Comparative analysis of surgical hemostatic sponges in liver injury: study in rats / Análise comparativa de esponjas hemostáticas cirúrgicas em ferimento de fígado: estudo em ratos

ABSTRACT Background Obtaining effective hemostasis either in the traumatic or surgical lesions of parenchymal viscera, especially the liver, has always been a challenge. Aim: Comparative study between the use of different hemostatic sponges in hepatic wound and their capacity of integration to cells in a short period. Methods: Fifteen Wistar rats were divided into three groups. Through laparotomy a standardized wound in hepatic right lobe was made. The animals were treated with three sponges, being gelatin in group I, equine collagen in group II, and oxidized cellulose in group III. The hemostatic capacity was analysed. On the 7º day after surgery samples for histology analysis (H&E and picrosirius) were collected for inflammatory evaluation and collagen quantification (types I and III) with polarized microscopy. Results: All materials used had similar haemostatic effects, with no significant difference in hemostasis time. In the assessment of tissue repair and adhesions provoked, as well as analysis of the inflammatory process, the gelatin sponge presented greater inflammation and adhesions to the contiguous structures to the procedure in relation to the other groups. Conclusion: Animals which had their wounds treated with collagen and regenerated cellulose sponges presented better results in relationship to the ones treated with gelatin sponge.

RESUMO Racional A obtenção de hemostasia eficaz nas lesões traumáticas ou cirúrgicas de vísceras parenquimatosas, em especial do fígado, sempre foi desafiante. Objetivo: Comparar o uso de hemostáticos absorvíveis em ferimento hepático quanto à capacidade hemostática e de integração aos tecidos em curto prazo. Métodos: Foram utilizados 15 ratos Wistar separados em três grupos. Foi realizada laparotomia e ferimento padronizado em lobo hepático direito. Os animais do grupo I foram tratados com esponja de gelatina sobre os ferimentos; os do grupo II com esponja de colágeno equino, e os do grupo III com celulose regenerada oxidada. Na ocasião foi estudada a capacidade hemostática. No 7º dia de pós-operatório nova laparotomia foi realizada e foram coletadas amostras para estudos histológicos (H&E e picrosirius) avaliando os processos por microscopia ótica e de polarização para quantificação de colágeno (tipos I e III). Resultados: Todos os materiais usados apresentaram efeitos hemostáticos semelhantes, não havendo diferença significativa no tempo de hemostasia. Na avaliação da reparação tecidual e aderências provocadas, assim como análise do processo inflamatório, os tratados com esponja de gelatina apresentaram maior inflamação e aderências às estruturas contíguas ao procedimento em relação aos outros grupos. Conclusão: Os animais tratados com a esponja de colágeno e celulose regenerada apresentaram resultados melhores que aqueles com esponja de gelatina.

Two HEmostasis Methods After TransradIal Catheterization: THEMATIC - protocol for a randomized clinical trial / Dos métodos de hemostasia luego de un cateterismo transradial: THEMATIC - protocolo de ensayo clínico aleatorizado / Dois métodos de hemostasia após cateterismo transradial: THEMATIC - protocolo de ensaio clínico randomizado

Abstract OBJECTIVE Randomized clinical trial protocol to evaluate the incidence of radial artery occlusion with two different arterial compression devices after transradial procedures. METHODS Barbeau's test will be performed in adults scheduled to undergo transradial interventional procedures. Those with A, B, or C plethysmographic patterns will be selected. At the end of the procedure, patients will be randomly assigned (1:1) to receive patent haemostasis with TR Band™ device or conventional haemostasis with an elastic adhesive bandage. The primary outcome is the incidence of radial artery occlusion. Secondary outcomes are Barbeau's test curve change, additional time to achieve haemostasis, incidence of bleeding at the puncture site, pain severity, development of arteriovenous fistula, radial pseudo aneurysm, any access-site complication requiring vascular surgery intervention and costs between the two devices. DISCUSSION The results of this trial should provide valuable additional information on the best approach for haemostasis after transradial percutaneous cardiovascular interventions.

