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Background The mean length of stay (LOS) following minimally invasive radical prostatectomy (MI-RP) is less than 2 days. Our main objective was to utilize the National Surgical Quality Improvement Program Database (NSQIP) to evaluate preoperative factors that may contribute to prolonged hospital stay and readmission. Materials and methods Utilizing the NSQIP database, records for surgery with the Current Procedural Terminology (CPT) code 55866 (prostatectomy) between 2007 and 2017 were evaluated. Chi-square and t-tests were used to assess the effects of preoperative factors on prolonged LOS and rates of hospital readmission within 30 days. Odds ratios, p-values, and confidence intervals were determined using multivariable logistic regression. Results 40,764 patients underwent MI-RP between 2007 and 2017. Of these, 11.7% reported a LOS of more than 2 days, while 3.9% of patients were readmitted to the hospital within 30 days. Preoperative congestive heart failure within 30 days of surgery was shown to be strongly associated with both prolonged LOS (OR = 6.16) and readmission (OR = 3.28). Bleeding requiring transfusion was demonstrated to be the most significant postoperative factor for prolonged LOS (OR= 23.9), while unplanned intubation was shown to be the most significant postoperative factor for readmission (OR=57.1). BMI over 30 was associated with both prolonged LOS and increase in readmission. Conclusions Upon NSQIP database analysis, cardiopulmonary factors and BMI were demonstrated to have negative impacts on postoperative quality indicators. Patients with comorbidities should be counselled preoperatively concerning their individual risk factors. Mitigation of these factors is important in ensuring optimal outcomes.

BACKGROUND Conversion total knee arthroplasty (TKA) may represent a more complex procedure compared with primary TKA. The purpose of this study was to compare 30-day complications between conversion TKA and primary, non-conversion TKA as well as between conversion TKA and revision TKA on a national scale using a multi-center surgical registry. METHODS Adult patients undergoing conversion TKA from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database and were compared with patients who underwent primary TKA and aseptic revision TKA. In this analysis, 30-day complications were assessed. Bivariate analyses, including chi-squared and analysis of variance, and multivariate logistic regressions were performed. RESULTS Of 299,065 total patients undergoing knee arthroplasty, 1,310 (0.4%) underwent conversion TKA, 275,470 (92.1%) underwent primary TKA, and 22,285 (7.5%) underwent revision TKA. Following adjustment, patients who underwent conversion TKA were more likely to have increased risks of any complications (P

Background and aim Surgical aortic valve replacement (SAVR) is the most common valvular surgery and thus needs to be widely available including minorities and socially disadvantaged patients. SAVR outcomes at safety-net hospitals, which serve a high percentage of these patients, are limited. We aimed to compare the outcomes of SAVR at different safety-net burden hospitals. Methods Nationwide Inpatient Sample from 2005 to 2011 was queried to identify SAVR performed for over the age of 50. The safety-net burden of hospitals was calculated as the number of admission to a hospital in a year who were uninsured or insured by Medicaid divided by the total number of admissions for the respective year. Hospitals were categorized into quintiles of safety-net rate and then into three categories based on the safety-net burden (low burden hospitals [LBHs], lowest quintile, medium burden hospitals [MBHs], 2nd-4th quintiles; and high burden hospitals [HBHs], highest quintile). Results A total of 85 441 SAVR were included. In unadjusted models, in-hospital mortality was higher in HBHs compared with LBHs but became nonsignificant after adjustments for patient and hospital-level characteristics. Major perioperative complications and hospital costs were similar, but hospital stay was longer at HBHs compared with LBHs. At MBHs, acute kidney injury requiring dialysis and bleeding requiring transfusion was lower compared with LBHs. Length of stay and cost were shorter and lower at MBHs compared with LBHs. Nonroutine discharge was similar for HBHs and MBHs compared with LBHs. Conclusion SAVR outcomes are reassuring at MBHs and HBHs.

Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery. The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample. Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79). Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods.

