleeding. Complete surgical resection of the hemolymphangioma is considered the most effective treatment for small intestinal hemolymphangioma.