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With the continuous development of robot-assisted technology, Robot-assisted Laparoscopic Partial Nephrectomy (RALPN) has gradually become an optional method for the treatment of Hemorrhage secondary to angiomyolipoma (HSA). However, there are rare clinical reports of the primary RALPN for HSA. Therefore, this research aims to evaluate the efficacy and safety of primary RALPN for HSA. Fourteen patients(six males and eight females), aged 14-56 years, underwent primary RALPN for HSA and were retrospectively analyzed from 2015 to 2023. The initial blood routine examination revealed decreased hemoglobin in all patients, and Contrast-enhanced computed tomography (CT) indicated retroperitoneal hematoma. After correcting shock and electrolyte imbalance through fluid therapy and medical treatment, all primary RALPN procedures were performed with transabdominal access on the side of the Hemorrhage. After tumor resection and hematoma removal with a monopolar Curved Scissor, the absorbable barbed suture was performed for inner and outer running stitches, respectively. Patient demographic information, perioperative characteristics, and functional outcomes were collected and analyzed. The initial tumor size of fourteen patients ranged from 57 to 145 mm, and the RENAL ranged from 7 to 11. All of the HSA was controlled, and primary RALPN was successful. The operating time it was ranged from 105 to 265 min. Postoperatively, one patient exhibited chylous drainage (Clavien-Dindo II), and another patient developed pleural effusion (Clavien-Dindo III). No postoperative transfusion and Digital Subtraction Angiography (DSA) highly selective embolization of the bleeding vessel was needed. No patients developed urinoma or urinary fistula. Within the follow-up period, the overall complications were manageable. Primary RALPN is a safe and effective procedure for HSA, which may be considered an alternative to selective renal artery embolization., (© 2024. The Author(s).)

Background: The Barcelona Clinic Liver Cancer (BCLC) staging system is an internationally recognized clinical staging system for hepatocellular carcinoma (HCC). However, this staging system does not address the staging and surgical treatment strategies for patients with spontaneous rupture hemorrhage in HCC. In this study, we aimed to investigate the prognosis of patients with BCLC stage A undergoing liver resection for HCC with spontaneous rupture hemorrhage and compare it with the prognosis of patients with BCLC stage A undergoing liver resection without rupture., Methods: Clinical data of 99 patients with HCC who underwent curative liver resection surgery were rigorously followed up and treated at Shandong Provincial Hospital from January 2013 to January 2023. A retrospective cohort study design was used to determine whether the presence of ruptured HCC (rHCC) is a risk factor for recurrence and survival after curative liver resection for HCC. Prognostic comparisons were made between patients with ruptured and non-ruptured BCLC stage A HCC (rHCC and nrHCC, respectively) who underwent curative liver resection., Results: rHCC (hazard ratio [HR] = 2.974, [p] = 0.016) and tumor diameter greater than 5 cm (HR = 2.819, p = 0.022) were identified as independent risk factors for overall survival (OS) after curative resection of BCLC stage A HCC. The postoperative OS of the spontaneous rupture in the HCC group (Group I) was shorter than that in the BCLC stage A group (Group II) (p = 0.008). Tumor invasion without penetration of the capsule was determined to be an independent risk factor for recurrence-free survival (RFS) after liver resection for HCC (HR = 2.584, p = 0.002)., Conclusion: HCC with concurrent spontaneous rupture hemorrhage is an independent risk factor for postoperative OS after liver resection. The BCLC stage A1 should be added to complement the current BCLC staging system to provide further guidance for the treatment of patients with spontaneous rupture of HCC., (© 2024 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

BACKGROUND Wünderlich syndrome (WS) is a rare diagnosis of nontraumatic spontaneous renal hemorrhage into the subcapsular, perirenal, or pararenal spaces. Prompt and effective intervention is necessary for an accurate pathological diagnosis and preservation of life. In the current literature, open surgery is the primary option when conservative treatment fails, but there can be serious trauma and corresponding consequences. Herein, we present 3 cases of Wünderlich syndrome managed by robot-assisted laparoscopic nephrectomy via a retroperitoneal approach. CASE REPORT Patient 1 was a 44-year-old woman with right flank pain for 6 h. Patient 2 was a 53-year-old woman with a history of diabetes who had pain in her right flank pain and nausea for 1 day. Patient 3 was a 45-year-old man with left flank pain for 1 day. All cases of WS were confirmed by CT. All 3 patients were treated with retroperitoneal robot-assisted nephrectomy after conservative treatment failed. Pathological examination confirmed that patient 1 had angiomyolipoma, and patients 2 and 3 had renal clear cell carcinoma. At the 9-month follow-up, renal function was good and no evidence of recurrence or metastasis has been detected. CONCLUSIONS These cases have highlighted the importance of the clinical history and imaging findings in the diagnosis of Wünderlich syndrome, and show that rapid management can be achieved using robot-assisted laparoscopic nephrectomy. However, it is crucial to have a skilled surgical team and adequate preoperative preparation.

Objective: To investigate the effect of different surgical timing on the surgical treatment of renal angiomyolipoma (RAML) with rupture and hemorrhage., Methods: The demographic data and perioperative data of 31 patients with rupture and hemorrhage of RAML admitted to our medical center from June 2013 to February 2023 were collected. The surgery within 7 days after hemorrhage was defined as a short-term surgery group, the surgery between 7 days and 6 months after hemorrhage was defined as a medium-term surgery group, and the surgery beyond 6 months after hemorrhage was defined as a long-term surgery group. The perioperative related indicators among the three groups were compared., Results: This study collected 31 patients who underwent surgical treatment for RAML rupture and hemorrhage, of whom 13 were males and 18 were females, with an average age of (46.2±11.3) years. The short-term surgery group included 7 patients, the medium-term surgery group included 12 patients and the long-term surgery group included 12 patients. In terms of tumor diameter, the patients in the long-term surgery group were significantly lower than those in the recent surgery group [(6.6±2.4) cm vs. (10.0±3.0) cm, P =0.039]. In terms of operation time, the long-term surgery group was significantly shorter than the mid-term surgery group [(157.5±56.8) min vs. (254.8±80.1) min, P =0.006], and there was no significant difference between other groups. In terms of estimated blood loss during surgery, the long-term surgery group was significantly lower than the mid-term surgery group [35 (10, 100) mL vs. 650 (300, 1 200) mL, P < 0.001], and there was no significant difference between other groups. In terms of intraoperative blood transfusion, the long-term surgery group was significantly lower than the mid-term surgery group [0 (0, 0) mL vs. 200 (0, 700) mL, P =0.014], and there was no significant difference between other groups. In terms of postoperative hospitalization days, the long-term surgery group was significantly lower than the mid-term surgery group [5 (4, 7) d vs. 7 (6, 10) d, P =0.011], and there was no significant difference between other groups., Conclusion: We believe that for patients with RAML rupture and hemorrhage, reoperation for more than 6 months is a relatively safe time range, with minimal intraoperative bleeding. Therefore, it is more recommended to undergo surgical treatment after the hematoma is systematized through conservative treatment.