Resumen OBJETIVO Protocolo de ensayo clínico randomizado para evaluar la incidencia de oclusión de la arteria radial con dos dispositivos de compresión arterial después de pasar por procedimientos transradiales. MÉTODO Se realizará el test de Barbeau en adultos que están esperando una intervención transradial. Se seleccionarán aquellos con padrones pletismográficos A, B o C. Al final del procedimiento, se dividirán a los pacientes de forma aleatoria (1:1) para recibir la hemostasia patente con dispositivo TR Band™ o hemostasia convencional con vendaje elástico adhesivo. El resultado primario es la incidencia de oclusión de la arteria radial. Los resultados secundarios son la alteración de la curva del test de Barbeau, tiempo adicional para alcanzar la hemostasia, incidencia de sangrado en el local de la punción, intensidad del dolor, desarrollo de una fístula arteriovenosa, pseudoaneurisma, cualquier complicación en el lugar de acceso que necesite intervención quirúrgica vascular y costos entre ambos dispositivos. DISCUSIÓN Los resultados de este estudio deben proporcionar informaciones adicionales valiosas sobre un mejor enfoque para la hemostasia luego de intervenciones cardiovasculares percutáneas transradiales.

Resumo OBJETIVO Protocolo de ensaio clínico randomizado para avaliar a incidência de oclusão da artéria radial com dois dispositivos diferentes de compressão arterial após procedimentos transradiais. MÉTODOS O teste de Barbeau será realizado em adultos que serão submetidos a procedimentos de intervenção transradial previamente agendados. Aqueles com padrões pletismográficos A, B ou C serão selecionados. No final do procedimento, os pacientes serão distribuídos aleatoriamente (1:1) para receber hemostasia patente com dispositivo TR Band™ ou hemostasia convencional com bandagem elástica adesiva. O desfecho primário é a incidência da oclusão da artéria radial. Os desfechos secundários são alteração da curva do teste de Barbeau, tempo adicional para atingir a hemostasia, incidência de sangramento no local da punção, intensidade da dor, desenvolvimento de fístula arteriovenosa, pseudoaneurisma, qualquer complicação no local de acesso que necessite intervenção cirúrgica vascular e custos entre os dois dispositivos. DISCUSSÃO: Os resultados deste estudo devem fornecer informações adicionais valiosas sobre a melhor abordagem para a hemostasia após intervenções cardiovasculares percutâneas transradiais.

Fibrinógeno-trombina como tratamiento puente en un caso de hemoptisis masiva / Fibrinogen-thrombin as bridge therapy in massive hemoptysis

Se presenta el caso de una paciente joven con hemoptisis masiva por tuberculosis que no pudo ser controlada de forma efectiva con la inserción de un catéter Fogarty por un fibrobroncoscopio. Ante esto y el alto riesgo de asfixia o desangramiento, se decidió infundir fibrinógeno-trombina a través de un catéter, introducido por el fibrobroncoscopio; con esto se logró controlar el sangrado, intubarla con un tubo orotraqueal de doble luz y estabilizarla para remitirla a otra institución, donde fue sometida a lobectomía y se le proporcionó tratamiento antituberculoso. La infusión de fibrinógeno-trombina podría considerarse como una opción terapéutica transitoria, de tipo puente, mientras se practica el manejo definitivo.

This article presents the case of a young woman with massive hemoptysis (1,000 mL in 6 hours) due to tuberculosis, which could not be controlled by insertion of a Fogarty catheter through a fiber-optic bronchoscope. Because of asphyxia and persistent bleeding risk we instilled fibrinogen-thrombin through a fiber-optic bronchoscope inserted catheter, achieving bleeding cessation and permitting the placing of a double-lumen oro-tracheal tube. Later on, the patient underwent lobectomy and anti-tuberculosis treatment. The fibrinogen-thrombin could be considered as a bridge, transitory measure for massive hemoptysis, while definitive treatment could be established.