Introduction: Coagulopathy after cardiac surgery is a serious multifactorial complication that results in postoperative bleeding requiring transfusion of red blood cells and procoagulant products. Use of cardiopulmonary bypass represents the major contributing factor affecting coagulation. We sought to prospectively investigate the effect of contemporary minimal invasive extracorporeal circulation (MiECC) on coagulation parameters using point-of-care (POC) rotational thromboelastometry and the relation to postoperative bleeding. Methods: Patients undergoing elective cardiac surgery on MiECC were prospectively recruited. Anticoagulation strategy was based on individualized heparin management and heparin level-guided protamine titration. Rotational thromboelastometry testing was performed before induction of anesthesia and after aortic cross-clamp release. A strict POC-guided transfusion protocol was implemented. The primary endpoint was the assessment of viscoelastic properties of the coagulating blood at the end of surgery compared to preoperative values and the relation to postoperative bleeding and 24-hour transfusion requirements. Results: Fifty patients were included in the study with a significant proportion having complex surgery. Thirteen patients (26%) required blood transfusion (mean rate: 0.5 ± 1 units per patient), 5/50 (10%) received coagulation factors while no patient received fresh frozen plasma, platelets or fibrinogen. Thromboelastometry analysis showed that the major derangement was CT EXTEM > 100 seconds in 28/50 (56%) and A10 EXTEM Conclusions: MiECC preserves clot quality throughout surgery acting in both key determinants of clot strength; fibrinogen and platelets. This is clinically translated into minimal postoperative bleeding and restricted use of blood products and coagulation factors.

Parotid gland pathologies requiring resection present with varying effects on surrounding tissue architecture, and we hypothesize that this spectrum of indications confers different risks of adverse events. The purpose of this study is to elucidate the complication profiles of parotidectomy in children across a spectrum of pathologies requiring parotid resection.The American College of Surgeons National Surgical Quality Improvement Program Pediatric data set was queried for parotidectomies performed from 2012 through 2017. Indications were subclassified based on International Classification of Diseases, Ninth Revision and Tenth Revision codes. Complications, readmissions, and reoperations were analyzed with appropriate statistics.Parotidectomies in children (n = 208) were mostly performed for neoplasms (47.6%), followed by inflammatory conditions (24.0%). Total parotidectomies took significantly longer (P0.001) and remained in the hospital significantly longer than superficial parotidectomies (P0.001). There was no significant difference (P = 0.417) between benign neoplasms (29.3%) and malignant neoplasms (37.9%) requiring total parotidectomy. However, there was a significant difference (P = 0.014) across various malformations, with 83.3% of lymphatic malformations requiring total parotidectomy. Although lymphatic malformations required more aggressive resection, these procedures had the lowest rate of adverse events (0%). Despite the unappreciable predilection toward total parotidectomy based on nature of neoplasms, parotidectomy performed for malignant neoplasms had a significantly increased risk of nerve injury (P0.001; odds ratio [OR], 3563) and medical complications (P0.001; OR, 67.2), whereas those performed for benign neoplasms did not have an increased risk of these complications (all P's0.209). Parotidectomy performed for vascular malformations had significantly increased risk of bleeding requiring transfusion (P0.001; OR, 14.9) and surgical complications (P0.001; OR, 9.2). Bleeding requiring transfusion was significantly related to longer surgical procedures (P0.001; 409 vs 191 minutes).Parotidectomy in pediatric patients for malignant neoplasms is associated with a significantly higher risk of nerve injury compared with parotidectomy for benign neoplasms. Parotidectomy for vascular malformations has a significantly higher risk of bleeding requiring transfusion, whereas parotidectomy for lymphatic malformations is associated with the lowest risk of medical and surgical complications.

Introduccion: la Organizacion Mundial de la Salud (OMS) recomienda que la incidencia de cesarea no supere el 15%; sin embargo, su uso se ha incrementado en las dos ultimas decadas, lo cual implica un problema de salud publica. Objetivo: caracterizar los resultados adversos maternos y neonatales de la cesarea en la Clinica Maternidad Rafael Calvo (CMRC) de Cartagena Colombia. Materiales y metodos: estudio descriptivo de corte transversal, donde se caracterizaron los resultados adversos maternos y neonatales posteriores a cesarea. Resultados: se realizaron 1.804 cesareas (46.5%) y 2.073 partos vaginales (53.5%). Las indicaciones mas frecuentes para cesarea fueron cesarea anterior (35.5%), desproporcion cefalo pelvica (30.6%) y oligoamnios (10.8%). Los resultados adversos maternos mas frecuentes fueron hemorragia que requirio transfusion (9.17%), hematoma en la herida quirurgica (3.28%) e ingreso a UCI (1.5%). Los resultados neonatales adversos mas frecuentes fueron APGAR