Case 1 : A 75-year-old man was emergently admitted to our hospital with a complaint of continuous bleeding from the ileal conduit. The conduit was constructed by a total pelvic resection for sigmoid colon cancer that invaded the urinary bladder 24 years ago. Swollen cutaneous mucosa was seen around the ileal conduit, but no obvious bleeding spot was observed. The contrast-enhanced computed tomographic (CT) scan and 3D visualization revealed varices extending to the abdominal wall. Percutaneous transhepatic embolization successfully stopped the bleeding, but it was needed again after two years. Case 2 : A 72-yearold man with a history of open cystectomy and ileal conduit for bladder cancer came to our hospital two years after the surgery, complaining of continuous bleeding from the conduit. The skin around the stoma site was discolored purple, but no obvious bleeding site or bloody urine was observed. The CT scan similar to Case 1 revealed varices in the ileal conduit, and percutaneous transhepatic embolization successfully stopped the bleeding, but it was needed again after five months. After that, three months passed without recurrence.

Iatrogenic arterial injuries are rare but well-recognised complications of spinal surgery. This paper presents a case of an iatrogenic arterial injury during a total en bloc spondylectomy resulting in significant haemorrhage and the patient's haemodynamic instability. The devastating complication was successfully treated with an emergency thoracic endovascular aortic repair via a percutaneous popliteal approach, while the patient remained in prone position. The patient had an uneventful recovery with no subsequent arterial injury or pseudoaneurysm to the access vessel., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Percutaneous access and use of vascular closure devices facilitate thoracic endovascular aortic repair (TEVAR) procedures during local anesthesia and allow immediate detection of signs of spinal ischemia. However, the very large bore access (usually ≥22F sheath) associated with TEVAR increases the risk of vascular complications. In this study, we sought to define the safety and feasibility of two percutaneous femoral artery closure devices during TEVAR, in terms of access site vascular complications and major, life-threatening, or fatal bleeding (≥major) within 48 hours. Access site vascular complications were defined as technical failure of vascular closure or later formation of pseudoaneurysm., Methods: From March 2010 to December 2022, 199 transfemoral TEVAR were performed at Helsinki University Central Hospital, Finland. We retrospectively categorized these into three groups, based on surgeon preference for the access technique and femoral artery closure method: (1) surgical cut-down and vessel closure, n = 85 (42.7%), (2) percutaneous access and vascular closure with suture-based ProGlide, n = 56 (28.1%), or (3) percutaneous access and vascular closure with ultrasound-guided plug-based MANTA, n = 58 (29.1%). The primary outcome measure was technical success of vascular closure and access site vascular complications during index hospitalization. Secondary outcome measures were ≥major bleeding, early mortality, and hospital stay., Results: The technical success rate was 97.6% vs 91.1% vs 93.1% for surgical cut-down, ProGlide, and MANTA, respectively (P = .213). The rate of access site vascular complication was 3.5% vs 8.9% vs 10.3%, respectively (P = .290), with two pseudoaneurysms detected postoperatively and conservatively managed in the MANTA group. The vascular closure method was not associated with increased risk of ≥major bleeding, early mortality, or hospital stay on univariate analysis. Predictors for ≥major bleeding after TEVAR in multivariable analysis were urgent procedure (odds ratio: 2.8, 95% confidence interval: 1.4-5.5; P = .003) and simultaneous aortic branch revascularization (odds ratio: 2.7, 95% confidence interval: 1.3-5.4; P = .008)., Conclusions: In this study, the technical success rates of the percutaneous techniques demonstrated their feasibility during TEVAR. However, the number of access site complications for percutaneous techniques was higher compared with open approach, although the difference was not statistically significant. In the lack of evidence, the safety of the new MANTA plug-based vascular closure for TEVAR warrants further investigation., Competing Interests: Disclosures None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is exceedingly rare. The aim of this study was to define its incidence and describe its management and outcomes in this subset of patients., Methods: A retrospective multi-institutional study was conducted, screening 9565 patients with VS managed with SRS at 10 centers affiliated with the International Radiosurgery Research Foundation., Results: A total of 25 patients developed ITH (cumulative incidence of 0.26%) after SRS management, with a median ITH size of 1.2 cm 3 . Most of the patients had Koos grade II-IV VS, and the median age was 62 years. After ITH development, 21 patients were observed, 2 had urgent surgical intervention, and 2 were initially observed and had late resection because of delayed hemorrhagic expansion and/or clinical deterioration. The histopathology of the resected tumors showed typical, benign VS histology without sclerosis, along with chronic inflammatory cells and multiple fragments of hemorrhage. At the last follow-up, 17 patients improved and 8 remained clinically stable., Conclusion: ITH after SRS for VS is extremely rare but has various clinical manifestations and severity. The management paradigm should be individualized based on patient-specific factors, rapidity of clinical and/or radiographic progression, ITH expansion, and overall patient condition., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: The purpose of this study was to describe the long-term outcomes and associated risks related to repeat stereotactic radiosurgery (SRS) for persistent arteriovenous malformations (AVMs) in pediatric patients., Methods: Under the auspices of the International Radiosurgery Research Foundation, this retrospective multicenter study analyzed pediatric patients who underwent repeat, single-session SRS between 1987 and 2022. The primary outcome variable was a favorable outcome, defined as nidus obliteration without hemorrhage or neurological deterioration. Secondary outcomes included rates and probabilities of hemorrhage, radiation-induced changes (RICs), and cyst or tumor formation., Results: The cohort included 83 pediatric patients. The median patient age was 11 years at initial SRS and 15 years at repeat SRS. Fifty-seven children (68.7%) were managed exclusively using SRS, and 42 (50.6%) experienced hemorrhage prior to SRS. Median AVM diameter and volume were substantially different between the first (25 mm and 4.5 cm3, respectively) and second (16.5 mm and 1.6 cm3, respectively) SRS, while prescription dose and isodose line remained similar. At the 5-year follow-up evaluation from the second SRS, nidus obliteration was achieved in 42 patients (50.6%), with favorable outcome in 37 (44.6%). The median time to nidus obliteration and hemorrhage was 35.5 and 38.5 months, respectively. The yearly cumulative probability of favorable outcome increased from 2.5% (95% CI 0.5%-7.8%) at 1 year to 44% (95% CI 32%-55%) at 5 years. The probability of achieving obliteration followed a similar pattern and reached 51% (95% CI 38%-62%) at 5 years. The 5-year risk of hemorrhage during the latency period after the second SRS reached 8% (95% CI 3.2%-16%). Radiographically, 25 children (30.1%) had RICs, but only 5 (6%) were symptomatic. Delayed cyst formation occurred in 7.2% of patients, with a median onset of 47 months. No radiation-induced neoplasia was observed., Conclusions: The study results showed nidus obliteration in most pediatric patients who underwent repeat SRS for persistent AVMs. The risks of symptomatic RICs and latency period hemorrhage were quite low. These findings suggest that repeat radiosurgery should be considered when treating pediatric patients with residual AVM after prior SRS. Further study is needed to define the role of repeat SRS more fully in this population.

