Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery

Purpose There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. Methods Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009–2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. Results 651 Patients included with a median age of 55 years (range 16–86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1–5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing’s disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher’s Exact, p = 0.99) or epistaxis (Fisher’s Exact, p > 0.99). Conclusions Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.

Introducing day case thyroid lobectomy at a tertiary head and neck centre

Background Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre. Methods We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery’s 5th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service. Results In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre. Conclusions Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

The rule of brain hematoma pressure gradient and its influence on hypertensive cerebral hemorrhage operation

To comparatively study the size of and variation in the ‘brain-haematoma’ pressure gradient for different surgical methods for hypertensive intracerebral haemorrhage (HICH) and analyse the gradient’s influence on surgical procedures and effects of the haemorrhage. Seventy-two patients with HICH treated from 1/2019 to 12/2019 were randomly divided into two groups, namely, the keyhole endoscopy and large trauma craniotomy groups, according to different operative methods. Intraoperative changes in intracranial pressure (ICP) were monitored to calculate intraoperative alterations in the ‘brain-haematoma’ pressure gradient. Intraoperative characteristics (operative time, bleeding volume, volume of blood transfusion, and haematoma clearance rate) and postoperative characteristics (oedema, postoperative activities of daily living (ADL) scores, mortality rate and rebleeding rate) were compared between the two groups. In the keyhole endoscopy group, ICP decreased slowly; the ‘brain-haematoma’ pressure gradient was large, averaging 251.1 ± 20.6 mmH2O, and slowly decreased. The mean operative time was 83.6 ± 4.3 min, the mean bleeding volume was 181.2 ± 13.6 ml, no blood transfusions were given, the average postoperative haematoma clearance rate was 95.6%, the rate of severe oedema was 10.9%, and the average postoperative ADL score was 85.2%. In the large trauma craniotomy group, ICP rapidly decreased after craniotomy. When the haematoma was removed, the ‘brain-haematoma’ pressure gradient was small, averaging 132.3 ± 10.5 mmH2O, and slowly decreased. The mean operative time was 232 ± 26.1 min, the mean bleeding volume was 412.6 ± 35.2 ml, the average volume of blood transfusion was 281.3 ± 13.6 ml, and the average postoperative haematoma clearance rate was 82.3%; moreover, the rate of severe oedema was 72.1%, and the average postoperative ADL score was 39.0%. These differences were statistically significant (P < 0.05). Neither the death rate (P > 0.05, 2.7% VS 2.8%) nor rebleeding rate (P > 0.05, 2.7% VS 2.8%) showed any obvious changes. The magnitude and variation in the ‘brain-haematoma’ pressure gradient for different surgical methods significantly influence surgical procedures and effects of HICH. During keyhole endoscopy surgery, this gradient was relatively large and slowly decreased; the haematoma was therefore easier to remove. Advantages of this approach include a high haematoma clearance rate, decreased bleeding volume, decreased operative time, reduced trauma, decreased postoperative brain oedema and improved postoperative recovery of neurological function.Chinese Clinical Trial Register: ChiCTR1900020655 registration in 12/01/02,019 registration in 28/02/02,020 Number: NCOMMS-20–08,091.

Flying brevet: a technique for mastectomy in female-to-male gender reassignment

Background: Several techniques are described for chest wall contouring in female-to-male (FTM) transgender patients, each with specific applications and limitations. Factors to consider are the aesthetic requirements of the male chest, elimination of anatomical female breast features, operative technique, scar minimisation and success of outcome. We describe the ‘flying brevet’ technique, named for the pattern of excised skin that resembles pilot’s wings. This procedure is tailored to FTM patients but can also be used for large gynaecomastia patients. We present a description of the technique with a retrospective review of outcomes and case series of patients who have undergone this procedure. Methodology: This is a retrospective review of a single surgeon experience with 113 consecutive patients who have undergone the flying brevet technique. The approach involves a semicircular areolar incision, with superior skin resection and glandular resection. A planned second stage procedure may be performed for larger breasts if required. Results: Seven per cent incidence of postoperative haematoma, one case of fat necrosis, one case of partial nipple-areolar-complex (NAC) necrosis and one case of full NAC necrosis in the series. There was one postoperative infection and six per cent incidence of hypertrophic scarring. Conclusions: The flying brevet provides a consistent method of mastectomy for FTM chest wall reconstruction. It permits large glandular and skin resection in ptotic breasts with preservation of NAC circulation. The flying brevet is an additional technique that can be added to the current options for mastectomy in FTM chest wall reconstruction.