In hip fracture patients with elevated international normalized ratios (INRs), the risks of delaying surgery for correction of INR are controversial. We examined the association of (1) preoperative INR values and (2) surgical delay with postoperative complications after intramedullary nailing of hip fractures.Using the National Surgical Quality Improvement Program database, we retrospectively identified patients that underwent intramedullary nailing for hip fractures from 2005 to 2016. Patients aged older than 55 years with preoperative INR recorded ≤1 day before surgery were included. Patients were stratified into five cohorts-(1) INR ≤ 1.0, (2) 1INR ≤ 1.25 (INR [1 to 1.25]), (3) 1.25INR ≤ 1.5 (INR [1.25 to 1.5]), (4) 1.5INR ≤ 2.0 (INR [1.5 to 2.0]), and (5) INR2.0. The primary outcomes of interest were postoperative bleeding requiring transfusion, surgical site infection, and 30-day mortality. Multivariate regression analysis was done to adjust for potential confounding variables.In total, 15,323 patients were included in this analysis. Adjusting for potential confounders, INR [1 to 1.25], INR [1.25 to 1.5], and INR [1.5 to 2.0] were associated with increased mortality (adjusted odds ratio [aOR]: 1.501, P0.001; aOR: 2.226, P0.001; aOR: 2.524, P0.001, respectively) and surgical delay48 hours (aOR: 1.655, P0.001; aOR: 3.434, P0.001; aOR: 2.382, P0.001, respectively). The INR2.0 cohort was not associated with mortality (P = 0.181) or surgical delay (P = 0.529). Surgical delay was associated with mortality (aOR: 1.531, P = 0.004). The INR2.0 cohort was associated with increased rate of transfusions (aOR: 1.388, P = 0.039).Elevated preoperative INR value within 1 day of surgery between 1.0 and 2.0 was associated with increased risk of 30-day mortality and surgical delay48 hour, which may represent attempts at INR correction. An INR greater than 2.0 was not associated with mortality or surgical delay but was associated with increased transfusions. Surgical delay was independently associated with increased risk of 30-day mortality. We therefore recommend that INR reversal be attempted but not delay surgical fixation of geriatric hip fractures over 48 hours and counsel patients and their families regarding the risks of surgery with elevated INR.Prognostic-level III/retrospective cohort study.

Introductions: Renal stone disease is one of the common urological disorders with prevalence approximately 2-3% in the general population and the incidence in children is increasing at a rate of 4% per year. Miniaturization of endoscopic instruments, minimally invasive endoscopic procedures of mini percutaneous nephrolithotomy (miniPCNL) in children is increasingly used. This study was conducted to assess the outcome of miniPCNL in pediatric population. Methods: This retrospective study analyzed the outcome of miniPCNL in children below 18 years of age from August 2015 to July 2018 at Patan Hospital, Nepal. Ethical approval was obtained. Outcome was assessed descriptively on stone localization, puncture success, stone clearance, bleeding requiring transfusion, gross hematuria, urosepsis, operative time, hospital stay, mortality and need of second procedures. Results: A total of 26 patients underwent miniPCNL, mean age 10.8±5.45 years (1-18 years), mean operative time was 122±26.03 minutes and mean hospital stay was 3.2±1.12 days. Postoperative transfusion was required in 1 (2.6%), gross hematuria occurred in 1 (2.6%), no urosepsis, no conversion to open surgery. Complete stone clearance was achieved in 22 (84.61%) patients. Mortality was nil. Second procedure was required in 4 (15.38%) to achieve residual stone clearance. Conclusions: Our study shows miniPCNL is an effective and safe procedure with minimal morbidity for the treatment of pediatric renal stones. Keywords: mini percutaneous nephrolithotomy (miniPCNL), renal stones, children

