Bleeding after Hysterectomy: Recommendations and What to Expect

Bleeding after gynecological surgery remains an infrequent life-threatening complication, demanding appropriate medical and surgical management. Classified as early/“reactionary” and delayed/secondary, unexpected postoperative hemorrhage may arise regardless of the route or subtype of hysterectomy. Timely recognition and prompt intervention to arrest bleeding are essential strategies for the suitable outcome of the patient. The present chapter presents an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand knowledge and skills in recognizing and treating this unpredicted potentially serious problem. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.

Preoperative hemostasis assessment in adenotonsillar surgery: is it really necessary?

<p class="abstract"><strong>Background: </strong>Adenoidectomy, tonsillectomy and adenotonsillectomy are among the most frequently performed procedures in otorhinolaryngology. Postoperative hemorrhage is, undoubtedly, the most feared complication of this kind of surgery. The authors aim to clarify the role of preoperative hemostatic assessment in adenotonsillar surgery, by reviewing the available literature on the subject.</p><p class="abstract"><strong>Methods: </strong>Articles adressing preoperative assessment on adenotonsillar surgery were searched in PubMed® database, since its publication till April 2020.</p><p class="abstract"><strong>Results:</strong> The role of hemostasis preoperative assessment in adenotonsillar surgery is still controversial, since some authors recommend its application in a selective range of patients, while others support its universal use. Most studies showed that a normal hemostatic study does not exclude the possibility of an hemostatic disease, and that most changed results are not correlated with the probability of postoperative hemorrhage. Hence, international recommendations discourage the screening of otherwise healthy patients, although most health care professionals continue to conduct preoperative tests in a systematic manner.</p><p class="abstract"><strong>Conclusions:</strong> The authors emphasize the need to discuss the subject and to protocol the preoperative approach for these patients, given the confusing and divergent existing data, in such frequently performed procedures in the otolaryngology field.</p>

Predictors of hydrocephalus after lateral ventricular tumor resection

The aim of this study was to identify the predictors of postoperative hydrocephalus in patients with lateral ventricular tumors (LVTs) and to guide the management of perioperative hydrocephalus. We performed a retrospective analysis of patients who received LVT resection at the Department of Neurosurgery, Zhongnan Hospital of Wuhan University between January 2011 and March 2021. Patients were divided between a prophylactic external ventricular drainage (EVD) group and a non-prophylactic EVD group. We analyzed the non-prophylactic EVD group to identify predictors of acute postoperative hydrocephalus. We analyzed all enrolled patients to determine predictors of postoperative ventriculoperitoneal shunt placement. A total of 97 patients were included in this study. EVD was performed in 23 patients with postoperative acute obstructive hydrocephalus, nine patients with communicative hydrocephalus, and two patients with isolated hydrocephalus. Logistic regression analysis showed that tumor anterior invasion of the ventricle (P = 0.020) and postoperative hemorrhage (P = 0.004) were independent risk factors for postoperative acute obstructive hydrocephalus, while a malignant tumor (P = 0.004) was an independent risk factor for a postoperative ventriculoperitoneal shunt. In conclusion, anterior invasion of the lateral ventricle and postoperative hemorrhage are independent risk factors for acute obstructive hydrocephalus after LVT resection. Patients with malignant tumors have a greater risk of shunt dependence after LVT resection.

The Use of IndoCyanine Green Fluorescence in the Assessment of Bowel Perfusion in Emergency and Elective Colorectal Surgery

Background The use of Indocyanine Green (ICG) fluorescence is a well-established technique in colorectal surgery for the evaluation of bowel stump perfusion. However there is still no definitive acceptance, except intraoperative macroscopic evidence, with reference to the incidence of anastomotic leakage (AL). The objective of this study is to confirm the same efficacy and reliability of ICG in elective colorectal surgery, and emergency cases, which would be more exposed to complications related to inadequate vascularization.Methods From January 2019 to June 2020, we used ICG to evaluate the perfusion of colonicstumps before and after packaging the anastomosis in right and left hemicolectomy, rectal resection and Hartmann’s reversals.Results A total of 40 patients underwent surgery, 21 (52.50%) had benign pathology and 19 (47.50%) exhibited malignant neoplasia. 13 (32.50%) were emergency surgeries and 27 (67.50%) were planned elective surgeries. In almost all cases, the postoperative course was regular, in only 1 (2.5%) case of TaTME there was an AL. Other complications were not related to the anastomosis, but some validated the excellent perfusion despite episodes of prolonged acute ischemia due to postoperative hemorrhage. Data were finally compared to a control group of 39 patients where the ICG fluorescence was not used.Conclusions The study confirms the validity of the use of ICG fluorescence as a method for intraoperative assessment of bowel perfusion even in emergency conditions and in acute postoperative hemorrhage, detecting an incidence of 2.5% (1 case out of 40) of AL. It’s evident that to validate our results, further randomized studies on a larger data set are required. It would also be beneficial to evaluate quantitatively the fluorescence between the mucous and serous layer, to confirm the reduction of AL rate, the better evaluation of bowel perfusion and, especially in emergency surgeries, the potential reduction of further operations.

Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension

Background Laparoscopic transgastric necrosectomy (LTGN) has been used in treatment of walled-off pancreatic necrosis (WON) for more than a decade. However, the safety and effectiveness of LTGN for WON with sinistral portal hypertension was still unclear. Methods WON patients with sinistral portal hypertension treated in our department between January 2011 and December 2018 were included and retrospectively analyzed in this study. Patients were divided into two groups according to different surgical approaches, LTNG or laparoscopic assisted trans-lesser sac necrosectomy (LATLSN). Perioperative and long-term outcomes were compared between two groups. Results 312 cases diagnosed with WON were screened and 53 were finally included in this study. Of the included patients, 21 and 32 cases were received LTGN and LATLSN, respectively. LTGN was associated with significantly lower morbidity than LATLSN (19.0% vs 46.9%, p = 0.04) and similar severe complication (Clavien–Dindo ≥ III) rate (12.5% vs 19.0%, p = 0.70). LTGN did not increase the rate of postoperative hemorrhage (9.5% vs 6.3%, p = 1.00) and mortality (9.5% vs 9.4%, p = 1.00). After 39 (11–108) months follow-up, the recurrence rate of WON and long-term complications were also comparable between groups. Conclusion From current data, LTGN was safe and effective in treatment of WON patients with sinistral portal hypertension in terms of short- and long-term outcomes.

Normalization of Peri-Arteriovenous Malformation Hemodynamics Prior to Direct Microsurgery: 2-Dimensional Operative Video

Arteriovenous malformations (AVMs) are highly complex vascular lesions characterized by abnormal connections between arteries and an intervening nidus. Definitive and safe treatment of AVMs may require the combination of multiple treatment modalities to address the various complex features of the AVM.1 Endovascular embolization can be used as an adjuvant to surgery in order to control deep feeders, reduce flow, and address high-risk features such as aneurysms. In addition, by progressively reducing the AVM flow, staged embolization can lead to normalization of peri-AVM hemodynamics and therefore may decrease the risk of postresection hemorrhage.2,3 In this operative video, we present a case of a 41-yr-old female who presented with progressively worsening left-sided hemiparesis. Magnetic resonance imaging (MRI) and angiography revealed a complex right fronto-parietal AVM with significant associated edema, likely due to the vascular steal phenomenon. The area of edema, which included the motor cortex, was thought to be at high risk for postoperative hemorrhage from normal perfusion pressure breakthrough. We therefore decided to proceed with staged presurgical embolization to gradually normalize the perilesional hemodynamics, and therefore possibly reduce the risk of postoperative morbidity. The patient underwent 3 embolization sessions at 6-wk intervals. An MRI after the last embolization showed near-complete resolution of the fluid-attenuated inversion-recovery (FLAIR) signal around the AVM. Microsurgical resection was performed on the day after the last embolization. The patient tolerated the procedure well and was discharged at her neurological baseline with mild contralateral hemiparesis, which has continued to improve at follow-up. Postoperative angiography showed complete resection of the AVM. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication.

Early implementation of stereoelectroencephalography in children: a multiinstitutional case series

OBJECTIVE Pediatric stereoelectroencephalography (SEEG) has been increasingly performed in the United States, with published literature being limited primarily to large single-center case series. The purpose of this study was to evaluate the experience of pediatric epilepsy centers, where the technique has been adopted in the last several years, via a multicenter case series studying patient demographics, outcomes, and complications. METHODS A retrospective cohort methodology was used based on the STROBE criteria. ANOVA was used to evaluate for significant differences between the means of continuous variables among centers. Dichotomous outcomes were assessed between centers using a univariate and multivariate logistic regression. RESULTS A total of 170 SEEG insertion procedures were included in the study from 6 different level 4 pediatric epilepsy centers. The mean patient age at time of SEEG insertion was 12.3 ± 4.7 years. There was no significant difference between the mean age at the time of SEEG insertion between centers (p = 0.3). The mean number of SEEG trajectories per patient was 11.3 ± 3.6, with significant variation between centers (p < 0.001). Epileptogenic loci were identified in 84.7% of cases (144/170). Patients in 140 cases (140/170, 82.4%) underwent a follow-up surgical intervention, with 47.1% (66/140) being seizure free at a mean follow-up of 30.6 months. An overall postoperative hemorrhage rate of 5.3% (9/170) was noted, with patients in 4 of these cases (4/170, 2.4%) experiencing a symptomatic hemorrhage and patients in 3 of these cases (3/170, 1.8%) requiring operative evacuation of the hemorrhage. There were no mortalities or long-term complications. CONCLUSIONS As the first multicenter case series in pediatric SEEG, this study has aided in establishing normative practice patterns in the application of a novel surgical technique, provided a framework for anticipated outcomes that is generalizable and useful for patient selection, and allowed for discussion of what is an acceptable complication rate relative to the experiences of multiple institutions.