Liver rupture repair surgery serves as one tool to treat liver rupture, especially beneficial for cases of mild liver rupture hemorrhage. Liver rupture can catalyze critical conditions such as hemorrhage and shock. Surgical workflow recognition in liver rupture repair surgery videos presents a significant task aimed at reducing surgical mistakes and enhancing the quality of surgeries conducted by surgeons. A liver rupture repair simulation surgical dataset is proposed in this paper which consists of 45 videos collaboratively completed by nine surgeons. Furthermore, an end-to-end SA-RLNet, a self attention-based recurrent convolutional neural network, is introduced in this paper. The self-attention mechanism is used to automatically identify the importance of input features in various instances and associate the relationships between input features. The accuracy of the surgical phase classification of the SA-RLNet approach is 90.6%. The present study demonstrates that the SA-RLNet approach shows strong generalization capabilities on the dataset. SA-RLNet has proved to be advantageous in capturing subtle variations between surgical phases. The application of surgical workflow recognition has promising feasibility in liver rupture repair surgery.

Introduction: This study aimed to assess the impact of gamma knife radiosurgery on brainstem cavernous malformations (CMs)., Methods: A total of 85 patients (35 females; median age 41.0 years) who underwent gamma knife radiosurgery for brainstem CMs at our institute between 2006 and 2015 were enrolled in a prospective clinical observation trial. Risk factors for hemorrhagic outcomes were evaluated, and outcomes were compared across different margin doses., Results: The pre-radiosurgery annual hemorrhage rate (AHR) was 32.3% (44 hemorrhages during 136.2 patient-years). The median planning target volume was 1.292 cc. The median margin and maximum doses were 15.0 and 29.2 Gy, respectively, with a median isodose line of 50.0%. The post-radiosurgery AHR was 2.7% (21 hemorrhages during 769.9 patient-years), with a rate of 5.5% within the first 2 years and 2.0% thereafter. The post-radiosurgery AHR for patients with margin doses of ≤13.0 Gy (n = 15), 14.0-15.0 Gy (n = 50), and ≥16.0 Gy (n = 20) was 5.4, 2.7, and 0.6%, respectively. Correspondingly, transient adverse radiation effects were observed in 6.7 (1/15), 10.0 (5/50), and 30.0% (6/20) of cases, respectively. An increased margin dose per 1 Gy (hazard ratio: 0.530, 95% CI: 0.341-0.826, p = 0.005) was identified as an independent protective factor against post-radiosurgery hemorrhage. Margin doses of ≥16.0 Gy were associated with improved hemorrhagic outcomes (hazard ratio: 0.343, 95% confidence interval [CI]: 0.157-0.749, p = 0.007), but an increased risk of adverse radiation effects (odds ratio: 3.006, 95% CI: 1.041-8.677, p = 0.042)., Conclusion: The AHR of brainstem CMs decreased following radiosurgery, and our study revealed a significant dose-response relationship. Margin doses of 14-15 Gy were recommended. Further studies are required to validate our findings., (© 2023 S. Karger AG, Basel.)

The assumption is that a number of controlled trials have been conducted to assess the impact of uterus retaining or hysterectomy on wound and haemorrhage, but there is no indication as to which method would be more beneficial for wound healing. This research is intended to provide a comprehensive overview of the availability of wound healing in case studies of both operative methods. From inception to October 2023, four databases were reviewed. The odds ratio (OR) and the mean difference (MD) for both groups were computed with a random effect model, as well as the corresponding 95% confidence intervals. A total of five studies were carried out in the overall design and enrolled 16 972 patients. No statistical significance was found in the rate of postoperative wound infection among the two treatments (OR,1.46; 95% CI,0.66,3.22 p = 0.35); The rates of bleeding after surgery did not differ significantly from one procedure to another (OR,1.41; 95% CI,0.91,2.17 p = 0.12); two studies demonstrated no statistical significance for the rate of incisional hernia after surgery (OR,2.58; 95% CI,0.37,18.05 p = 0.34). Our findings indicate that there is a similar risk between uterine preservation and hysterectomies for the incidence of wound infection, haemorrhage and protrusion of incision., (© 2024 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Objectives: The objective of study is to describe a new surgical approach to cesarean delivery in women with invasive placenta accreta spectrum (PAS) accompanied by placenta previa., Material and Methods: Cesarean delivery was initiated with a transverse abdominal (Pfannenstiel) incision. A transverse incision was made above the vascular area in the lower uterine segment, and the fetus was delivered. The uterine fundus was removed from the abdomen and wrapped. Placental removal was started at posteriorly, continuing toward the anterior region. If dense adhesions were encountered, dissection was performed by inserting a finger between the adhesions to carefully separate them. It was recognized that two types of vessels develop to supply blood to the placenta. First, a perforating vessel emerges from adjacent tissues, entering the placental bed by perforating the uterine wall. Second, a superficial vessel runs along the uterine wall to enter the placental bed. The new emerging vessels were identified and ligated. Uterine sparing surgery was performed if the hemorrhage ceased. A cesarean hysterectomy was performed if hemorrhage did not cease., Results: Eight cesarean deliveries were performed using this new surgical approach. Cesarean hysterectomy was performed in three patients in who want to sterilization diser and don't mind fertility preservation. Severe maternal morbidity, invasive procedures, intensive care unit admission, and relaparotomy were not required., Conclusions: The described new surgical approach provide surgeon to perform cesarean delivery without causing increase maternal morbidity and mortality. Although the approach is new and the study population is small, the results have acceptable rationality and applicability.