Introduction This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program–Pediatric (NSQIP-P) database. Methods We performed a retrospective cohort study involving patients in the 2012–2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions. Results Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p

Objective: The objective was to assess the reliability and validity of “S.T.O.N.E” nephrolithometry scoring system to predict the stone-free rate (SFR) after percutaneous nephrolithotomy (PNL). Methods: A total of 123 patients with unilateral radiopaque stones ≥2 cm were included in the study. According to S.T.O.N.E score, five parameters available from preoperative computed tomography (CT) without contrast were measured: stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence of stone (E). The Stone free rates evaluated within one month postoperatively by plain X-ray and/or CT scan without contrast. Results: The mean S.T.O.N.E. score in this study was 7.4 in stone-free (SF) group and 9.3 in residual stone group (P = 0.0001). Patients with SF comprised 82.1% after the first PNL, whereas 17.9% had significant residual stones >4 mm. Postoperative complications were 8%. The most common complications were bleeding requiring transfusion. The size of stone (P = 0.002) and number of calices involved (P = 0.001) had a statistically significant difference between patients with residual stones, other components were not. There was a statistically significant difference between non-SF and SF according to the hospital stay (P = 0.002). Conclusion: This score predicted the clearance after PNL. The size of calculi and number of calices involved statistically affected the stone clearance, whereas other S.T.O.N.E scoring parameters were not. There was a statistically significant difference between SF and residual stones groups according to the hospital stay (P = 0.0001).

To find out better treatment option in treating renal stone safely, expeditiously. A total of 90 patient were prospectively randomized for Percutaneous Nephrolithotomy (PCNL) (40) and Extra Corporeal Shock Wave Lithotripsy (ESWL) (50). Stone clearance, adjuvant procedures, hospital stay, post procedure morbidity, were compared for both methods. Stone clearance in PCNL and ESWL group was 87.50 and 66 percent respectively with a significant difference of clearance (P0.05). But in larger stones, stone clearance was 87.50% and 60.72% among PCNL and ESWL group respectively with significant difference in clearance between the groups (P

Aim: In this study, we aimed to present the functional and oncologic results of robotic assisted partial nephrectomy (RAPN) in clinical stage T1 tumors.Material and Methods: Fifteen patients who had undergone RAPN for T1a-b kidney tumor between July 2017 and January 2019 were included in the study. The demographic data, mean operation time, estimated blood loss, duration of warm ischemia, length of hospital stay and oncologic results were evaluated retrospectively.Results: Ten male and five female patients with a mean age of 55.4±7.6 (48-71) years were included in the study. A 4-port trans peritoneal approach was applied to all the patients. Nine right and six left renal masses with a mean tm diameter of 2.8±0.4 (2.4-3.6) cm were operated. The mean operation time was 217 (185-250) minutes, the mean blood loss was 225.6 (180-265) cc. Bleeding requiring transfusion was seen in one patient and a spontaneously resolved ileus was seen in another patient. Urethral stents were placed into two patients because the collector system was opened. 8 (53%) of renal masses were reported as renal cell carcinoma. Surgical margin positivity was identified in 2 (13%) of the patients. No local recurrence or distant metastasis was observed in any of the patients. None of the patients experienced incisional hernia and late complications. Conclusion: Robot-assisted partial nephrectomy is presently the gold standard treatment for patients with clinical stage T1 renal tumor. RAPN is an effective, safe and minimally invasive treatment modality in patients eligible for partial nephrectomy.

Transcatheter embolization is defined as the intravascular deposition of particles, liquid, or mechanical agents to produce vessel occlusion. Technical success is typically defined as a cessation of active contrast media extravasation (if present before embolization) from the bleeding site at the end of the procedure. In presence of only indirect signs, it is considered as complete occlusion of pathologically changed arteries or pseudoaneurysms. Clinical success definition varies greatly between the various reports in the literature. It is usually associated with the resolution of signs and symptoms of bleeding in a defined time period (mostly 30 days). Some studies also include secondary clinical success after repeated embolization in case of recurrent bleeding. Persistence of melena or hematemesis within 12–24 h after the procedure should not be considered a clinical failure if not associated with clear laboratory or clinical signs of blood loss and should not indicate the need for a reintervention. Acute significant bleeding is generally considered as bleeding requiring transfusion of at least 4 units of blood within 24 h or causing signs of hemodynamic instability and shock (hypotension systolic BP of 100) [8, 9, 10].