Haematomas after carotid endarterectomy can be reduced by direct pressure to the neck postoperatively

Introduction A recognised complication of carotid endarterectomy (CEA) is postoperative haematoma, which can threaten the airway. Previous studies have looked at medical methods of preventing this complication. This study aims to evaluate the impact of simple direct pressure postoperatively on the development of haematoma. Materials and methods From 2011 to 2016, 161 consecutive CEA were performed by a single surgeon or trainee under supervision. After 80 operations, the postoperative technique was altered, with additional pressure being applied by the surgeon to the skin incision from completion of suturing until each patient was awake in the recovery room. The rates of postoperative haematoma and other complications were compared between the pre- and post-intervention groups, as well as grade of surgeon, urgency of operation and antiplatelet/anticoagulant use. Results Post-carotid haematomas were eliminated in the post-intervention group (0/81); in the pre-intervention group 7/80 patients developed haematoma (P < 0.05). There were no significant differences in urgency of surgery, antiplatelet/anticoagulant use, grade of surgeon or other complications (stroke: 2/80 vs 0/81 P < 0.05), suggesting that this was not a learning curve effect. Discussion The results suggest that applying direct pressure helps to reduce oozing, provides time to monitor and identify additional bleeding and protects the wound from excessive strain that may be caused by coughing while the patient wakes up. We advise that the lead surgeon should apply such pressure to ensure precise and focal targeting, for maximum effect. Conclusion During recovery from CEA, focused and prolonged pressure by the operating surgeon is a highly effective method of reducing haematoma.

Paravesical haematoma following placement of an isolated anterior mesh for cystocele repair

Introduction. Pelvic organ prolapse is a substantial health problem for women around the world. Given the limitations of traditional surgery in the reconstruction of normal vaginal anatomy and function in genitourinary prolapse, various synthetic implants have been developed for surgical repair. Mesh procedures are gaining in popularity, encouraged by preliminary data. Although minimally invasive and relatively safe, serious complications following these procedures have been described. Case report. We presented a patient who had underwent an isolated anterior mesh procedure and developed postoperative haematoma which required surgical intervention. Conclusion. This report suggests that minimally invasive urogynecological procedures could result in significant complications. Thus, surgeons should be familiar with effective interventions in order to manage them.

Endostripping: A New Minimally Invasive Technique for Limited Stripping of the Greater Saphenous Vein

Objective: To describe a new technique for limited stripping (in the thigh) of the greater saphenous vein (GSV) to avoid painful postoperative haematomas. Design: Pilot study. Setting: General Hospital Linz, Second Surgical Department, Linz, Austria. Patients: Sixteen patients undergoing primary varicose vein surgery for varices on the long saphenous vein. CEAP clinical stage: C2 ( n = 12), C3 ( n = 4). Intervention: Removal of the GSV from the thigh by endoscopic dissection with electrocautery division of the main tributaries. Phlebectomy for varices in GSV tributaries. Main outcome measures: Clinical assessment of the extent of haematomas and cosmetic appearance. Results: Fifteen of 16 operations were completed as intended without any technical problem. In one case conversion to conventional stripping was required due to adhesion of the saphenous vein to a previous operation scar in the thigh. The median total operation time for one limb was 57 min. A postoperative haematoma occurred in only one patient. There was no additional postoperative complication. Conclusion: Endostripping is a new technique for stripping of the GSV and reduces postoperative haematoma. It can be performed in a reasonable operation time and is safe. The value of this technique should be assessed in clinical trials.