Purpose: To compare the effectiveness and safety of a 27-gauge (27G) beveled-tip microincision vitrectomy surgery (MIVS) with a 25-gauge (25G) flat-tip MIVS for the treatment of proliferative diabetic retinopathy (PDR)., Methods: A prospective, single-masked, randomized, controlled clinical trial included 52 eyes (52 patients) with PDR requiring proliferative membrane removal. They were randomly assigned in a 1:1 ratio to undergo the 27G beveled-tip and or 25G flat-tip MIVS (the 27G group and the 25G group, respectively). During surgery, the productivity of cutting the membrane, the number of vitrectomy probe (VP) exchanges to microforceps, total operation time, vitrectomy time and intraoperative complications were measured. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) and postoperative complications were also assessed to month 6., Results: Forty-seven eyes (47 patients) completed the follow-up, including 25 in the 27G group and 22 in the 25G group. During surgery in the 27G group, cutting the membrane was more efficient (P = 0.001), and the number of VP exchanges to microforceps was lower (P = 0.026). The occurrences of intraoperative hemorrhages and electrocoagulation also decreased significantly (P = 0.004 and P = 0.022). There were no statistical differences in the total operation time or vitrectomy time between the two groups (P = 0.275 and P = 0.372), but the former was slightly lower in the 27G group. Additionally, the 27G group required fewer wound sutures (P = 0.044). All the follow-up results revealed no significant difference between the two groups., Conclusions: Compared with the 25G flat-tip MIVS, the 27G beveled-tip MIVS could be more efficient in removing the proliferative membrane while reducing the occurrence of intraoperative hemorrhages and electrocoagulation using appropriate surgical techniques and instrument parameters. Its vitreous removal performance was not inferior to that of the 25G MIVS and might offer potential advantages in total operation time. In terms of patient outcomes, advanced MIVS demonstrates equal effectiveness and safety to 25G flat-tip MIVS., Trial Registration: The clinical trial has been registered at Clinicaltrials.gov (NCT0544694) on 07/07/2022. And all patients in the article were enrolled after registration., (© 2023. The Author(s).)

Purpose: Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, in England there is evidence of wide variation in day-case rates across hospitals. Reducing the extent of this variation has the potential to support more efficient use of resources (e.g., clinician time, hospital beds) and help the recovery of elective surgical activity following the COVID-19 pandemic. The aims of this study were to explore the extent of variation in day-case rates across healthcare providers in England and to evaluate the safety of day-case elective primary inguinal hernia repair surgery., Methods: This was an exploratory, retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 were identified. The exposure of interest was day-case or in-patient stay, and the primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level., Results: A total of 413,059 elective primary inguinal hernia repairs were identified over the 8-year study period. Of these, 326,833 (79.1%) were day-case procedures. During the most recent financial year (2021-22), the highest day-case rate for an ICB was 93.8% and the lowest 66.1%. After adjusting for covariates, day-case surgery was associated with significantly lower rates of 30-day emergency readmission (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.58-0.64, p < 0.001) and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge. Rates of 30-day emergency readmission were significantly lower in ICBs with high rates of day-case surgery (OR 0.84, 95% CI 0.74-0.96, p < 0.001) than in ICBs with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates (OR 1.20, 95% CI 1.04-1.40, p = 0.015)., Conclusions: For the outcomes studied, we found no consistent evidence that day-case elective inguinal hernia repair was unsafe for selected patients. Currently, there is substantial variation between ICBs in terms of delivering day-case surgery. Reducing this variability may help address the current pressures on the NHS in elective surgery., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A 69-year-old woman was admitted to a territory hospital because of severe right hypochondoralgia after 2 weeks of internal medicine for persistent epigastralgia. Gastroduodenal endoscopy revealed a large tumor with a fistula in the duodenal bulb that expanded to the stomach. Histopathologically, the biopsy specimen indicated a poorly differentiated adenocarcinoma and HER2 negative. Computed tomography revealed that the tumor invaded the left lobe of the liver. The patient was referred to our hospital for cancer treatment. After 1 course of chemotherapy with S-1 and CDDP, laparoscopic gastroenterostomy bypass was performed because of tumor hemorrhage and poor food intake. However, the tumor hemorrhage and poor food intake continued, and the tumor enlarged. Therefore, left hemihepatectomy and distal gastrectomy with resection of the duodenal bulb were performed 1 month after bypass surgery. Histological testing confirmed the diagnosis of duodenal large-cell neuroendocrine carcinoma invading the liver without lymph node metastasis. Adjuvant chemotherapy was not administered, and the patient has been alive without recurrence for 7 years and 3 months. Neuroendocrine carcinoma of the non-ampullary duodenum is very rare; however, a large cell type without lymph node metastasis may be a factor in the long-term prognosis.

Hepatocellular adenomas are benign liver tumors, more frequently seen in young women with a history of long-standing use of estrogenic hormonal contraception. An acute rupture of these adenomas can be the first sign of symptoms; however, they can be life-threatening. The definitive management of hepatic adenoma is liver resection for those larger than 4 cm as this cutoff size is known to be associated with an exponential risk of harboring malignancy and an increased risk for intratumor bleeding. Once intratumor hemorrhage occurs however, the management of hepatic adenoma becomes much more timely critical. In this study, we describe the use of robotic liver resection for the management of hemorrhagic hepatocellular adenoma in a semi-acute setting. We also include a series of robotic hepatic adenoma resection completed in our hepatobiliary program since 2016, which demonstrated the safety, feasibility, and reproducibility of robotic technique in treating hepatic adenoma., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sharona Ross, MD received support from Intuitive Surgical Inc for the Women in Surgery career symposium in 2022.