Introduction: This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. Methods: All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. Results: A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. Conclusion: This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily.

Background— Women are at a higher risk for bleeding/vascular complications (VC) related to cardiovascular procedures. Although the overall incidence of percutaneous coronary intervention (PCI)-related bleeding/VC has declined, the impact of this decline, specifically in women, is unknown. Methods and Results— We studied 13 653 female and 32 334 male consecutive cases, from 2002 to 2007, in the Northern New England PCI Registry. We sought to (1) compare absolute rates of bleeding/VC in women and men over time, (2) define predictors of bleeding/VC in women and men undergoing PCI, and (3) trend the impact of female gender in predicting bleeding/VC over time. Bleeding/VC was defined as any access-site vessel injury requiring surgical intervention or bleeding requiring transfusion. The overall risk of bleeding/VC was significantly higher in women versus men (4.5�1.3% versus 1.6�0.5%; P P Conclusion— Women undergoing PCI have had a significant decline in bleeding/VC rates during the last 6 years. Despite the improvement in procedural safety, female gender continues to be associated with a >2-fold risk of bleeding/VC compared with men.

BACKGROUND AND OBJECTIVE: Transfemoral arterial access of catheterization requires a method of hemostasis that is allways easily and quickly applicable, but also safe, inexpensive and comfortabel for the patient. Current methods meet these requirements only in part. The pneumatic pressure-controlled FemoStopTM system has been described as straightforward and safe. But the conventional procedure has been to achieve primary hemostasis with FemoStopTM and then switch to a pressure bandage. We here present our method of using FemoStopTM alone for the entire duration of the compression and compare the results with those of manual compression. PATIENTS AND METHODS: The preferred methods of managing the arterial puncture site in our center were compared for two different periods. Group MC (manual compression) comprised 1,085 patients (mean age 63.310.5 years, 29.8% females) in whom manual compression had been applied followed by a pressure bandage. Group FS (pneumatic compression) comprised 1,087 consecutive patients (mean age 64.610.7%, 35.1% females) in whom pneumatic compression only had been applied. The incidence of pseudoaneurysms, a-v fistulas and bleeding requiring transfusion were compared. RESULTS: The incidence of pseudoaneurysms after diagnostic cardiac catheterizationin the FS group was lower than in the MC group. In patients after an angioplasty the results were similar other than the time the patient has to remain in bed. The incidence of a-v fistulas was similar in the two groups. There was only one episode pf bleeding that required transfusion (MC group). A multivariate analysis indicated that female gender is an independent risk factor for the occurrence of pseudoaneurysms and a-v fistulas. CONCLUSIONS: The FemoStopTM system used by itself took less time than manual compression and was associated with a slightly lower risk of complications.

Graphical abstract, Highlights • Severe haematuria following PCN and antegrade stent insertion. • The severe bleeding recorded in this case could not have been attributed to the stent. • CT renal angiogram organised early to exclude and renal vascular injury following PCN and antegrade stent insertion. • CT renal angiogram revealed stent was in the nephrostomy tract. • Change of stent settled haematuria., Introduction Transient minor bleeding after nephrostomy tube placement is very common, occurring in up to 95% of cases. Often this is due to small vessel or venous bleeding. Severe post procedure bleeding requiring transfusion or other intervention is RARE. Presentation of case A case of a 79 year old man, who had antegrade stent insertion for 10 mm left upper ureteric stone. He was alright for up to one week but developed severe haemturia requiring three way catheter. Catheter was blocking regularly and needed to go to theatre for bladder washout. No source of bleeding was found in bladder. CT renal angiogram revealed his stent has migrated into the nephrostomy tract. He was taken to theatre and had his stent changed. His haematuria settled. Discussion The severe bleeding recorded in this case could not have been attributed to the stent, though the initial bleeding following the procedure has settled it seemed likely to blame vascular injury following PCN as the cause of bleeding. Subsequent CT scan was able to point at the right source of bleeding. Conclusion All possibilities should be considered when presented with a case severe bleeding following antegrade stent insertion.