Preventing Surgical Complications During Microscopic Fenestration in Middle Fossa Arachnoid Cysts: A Retrospective Study for 38 Cases and Literature Review

Purpose Middle fossa arachnoid cyst (MFAC) is one of the most common cranial cysts in children. The various postoperative complications following cyst fenestration are still the major concern for most surgeons. We systemically review the short-term postoperative complications in the literature and introduce our experience in preventing these complications.Methods A retrospective survey was conducted on the 38 cases of patients having MFAC (<14 years old) who underwent microscopic fenestration from January 2019 to December 2020. Short-term postoperative complications including postoperative hemorrhage/hematoma, subdural hygroma (SH), cranial nerve palsy, and central nervous system infection (PCNSI), and cerebrospinal fluid (CSF) leak were collected. A systematic PubMed search for cohort studies of surgically treated MFAC published from 2000 was performed. The short-term postoperative complications in the included studies were illustrated.Results The overall complication rate in our series is 5.2%. Eight patients (21.1%) developed postoperative SH. One of them required reoperation. Patients who developed SH were significantly younger (4.1±1.6 versus 6.2±3.4 y.o., p=0.018). Binary logistic analysis showed that a lower age could be a risk factor for developing SH (P=0.115). No postoperative hemorrhage, cranial nerve palsy, or CSF leak was observed. In the systemic review, eighteen studies were included, comprising 649 cases of MFAC. The most common complication was SH (4.9%). The short-term postoperative complication rate between microscopic and endoscopic techniques was similar.Conclusion The complication rate in MFAC fenestration is low in children. SH is the most common postoperative complication, and it is prone to occur in young children.

К ВОПРОСУ ПРЕВЕНЦИИ И РАННЕЙ ИДЕНТИФИКАЦИИ ХАРАКТЕРА И ПРИЧИН ПОСЛЕОПЕРАЦИОННЫХ ОСЛОЖНЕНИЙ ПРИ ВМЕШАТЕЛЬСТВАХ ПО ПОВОДУ РАЗЛИЧНЫХ КЛИНИКО-АНАТОМИЧЕСКИХ ФОРМ ТЯЖЕЛОЙ ЧЕРЕПНО-МОЗГОВОЙ ТРАВМЫ

The analysis of the causes of postoperative complications was carried out, as well as of the failures and errors or the same omissions in postoperative management. The total number of cases was 177 (5%) among more than 3500 patients, being operated on various clinical and anatomical forms of craniocerebral trauma.In 63.8% (in 113 patients), worsening of condition was associated with the postoperative hemorrhage, which in 54% of cases was shell- recurrent. In 36.6% of observations (in 64 patients), deteriorated states of the brain swelling or edema were associated with an increase of cerebral edema.The main causes of the postoperative volume hemorrhages were the inadequacy of homeostasis and fluctuations in blood pressure during the first hours and days after surgery, with a tendency of significant increase of that latter. Diagnostic errors were the result of underestimation or incorrect evaluation of neurological symptoms and clinical signs of repeated volumetric hemorrhages.Late diagnosis of postoperative complications resulted in a lethal outcome in 79 (44.6%) cases among 177 patients with the complications in the postoperative process. Neurological and clinical signs and their combinations characteristic for postoperative volumetric hemorrhages are given in the article, as well as are offered the ways of their prevention.

Congenital hemophilia A diagnosed with postoperative hemorrhage after thyroidectomy for papillary thyroid carcinoma: a case report

Background Postoperative bleeding in thyroid surgery is a serious complication with fatal outcomes. Risk factors for postoperative hemorrhage have been reported as old age, male sex, Graves' disease, use of anticoagulants, and hematological disorders. Among the hematological diseases, congenital hemophilia is an inherited bleeding disorder characterized by absence or reduced levels of clotting factors VIII or IX. Most patients with hemophilia display bleeding symptoms during infancy or childhood, but diagnosis could be delayed in mild cases. We report a case of congenital hemophilia A that was diagnosed after three episodes of postoperative bleeding after thyroid surgery. Case presentation A 46-year-old man developed repeated postoperative hemorrhage after thyroid surgery for thyroid cancer. In this case, several irregularities were seen in the postoperative course, such as a relatively long interval between surgery and bleeding, the lack of an obvious bleeding point, fresh red blood dripping from the drain insertion site on the second postoperative day, and repeated bleeding three times. We therefore considered that the cause of postoperative hemorrhage might be other than the surgical operations. After a thorough examination, hemophilia A was diagnosed. Conclusions Hemophilia is a risk factor for postoperative bleeding in thyroid surgery. However, mild hemophilia shows normal prothrombin time and activated partial thromboplastin time. We encountered a case of papillary thyroid carcinoma associated with congenital hemophilia A, which was diagnosed after repeated bleeding.