Immune thrombocytopenic purpura (ITP) is a disorder caused by autoimmune antibodies which target glycoprotein IIb/IIIa complex or other platelet membrane antigens leading to platelet destruction. These platelets are then cleared by the spleen resulting in thrombocytopenia. Immune thrombocytopenic purpura affects about 1 to 6.4 cases in 100 000 children making it one of the most common causes of symptomatic thrombocytopenia in the pediatric population. It is rare that children or adolescents present with serious bleeding due to ITP. Common presentations include petechiae, bleeding gums, or bruising. Bleeding requiring hospitalization or transfusions is unusual and only occurs in approximately 5% of children. Even more uncommon is the presentation of severe bleeding complications requiring surgery for resolution. We present a case of a 17-year-old girl with acute ITP complicated by intraperitoneal hemorrhage and refractory thrombocytopenia due to ovarian cyst requiring oophorectomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The goal of this systematic review and meta-analysis was to provide an updated analysis of studies investigating outcomes, morbidity, and mortality associated with MR-guided laser interstitial thermal therapy (MRgLITT) corpus callosum ablation (CCA)., Methods: Study inclusion criteria for screening required that studies report on human subjects only, including patients aged 1-52 years diagnosed with drug-resistant epilepsy who underwent CCA. Sixteen articles published between 2016 and 2023 were included for the systematic review and analysis, including 4 case reports, 11 case series, and 1 case-control study. Altogether, 85 pediatric and adult patients undergoing CCA were included in the systematic review (46 patients younger and 39 patients older than 21 years). The main outcome of seizure freedom was measured using the decrease in the frequency of atonic seizures following surgery, percentage of atonic seizure freedom following surgery, and percentage of overall seizure freedom following surgery. These measurements were made using data from the last follow-up for patients with at least 6 months of follow-up post-CCA., Results: The extent of CCA differed across the pooled cohorts, including anterior two-thirds CCA (38.89%, n = 35) and posterior one-third CCA for completion of a prior partial CCA (22.22%, n = 20), complete CCA (27.78%, n = 25), or CCA of residual white matter in the case of subtotal initial ablation (5.56%, n = 5). Overall, 12.94% of the patients undergoing CCA experienced operational complications. The most common operative complications across 90 CCA operations were probe malpositioning (n = 6), hemorrhage (n = 5), off-target extension of splenium ablation to the thalamus (n = 1), infection (n = 1), and postoperative CSF leak (n = 1). Neurological deficits following CCA were reported as transient in 18.82% and permanent in 4.71% of patients across all studies. The most common neurological deficits were disconnection syndrome (n = 4) or transient hemiplegia (supplementary motor area-like syndrome; n = 4). The 6-month overall seizure freedom rate was 18.87% of 53 patients, and the atonic seizure freedom rate was 46.28% of 52 patients postoperatively. CCA resulted in an average decrease in atonic seizure rate from 8.30 to 1.65 atonic seizures per day (average decrease 80.12%)., Conclusions: CCA is associated with an acceptable complication profile, and most patients experience a meaningful reduction in target seizure semiologies. Accurate MRgLITT probe placement is likely important for maximizing CCA while avoiding collateral damage. Avoidable complications of CCA include off-target ablation (and associated deficits), hemorrhage, and future surgery for residual CCA to palliate continued seizures.

Objective: To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions., Methods: We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups., Results: From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P = .01)., Conclusion: Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: We aimed to evaluate the efficacy of bipolar cauterization for tract site bleeding during standard percutaneous nephrolithotomy (PCNL). Methods and Materials: We defined tract site bleeding as when the visual field across the parenchymal tract starts to bleed while the sheath of a balloon dilator is being withdrawn just before the operation is completed. Among 181 patients, 90 patients showed no significant bleeding, and 91 patients required further procedures to resolve tract site bleeding. In cases of unresolved tract site bleeding, either nephrostomy placement ( n  = 60) or cauterization ( n  = 31) was performed. The outcomes of three groups (no procedure group, nephrostomy group and cauterization group) were compared. Results: The median decrease in hemoglobin at 2-hour intervals postoperatively was -1.75, -1.0, and -0.2 in the nephrostomy, cauterization, and no procedure groups, respectively ( P  < .001). There were 25 patients (41.7%) who received transfusions in the nephrostomy group, whereas only 1 patient (3.2%) received a transfusion in the cauterization group ( P  < .001). Conclusion: The bipolar cauterization of bleeding points at the end of PCNL could efficiently decrease tract site bleeding and reduce the need for transfusion. Clinical Research Information Service (https://cris.nih.go.kr/cris; No. KCT0008303).

Introduction: Radiation-induced haemorrhagic cystitis (RIHC) is one complication of the pelvic radiotherapy. The GREENLIGHT© laser (GL) has been barely studied in the treatment of radiation cystitis. The primary objective was to evaluate the efficacy of GL in refractory RIHC patients (RRC) in a single-centre series., Materials and Methods: Twenty-nine patients were treated by GL bladder photocoagulation (GLBP). These patients showed signs of refractory haematuria in the context of RIHC. The primary endpoint was the absence of haematuria that would require a subsequent surgical intervention. Secondary endpoints were postoperative hospitalization length of stay, the occurrence of complications according to the Clavien-Dindo classification, the occurrence of functional urinary disorders and the number of cystectomies., Results: After a median follow-up of 30 months, 24 (82.7%) patients had no recurrence of haematuria. No postoperative complications were reported. A disabling overactive bladder secondary to the procedure occurred in 9 patients (31.0%). Two patients needed a cystectomy at 1 and 11 months., Conclusion: GLBP may constitute an efficient line of treatment for RIHC. Despite overactive bladder it allowed to avoid or delay cystectomy., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

The minimally invasive repair of pectus excavatum (MIRPE), or Nuss procedure, is regarded as the gold standard technique for the treatment of symptomatic pectus excavatum. Minimally invasive repair of pectus excavatum is regarded as a low-risk operation with a reported life-threatening complication rate estimated at around 0.1%. Presented are three cases of right internal mammary artery injury (RIMA) after MIRPE resulting in massive hemorrhage in both the acute and chronic postoperative setting and subsequent management strategies. Exploratory thoracoscopy and angioembolization were utilized which achieved prompt hemostasis and allowed for complete patient recovery.