Large multicenter studies comparing outcomes between TURP and photoselective vaporization of the prostate (PVP) are sparse, with no studies having compared the influence of trainee involvement on these outcomes. Our objectives were to assess 30-day outcomes after TURP and PVP with respect to trainee involvement using an independent national surgical database. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data (2005–2011), 7893 men were identified who underwent TURP or PVP. Regression models were constructed to assess associations between surgical approach, risk-adjusted morbidity and individual complications. Relationships between operative approach, operative duration and duration of stay were also examined and subdivided based upon trainee level. Of 7893 patients, 4950 (62.7%) underwent TURP and 2943 (37.3%) underwent PVP. TURP patients were older, more likely to have diabetes, cancer, history of steroid use and preoperative transfusion compared with PVP patients, who were more likely to have coronary artery disease or bleeding disorders. Risk-adjusted overall morbidity was similar; however, PVP was associated with less pneumonia (0.2% vs 0.5%, P

To estimate the costs to manage selected types of bleeding complications in patients with acute coronary syndrome (ACS) treated with antithrombotics, including antiplatelet, and fibrinolytic therapies: decrease in haemoglobin3 g/dL, puncture site, and bleeding requiring transfusion of blood products.Retrospective chart reviews of ACS patients experiencing decrease in Hb, puncture site, or bleeding requiring transfusion were conducted in hospitals in France, Germany, Italy, Spain and Sweden to determine the total length of stay (LOS), stay post-bleeding, procedures to identify the extent of bleeding, number and types of transfusion products, patient demographics, reason for hospital admission and disposition upon discharge. Country-specific costs were applied to estimate the average cost per patient by type of bleeding event.Records of 158 ACS patients with the bleeding complications were examined (26.9% decrease in Hb, 35.5% puncture site, and 37.8% transfusion). The average LOS was 10.6 days for decreasing Hb, 7.7 days for puncture site bleeding, and 11.3 days for patients receiving transfusions due to these bleeding events. The average costs per patient ranged between €3,986 and €10,252. The LOS ranged widely both within and across countries.The study has a small sample size and costs are confounded by co-morbidities.The estimated costs for decreasing Hb, puncture site bleeding and bleeding resulting in transfusions provide a tool for researchers to conduct economic analyses of bleeding events associated with therapies for ACS.

We compared single- and double-stick techniques of percutaneous nephrostomy insertion by retrospectively reviewing 140 percutaneous nephrostomy procedures in 101 patients. All procedures were performed by residents or fellows with direct attending supervision. Either the single-stick or double-stick technique was used based solely on personal attending preference. There were no significant differences in groups in terms of age, sex, or degree of hydronephrosis. In the single-stick technique, the kidney was punctured with sonographic guidance and the tract was serially dilated to accept an 8.5 Fr. nephrostomy catheter. In the double-stick technique, the kidney was punctured with sonographic guidance and a mixture of air and contrast were injected into the collecting system. The affected side was then elevated and a posterior calyx was punctured using fluoroscopic guidance. Both groups were compared in terms of complications and early tube dysfunction using the chi-squared test. All procedures were successful without immediate complications. Bleeding requiring transfusion occurred in 4.7% (4/86) procedures in the single stick group and 3.7% (2/54) in the double stick group (p-value not significant). None of these patients required further interventions for bleeding. Tube dysfunction leading to premature tube exchange occurred in 3.5% (3/86) of catheters in the single stick group and 3.7% (2/54) of catheters in the double- stick group (p-value not significant). We found no significant difference between the single and double- stick methods of percutaneous nephrostomy in terms of success rates, complications, or tube function. We believe that the single-stick method should be adopted as the insertion technique of choice.