The spleen is the most frequently affected organ in blunt abdominal trauma. Initial diagnostics include the physical examination, laboratory blood controls and ultrasound. Furthermore, a triphasic dynamic contrast-enhanced computed tomography (CT) scan is indicated. Apart from the imaging-based classification of the injury with consideration of vascular alterations and active bleeding, the hemodynamic condition of the patient is a crucial factor. For patients who are hemodynamically stable or can be stabilized, a nonoperative management with a minimum of 24 h of continuous monitoring, regular blood controls of the hemoglobin level as well as ultrasound follow-up should be given precedence. In cases of active bleeding or pathological vascular alterations, a radiological intervention in the sense of an embolization should be initiated. A hemodynamically unstable patient must immediately undergo surgical treatment, during which a spleen-preserving approach via splenorrhaphy should principally be favored over splenectomy. This also applies to patients where the intervention has failed. To prevent severe infections after splenectomy it is advised to vaccinate against Pneumococcus, Haemophilus influenzae type B and Meningococcus as well as the annual seasonal influenza vaccination according to the Standing Committee on Vaccination (STIKO) recommendations., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: We aimed to assess the outcomes and patterns of toxicity in patients with melanoma brain metastases (MBM) treated with stereotactic radiosurgery (SRS) with or without immunotherapy (IO)., Methods: From a prospective registry, we reviewed MBM patients treated with single fraction Gamma Knife SRS between 2008 and 2021 at our center. We recorded all systemic therapies (chemotherapy, targeted therapy, or immunotherapy) administered before, during, or after SRS. Patients with prior brain surgery were excluded. We captured adverse events following SRS, including intralesional hemorrhage (IH), radiation necrosis (RN) and local failure (LF), as well as extracranial disease status. Distant brain failure (DBF), extracranial progression-free survival (PFS) and overall survival (OS) were determined using a cumulative Incidence function and the Kaplan-Meier method., Results: Our analysis included 165 patients with 570 SRS-treated MBM. Median OS for patients who received IO was 1.41 years versus 0.79 years in patients who did not (p = 0.04). Ipilimumab monotherapy was the most frequent IO regimen (30%). In the absence of IO, the cumulative incidence of symptomatic (grade 2 +) RN was 3% at 24 months and remained unchanged with respect to the type or timing of IO. The incidence of post-SRS g2 + IH in patients who did not receive systemic therapy was 19% at 1- and 2 years compared to 7% at 1- and 2 years among patients who did (HR: 0.33, 95% CI 0.11-0.98; p = 0.046). Overall, neither timing nor type of IO correlated to rates of DBF, OS, or LF. Among patients treated with IO, the median time to extracranial PFS was 5.4 months (95% IC 3.2 - 9.1)., Conclusion: The risk of g2 + IH exceeds that of g2 + RN in MBM patients undergoing SRS, with or without IO. IH should be considered a critical adverse event following MBM treatments., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Hemorrhage is an uncommon complication of liposuction that may be trauma-induced by the cannula on the subcutaneous perforators. It usually resolves spontaneously with external compression and results in mild to moderate ecchymosis on the liposuction site. However, in sporadic cases, active bleeding may persist and require urgent intervention for hemostasis., Case Presentation: We report the case of a 60-year-old White female who developed a massive hematoma in the hour following liposuction of the right internal thigh, with active bleeding in the subcutaneous plane reported on contrast-enhanced computed tomography. The initial angiogram was conducted in the right common femoral artery and showed active bleeding from a profunda artery perforator. After careful selective catheterization of the feeding artery using a 2.0-French microcatheter, 0.3 mL of Onyx 34 was injected. Control angiography showed no immediate complication and confirmed the exclusion of the pseudoaneurysm. No postoperative event occurred. Blood pressure and hemoglobin levels remained stable throughout the episode., Conclusions: Although liposuction is a very common procedure in plastic surgery, hemorrhagic complications may occur and require urgent hemostasis. This case suggests a vital place for interventional radiology in the management of hemorrhagic complications after liposuction., (© 2023. The Author(s).)

Acetabular fractures are challenging fractures and finding the best supportive treatment is complex. Many operative treatment options exist - one of them is the plate osteosynthesis via the modified Stoppa approach gaining popularity over the last decades. The purpose of this study is to give an overview of this surgical techniques and its main complications. Patients ≥ 18 years between the years 2016 and 2022 with acetabular fractures in our department received a surgical intervention with plate fixation via the modified Stoppa approach. All protocols and documents during a patient's hospital stay were analyzed to find relevant perioperative complications concerning this operative technique. Between 01/2016 und 12/2022 75 patients with acetabular fractures were treated surgically in the author's institution with a plate osteosynthesis via the modified Stoppa approach. In 26.7 % (n = 20) of all cases, patients were confronted with one or more perioperative complications typical for this operation. Intraoperative venous bleedings were the main complication with 10.6 % (n = 8). Postoperative functional impairment of the obturator nerve and deep vein thrombosis occurred with 2.7 % (n = 2) and 9.3 % (n = 7). This retrospective study shows that plate fixation via the Stoppa approach is a good treatment option because of the excellent intraoperative overview of the fracture, but has its pitfalls and complications. Especially severe vascular bleedings must be taken into account and its management well known., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Intramedullary spinal arteriovenous malformation (ISAVM, glomus type) is a type of spinal cord arteriovenous malformation, which is a rare disease known often to have a complex vascular supply interfering with that of the spinal cord, and is in complex anatomical relations with cord structures and nerve roots. Though microsurgical and endovascular treatment has mainly been the standard options, in high-risk cases with these treatments, stereotactic radiotherapy (SRT) might be the option of choice., Methods: We retrospectively reviewed 10 consecutive patients with ISAVM who received SRT using CyberKnife at the Japanese Red Cross Medical Center (Tokyo, Japan) from January 2011 to March 2022., Results: No case in this series suffered from hemorrhage after applying SRT. One case experienced neurological impairment 10 years after SRT, which we attributed to venous congestion due to the remaining lesion. No case of radiation myelopathy was observed in this series. In one case, the nidus volume reduction and loss of flow voids were obvious, though improvement in the neurological outcome was not apparent. No radiological changes were observed in the other 9 patients., Conclusions: Even in lesions without radiological changes, no hemorrhagic events were observed for an average period of 4 years. SRT may be a feasible option in treating ISAVM, especially for lesions in which microsurgical resection and endovascular treatment are inapplicable. To ascertain the safety and efficacy of this approach, further studies with more patients and longer follow-up is required., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Dissecting and ligating the splenic artery is crucial for bleeding control during laparoscopic splenectomy (LS). However, for patients with portal hypertension from liver cirrhosis, it is difficult for identification and ligation because the splenic vessel is circuitous and dilated. The aim of this study was to describe a simple technique of constructing a tunnel behind the tail of the pancreas for occluding the splenic vessels during LS in patients with portal hypertension. Materials and Methods: The clinical data of 61 patients who underwent LS from April 2016 to January 2017 were retrospectively analyzed. In 27 patients, the tunnel construction (TC) behind the tail of the pancreas approach was performed owning to difficulty in dissecting and ligating the splenic artery (TC group), including 17 patients who received the TC method directly and 10 patients who received the TC method after trying to dissect the splenic artery. The remaining 34 patients underwent traditional ligating of the splenic artery (LA group). The peri- and postoperative outcomes of operative time, blood loss, conversion rate, postoperative oral diet intake, postoperative hospital stay, and postoperative complication rate of the two groups were analyzed. All the operations were completed by the same group of surgeons. Results: All 61 operations were successfully completed. Compared with patients in the LA group, patients in the TC group had less blood loss (120.37 ± 40.74 mL versus 162.65 ± 87.47 mL; t  = -2.317, P  = .024). There was no statistical difference of operative time, conversion rate, complication rate, postoperative hospital stays, and follow-up between the two groups. Conclusions: The technique of constructing a tunnel behind the tail of the pancreas for occluding the splenic vessels was effective and safe in those patients whose splenic artery was difficult to dissect and ligate.

A 59-year-old woman was transferred to our hospital because of a sudden onset of chest and back pain. Computed tomography (CT) demonstrated Stanford type A acute aortic dissection with cardiac tamponade and right airway bleeding. Hemorrhage from ruptured false lumen extended along the pulmonary artery (PA), compression of the right PA were recognized due to hematoma surrounding the PA. An emergency operation was performed. The primary tear was located at the distal aortic arch, and total arch replacement with frozen elephant trunk was performed. During the operation, she had airway bleeding. The bleeding was thought to be due to the hematoma extending along the pulmonary artery. She was extubated 7th postopratively. She was discharged 44 days after the operation.