In this study, 144 consecutive percutaneous liver biopsies performed with a 1.6 mm Menghini needle, during a 2-year period were reviewed. All the children were aged under 15 years, 57 patients less than 1 year and 87 more than 1 year. All biopsies were adequate and the mean number of portal tracts examined was 17.6 per biopsy (14.3 in patients weighing less than 10 kg and 19.1 in the others). There were no deaths and we observed only bleeding complications. In patients with normal coagulation (128 cases), 1 bleeding requiring transfusion occurred; and in patients with abnormal coagulation (16 cases), we observed 2 bleeding cases requiring transfusion.Percutaneous liver biopsy can be performed with 1.6 mm needles in children. For increased safety, ultrasound-guided biopsies are recommended.

Introduction ERCP has become a well established therapeutic intervention. Indications and practice of ERCP have changed over the years due to advent of new imaging modalities. Our aim was to evaluate the ERCP indications, diagnosis and complications over 12month period, a decade apart. Methods Retrospective observational audit, data extracted from endoscopy reporting system and electronic patient’s records. Consecutive patients undergoing ERCP over 12 months in 2002 and 2012. Results Total number of ERCP’s performed was 233 and 212 in the year 2012 and 2002. Median age was 73 and 69 with IQR (58–82) and (56–80) years respectively. Gender ratio in 2012 of 1:1.1 and 1:1.5 in 2002. Diagnosis: in year 2012: stone disease 109 (46%). Pancreatic Cancer 31 (13.7%). Normal biliary tree 22(9%)whilst in the year In the year 2002 stone disease 90(42%). Pancreatic Cancer 16(7.5%). Normal Biliarytree 60(28%). Interventions: Year 2012: stent insertion 72(30.9%) and sphincterotomy 155(66.5%). year 2002 stent insertion 39(18.3%) and sphincterotomies 86(40.6%). Technical success rate in both the years was 95%. Complications: 30 day mortality in 2012 was 22(9.4%)and 12(5.7%) in 2002. There was one procedure related death in year 2012 (0.4%), none in 2002. Bleeding requiring transfusion : 14(6%) in 2012 6(2.6%) in 2002. Pancreatitis 6(2.6%) and 6(3.3%) in 2012 and 2002. Seven patients required sedation reversal in year 2002 as opposed to 0 in 2012. Reflecting the significantly reduced doses being used in the latter year. Conclusion 1) Work load remained the same. 2) Less number of normal ERCP’S 3) More pancreatic malignancies identified 4) More therapeutic procedures undertaken. Disclosure of Interest None Declared.

BACKGROUND AND STUDY AIMS The use of pure cut electrocautery current for endoscopic sphincterotomy lowers pancreatitis rates following endoscopic retrograde cholangiopancreatography (ERCP), but at the expense of greater localized bleeding which partially obscures the endoscopic view. We hypothesized that localized bleeding could be decreased by using blended current at the end of the sphincterotomy, without losing the benefit associated with pure cut current of lower post-ERCP pancreatitis benefit. PATIENTS AND METHODS Patients undergoing sphincterotomy were randomly allocated to receive pure cut current alone or a sequential combination of pure cut then blended current. In the sequential combination patients, the first 75 - 80 % of the sphincterotomy was done using pure cut current at 30 W and the remainder completed at a blend 2 setting (pure cut plus coagulation current), also at 30 W. RESULTS 142 patients were enrolled in the study. No statistical difference was noted between the two groups in the rates of overall pancreatitis or bleeding requiring transfusion. When comparing visible bleeding rates (more than a few drops), we found that there was significantly more bleeding (P < 0.05) in the pure cut group (31/75, 41 %) at the time of sphincterotomy compared with the sequential combination group (16/67, 23 %). CONCLUSIONS A sequential combination of pure cut and blended current for sphincterotomy caused less visible bleeding than pure cut alone. This occurred without a change in the rate of post-ERCP pancreatitis.

If laparoscopic cholecystectomy is to be a viable option for community surgeons and their patients, it should have a safety profile similar to or better than that of open cholecystectomy. Morbidity and mortality from 100 consecutive open cholecystectomies were compared to morbidity and mortality from 100 consecutive laparoscopic cholecystectomies. All procedures were done at Davis Community Hospital (Statesville, NC, population 25,000). Open cholecystectomies were done by seven staff surgeons from July 1987 to March 1990. Laparoscopic cholecystectomies were done by three staff surgeons from February 1990 to August 1990. Cholangiography during open cholecystectomy was selective. After an initial learning experience of 11 cases, cholangiography was routine during laparoscopic cholecystectomy. Patients having cholecystectomy coincidental to a planned common duct exploration for stones or neoplasia were excluded. For open cholecystectomy, morbidity was 13% and mortality, 2%. For laparoscopic cholecystectomy, morbidity was 9% and mortality, 1%. One death after open cholecystectomy was due to pulmonary embolus. The other two deaths in the series were due to underlying severe cardiopulmonary disease. Complications related directly to cholecystectomy were bleeding requiring transfusion (open 2, laparoscopic 1), bile leak (open 1, laparoscopic 1), wound infection (open 1), and prolonged back pain (laparoscopic 2). In two patients, the laparoscopic procedure was converted to open cholecystectomy. There were no common bile duct injuries in either group of patients. Results of this study suggest that laparoscopic cholecystectomy can be done as safely as open cholecystectomy, even in smaller community hospitals.

Purpose: The purpose of our study was to evaluate the procedural success, 6-month patency, and clinical outcome of a new 4F sheath-compatible, selfexpanding nitinol stent after failed conventional angioplasty or atherectomy of infrapopliteal lesions in critical limb ischemia (CLI). Methods: Clinical records of 13 patients with CLI (Rutherford class 4–6), who underwent stent implantation following percutaneous transluminal angioplasty (PTA) and/or atherectomy were reviewed. Stent placement was carried out due flow-limiting dissections, or elastic recoil after PTA. Before and after the intervention and during the 6-month follow-up, clinical evaluation and color-flow and duplex Doppler ultrasonography were performed. Technical success, primary patency at 6 months, and clinical improvement as defined by Rutherford with clinical and hemodynamic measures and complications were evaluated. Results: A total of 19 arterial territories were intervened upon. 4F Sheathcompatible, self-expanding nitinol stent system (XPERT; Abbott Vascular) with a diameter of 3–5 mm and a length of 20–60 mm was used. A total of 29 stents were deployed. Stent implantation was successfully performed in all patients. After stent placement, the primary cumulative patency rate for the study group at 6 months was 90%. The mean resting ankle-brachial index at baseline was 0.40±0.1 and significantly increased to 0.90±0.13 (Pb.001) at 24 h after intervention and 0.84±0.15 at 6-month follow-up (P b.001). The sustained clinical improvement rate was 78% at the 6-month follow-up. The 6-month limb salvage rate regarding major amputation was 85%. One patient (7.7%) developed major access site bleeding requiring transfusion. Conclusions: Nitinol self-expanding stents in infrapopliteal arteries can be deployed safely with good short-term patency rate and clinical benefit in the treatment of CLI.

Source Citation Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) t...

OBJECTIVE To identify a target group of children with acute immune thrombocytopenic purpura (ITP) that may not require hospitalization for management. METHODS A retrospective chart review was conducted of all children admitted over a two-year period to a tertiary care paediatric hospital with the diagnosis of acute ITP. Patients were classified according to typical and atypical presentations. Typical patients were defined as those aged between one and 10 years, with no hepatomegaly or significant splenomegaly and who had typical laboratory features for ITP. Patients who did not meet these criteria were categorized as atypical. Outcome measures included length of stay (LOS) in hospital; frequency of bone marrow aspiration (BMA); type of treatment; incidence of intracranial hemorrhage (ICH) or severe bleeding; and admission and discharge platelet counts. RESULTS There were 74 patients hospitalized for a mean of 3.6 days. No patients suffered an ICH or bleeding requiring transfusion. Patients with typical presentations (42) were compared with patients with atypical presentations (32) and were not significantly different for clinically important outcomes such as admission and discharge platelet counts, serious complications or type of therapy. Typical patients had significantly fewer BMAs than did atypical patients - 22 of 42 (52%) versus 25 of 32 (78%) (P=0.02), and a shorter LOS - 3.1 (+/-0.9) days versus 4.2 (+/-1.8) days (P=0.01). CONCLUSIONS Children presenting with ITP have a low incidence of bleeding complications and many of these patients can be managed as outpatients. A multicentre study is needed to properly delineate a low risk group suited for outpatient medical management.