Background: Cavernous malformations are clusters of abnormal and hyalinized capillaries without interfering brain tissue. Here, we present a cavernous malformation operated under awake conditions, due to location, in an eloquent area and using intraoperative magnetic resonance imaging due to patient's movement upon the awake phase., Case Presentation: We present the pre-, per-, and postoperative course of an inferior parietal cavernous malformation, located in eloquent area, in a 27-year-old right-handed Caucasian male, presenting with intralesional hemorrhage and epilepsy. Preoperative diffusion tensor imaging has shown the cavernous malformation at the interface between the arcuate fasciculus and the inferior fronto-occipital fasciculus. We describe the microsurgical approach, combining preoperative diffusion tensor imaging, neuronavigation, awake microsurgical resection, and intraoperative magnetic resonance imaging., Conclusion: Complete microsurgical en bloc resection has been performed and is feasible even in eloquent locations. Intraoperative magnetic resonance imaging was considered an important adjunct, particularly used in this case as the patient moved during the "awake" phase of the surgery and thus neuronavigation was not accurate anymore. Postoperative course was marked by a unique, generalized seizure without any adverse event. Immediate and 3 months postoperative magnetic resonance imaging confirmed the absence of any residue. Pre- and postoperative neuropsychological exams were unremarkable., (© 2023. The Author(s).)

Background: To compare the surgical status in idiopathic epiretinal membrane (IERM) patients with or without disorganization of retinal inner layers (DRIL) and to correlate with optical coherence tomography angiography (OCTA) and clinical data., Methods: In 74 eyes from 74 patients with IERM treated by surgery with 12-month follow-up. According to the superficial hemorrhage, the patients were divided into group A (no macular bleeding), group B (macular parafoveal bleeding) and group C (macular foveal bleeding). Optical coherence tomography (OCT) were evaluated for presence of DRIL,central retina thickness and integrity of the inner/outer segment layer recorded at baseline and at 1, 3, 6, and 12 months postoperatively and best-corrected visual acuity (BCVA) was recorded simultaneously. OCTA was conducted at 12 months postoperatively. Main outcome measures is correlation between DRIL and superficial hemorrhage in membrane peeling,and BCVA and OCTA outcomes postoperatively., Results: The rate of DRIL and BCVA had statistically significant differences between the three groups at the time points(baseline and 1, 3, 6, and 12 months after surgery), respectively (P < 0.001 for all). FD-300 value (P = 0.001)and DCP in all parafoveal regions (superior: P = 0.001; inferior: P = 0.002;Nasal: P = 0.014;Tempo: P = 0.004) in eyes with DRIL were lower than those without DRIL.There was a linear regression relationship between FD-300 and postoperative BCVA (P = 0.011)., Conclusion: IERM Patients with DRIL have more intraoperative adverse events and limited benefits from surgery which should be considered in the decision whether to perform mebrane peeling.OCT-A provides more detailed vascular information that extends our understanding of persistent DRIL., (© 2023. The Author(s).)

Background: Preperitoneal packing (PPP) has been widely accepted as a damage control technique for severe bleeding from pelvic fractures. It is supposed to work by direct compression and tamponade of the bleeding source in the pelvis and it has been suggested to be effective for both venous and arterial bleeding. However, there is little evidence to support its efficacy or the ability to place the laparotomy pads in proximity of the desired location., Methods: Bilateral PPP was performed on 10 fresh human cadavers, followed by laparotomy and measurements of resultant pad placement in relation to critical anatomic structures., Results: A total of 20 assessments of laparotomy pad placement were performed. Following completion of PPP, a midline laparotomy was performed to determine proximity and closest distance of the laparotomy pads to sites of potential bleeding in pelvic fractures. In almost all cases, the pad placement was not contiguous with the key anatomic structure with mean placement 3.9 + 1.1 cm from the sacroiliac joint, 3.5 + 1.6 cm from the common iliac artery, 1.1 + 1.2 cm from the external iliac artery, 2.8 + 0.8 cm from the internal iliac artery, and 2.3 + 1.2 cm from the iliac bifurcation. Surgeon experience resulted in improved placement relative to the sacroiliac joint, however the pads still did not directly contact the target point., Conclusion: This human cadaver study has shown that PPP, even in experienced hands, may not be placed in significant proximity of anatomical structures of interest. The role of PPP needs to be revisited with better clinical or human cadaver studies., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Purpose: Endoscopic access and treatment of bleeding upper urinary tract urothelial carcinomas (UTUCS) is sometimes difficult and inefficient as resection and/or laser coagulation are often incomplete. We report two cases of successful cryoablation of bleeding UTUCs., Materials and Methods: This study evaluated an adjunctive method in using cryoablation as a hemostatic technique. Cryoprobes were inserted inside the affected calices and a standard renal cryoablation protocol was used. Track ablation was performed during the pullback of the cryoprobes to prevent tumor seeding and bleeding., Results: Cryoablation of the bleeding upper urinary tract tumors allowed to efficiently resolve macrohematuria in both patients and to provide prolonged remission in one patient., Conclusions: Taking advantage of the microcirculatory stasis and the hemostatic properties of cryoablation, we achieved palliative cessation of refractory macrohematuria while sparing nephrons, without the need for renal embolization in patients with bleeding UTUCs., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Catheter ablation (CA) of atrial fibrillation (AF) is used routinely to establish rhythm control. There is mounting evidence that CA procedures should be performed during continuous oral anticoagulation and direct oral anticoagulants (DOACs) are considered the first anticoagulation strategy. Few real-life data are now available and even less in the Italian panorama., Methods: IRIS is an Italian multicenter, non-interventional, prospective study which will be enrolled consecutive AF patients eligible for CA and treated with Rivaroxaban; patients in treatment with Rivaroxaban proceeded directly to CA while Rivaroxaban-naive patients were scheduled for CA after 4 weeks of uninterrupted anticoagulation unless the exclusion of atrial thrombi. Rivaroxaban was uninterrupted or shortly uninterrupted (<24 hours) prior CA, in line with routinely practice of each operator. Patients will be followed on continuous anticoagulation for 1 month after the ablation. The primary efficacy outcome is the cumulative incidence of all-cause death and systemic embolism while the primary safety outcome is the incidence of major bleeding events. The secondary outcomes are represented by non-major bleeding events. All events must be occurred within the first 30 days after the procedure., Results: Two hundred fifty patients are expected to be enrolled and the study is estimated to be completed by the end of 2022. Up to now 56 patients have been enrolled., Conclusions: This study is the first large Italian prospective study on the management of Rivaroxaban in patients undergoing CA of AF. It aims to depict a comprehensive view of anticoagulation strategy prior CA in several Italian electrophysiology labs.

Objective: Recent studies have suggested an impact of the ABO-blood group type on thromboembolic and haemorrhagic events following trauma and surgical procedures. However, only limited data are available on the impact of ABO-blood group types in neurosurgical patients. The goal of the present study was to evaluate the role of the ABO-blood group type on the frequency of thromboembolic and haemorrhagic complications in patients treated surgically for intracranial meningiomas at our institution., Methods: We retrospectively analysed the medical records of consecutive patients undergoing resection of intracranial meningiomas at our institution during a period of 12.5 years (2006-2018). Clinical characteristics, modalities of surgical treatment, histopathological results and the postoperative course of patients were analysed with specific focus on ABO-blood group typing results, need for transfusion of blood products, events of postoperative thromboembolism and intracranial re-haemorrhage requiring surgical revision, as well as in-hospital mortality., Results: A total of 1,782 patients were included in this study. Based on the ABO-blood group type, patients were subdivided into four categories, corresponding to their ABO-blood group: Blood group A ( n  = 773; 43%); blood group B ( n  = 222; 12%); blood group AB ( n  = 88; 5%); and blood group O ( n  = 699; 39%). Intracranial re-haemorrhage requiring re-craniotomy and haematoma evacuation occurred in a total of 49 patients (2.7%). Thromboembolic events such as pulmonary embolism occurred in a total of 27 patients (1.5%). Statistical analysis showed no significant differences regarding the ABO-blood group type in patients suffering from re-haemorrhage or thromboembolism compared with patients with uneventful course after surgery. The overall in-hospital mortality rate was 0.17% ( n  = 3)., Conclusion: Our findings suggest a lack of relevance of the ABO-blood group type regarding haemorrhagic and thromboembolic complications in patients undergoing neurosurgical meningioma resection.

We performed a meta-analysis to evaluate the effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma. A systematic literature search up to April 2022 was performed and 3517 subjects with clinically node-negative papillary thyroid carcinoma at the baseline of the studies; 1503 of them were treated with prophylactic central neck dissection following total thyroidectomy, and 2014 were using total thyroidectomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma using the dichotomous method with a random or fixed-effect model. The prophylactic central neck dissection following total thyroidectomy subjects had a significantly lower surgical site wound infection (OR, 0.40; 95% CI, 0.20-0.78, P = .007) in subjects with clinically node-negative papillary thyroid carcinoma compared with total thyroidectomy. However, prophylactic central neck dissection following total thyroidectomy did not show any significant difference in hematoma (OR, 0.08; 95% CI, 0.43-2.71, P = .87), and haemorrhage (OR, 0.72; 95% CI, 0.26-1.97, P = .52) compared with total thyroidectomy in subjects with clinically node-negative papillary thyroid carcinoma. The prophylactic central neck dissection following total thyroidectomy subjects had a significantly higher surgical site wound infection, and no significant difference in hematoma, and haemorrhage compared with total thyroidectomy in subjects with clinically node-negative papillary thyroid carcinoma. The analysis of outcomes should be with caution because of the low number of studies in certain comparisons., (© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background: Surgical removal of a vestibular schwannoma is a complex and challenging procedure, which may be complicated by development of postoperative hematomas, particularly after incomplete resection of the tumor., Objective: To investigate the occurrence of postoperative intra- or peritumoral hematomas after surgery for a vestibular schwannoma., Methods: This retrospective study evaluated 49 patients (age range 17-78 years) with a vestibular schwannoma, who were treated surgically via the lateral suboccipital approach between 2011 and 2016. The tumors ranged in size from 0 mm (in a case of an intracanalicular lesion) to 56 mm. In 30 cases (61%), total or near-total resection was accomplished, and in 19 cases (39%), subtotal or partial resection was done. On the basis of their bleeding tendency during tumor removal, the patients were divided into a "less-bleeding" (38 cases; 78%) and a "more-bleeding" (11 cases; 22%) subgroups., Results: A maximal vestibular schwannoma diameter >30 mm, patient age >60 years, and more bleeding during tumor removal were significantly associated with incomplete (subtotal or partial) resection. In six cases (12%), serial computed tomography after surgery demonstrated a postoperative hematoma, which was caused by insufficient irrigation of the surgical field (in two cases) or resulted from peritumoral hemorrhage (in two cases), intratumoral hemorrhage (in one case), or both intra- and peritumoral hemorrhage (in one case). The latter patient required urgent reoperation. In all cases, postoperative hematomas occurred after incomplete (subtotal or partial) resection of a vestibular schwannoma, and their development was significantly associated with more bleeding during tumor removal., Conclusion: For avoidance of postoperative hematomas, careful hemostasis is required after completion of vestibular schwannoma removal, especially in cases with incomplete resection and an excessive bleeding tendency of the tumor tissue., (© 2023. Springer Nature Switzerland AG.)

Introduction: Staple line oversewing (SLO) is a prophylactic alternative due to its low cost and its effect of decreasing the incidence and severity of bleeding complications in sleeve gastrectomy (SG). However, this approach significantly increases the surgical time and may be associated with stenosis. The study aims to identify whether its usage was sufficient to optimize the surgical time in patients whose screening for the risk of occult bleeding was negative. Materials and Methods: The study enrolled 103 patients. Having the systolic blood pressure goal of 140 mmHg, the staple line is checked for bleeding points, counting as follows: >5 bleeding points proceed to SLO, <5 bleeding points are managed using clips, and if no bleeding points are found, the procedure can be completed. Results: The bleeding test was positive in 79.6% of the cases and oversewing was necessary for 44.7% of the total. The bleeding test result was significant for the increased surgical time. The mean surgical time in SLO was 16.4% higher than in clipping. There was a significant difference in surgical time between SLO and clipping; however, no significant difference was identified between clipping and continuing the procedure without further measures. No postoperative complication related to staple line bleeding was identified. Discussion: In a scenario with limitations for the use of high-cost homeostatic agents, the stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time without significant added risks. Conclusion: A stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time.

Objective: Small anterior branch of gastrocolic trunk (SABGT) can be occasionally observed during transverse colectomy and right hemicolectomy. Improperly dealing with the branch may lead to unwanted bleeding and affect the operation process. The purposes of this study are to analyze the frequencies and injury of SABGT. Methods: Intact operation data were collected retrospectively from 39 colon cancer patients who underwent curative laparoscopic transverse colectomy or right hemicolectomy. Frequencies and injury of SABGT were analyzed. Results: Eight cases had SABGT, the frequencies of which is 20.5%. Injury of SABGT occurred intraoperatively in 2 patients. Conclusion: We suggest that SABGT should be considered in surgical management. Consciously looking for and properly dealing with the branch can minimize the influence on the operation process.