A Retrospective Review on Feasibility and Safety of a New Pneumatic Compression Device for Femoral Arteriotomy Hemostasis

OBJECTIVE: To report our initial experience on the technical feasibility and safety for hemostasis of a new pneumatic compression device in patients undergoing femoral arteriotomy. MATERIALS AND METHODS: This study included 40 consecutive patients in whom hemostasis after transfemoral catheterization was readered by using a pneumatic compression device consisting of an inflatable bulb-containing main body and four pieces of supplementary tape. Medical records were retrospectively reviewed for outcomes and complications of hemostasis. Technical success was defined as achieving immediate hemostasis 10 minutes after applying the device over the arteriotomy sites, and clinical success was defined as the ability to ambulate after 4 hours of bed rest without any complications. RESULTS: Technical and clinical success was achieved in 38 (95%) and 37 (93%) patients, respectively. In two patients, hemostasis was achieved after conversion to manual compression. One patient required sand bag placement after removal of the device to control minimal oozing of blood. No patients had late complications. CONCLUSION: The new pneumatic compression device provides effective and safe hemostasis after transfemoral catheterization in selected patient populations.

Hemostasia hepática utilizando eletrocautério seco ou emplastrado com lidocaína ou neomicina ou glicerina ou vaselina, em coelho / Liver hemostasis using a dry eletrocautery or greased with lidocaine or neomycin or glycerin or vaseline, in rabbit

OBJETIVO: Avaliar a hemostasia e a cicatrização hepática após hepatectomia segmentar, utilizando eletrocautério seco, ou emplastrado com: gel de lidocaína, pomada de neomicina, loção de glicerina e pomada de vaselina. MÉTODOS: Coelhos foram submetidos à hepatectomia parcial e distribuídos em seis grupos (n=10): Grupo 1: sem tratamento; Grupo 2: tratamento com eletrocautério seco; Grupo 3: emplastrado com gel de lidocaína; Grupo 4: pomada de neomicina; Grupo 5: loção de glicerina; Grupo 6: pomada de vaselina. Foram mensurados o peso do fígado ressecado, o volume de sangramento e o tempo dispendido para hemostasia. Cinco coelhos de cada grupo foram reoperados após 24 horas, e cinco após sete dias, para biópsia da ferida hepática e exploração da cavidade abdominal. Eritrograma e marcadores de função e lesão hepática foram avaliados no pré-operatório e antes das reoperações. RESULTADO: O gel de lidocaína e a loção de glicerina reduziram o volume do sangramento e o tempo de hemostasia, além de conduzirem a energia térmica do eletrocautério, provocando degeneração hidrópica celular após 24 horas e necrose após sete dias, com profundidade maior no tecido hepático. Todas as substâncias elevaram as aminotransferases. Esses valores normalizaram-se em até sete dias. CONCLUSÃO: O eletrocautério emplastrado com gel de lidocaína e a loção de glicerina foram os métodos mais eficazes na hemostasia do parênquima hepático de coelhos.

OBJECTIVE: To assess the hemostasis and healing of the hepatic parenchyma after segmental hepatectomy, using a dry electrocautery or an electrocautery greased with lidocaine gel, neomycin pomade, glycerin lotion, or a vaseline pomade. METHODS: Rabbits were submitted to partial hepatectomy and divided into six groups of 10 animals each: Group 1: untreated; Group 2: treated with a dry electrocautery; Group 3: treated with an electrocautery greased with lidocaine gel; Group 4: with neomycin pomade; Group 5: with glycerine lotion; Group 6: with vaseline pomade. Resected liver weight, bleeding volume and time spent to achieve hemostasis were determined. Five rabbits from each group were re-operated upon after 24 hours and five after 7 days in order to obtain a biopsy of the hepatic wound and to explore he abdominal cavity. Red blood cell levels and markers of hepatic function and injury were determined before surgery and before re-operation. RESULTS: Lidocaine gel and glycerine lotion reduced the bleeding volume and the time to achieve hemostasis and conducted the thermal energy of the electrocautery, causing hydropic cell degeneration after 24 hours and deeper necrosis of hepatic tissue after 7 days. All substances increased the aminotransferase concentrations. These values returned to normal after a maximum of seven days. CONCLUSION: The electrocautery coated with lidocaine gel and glycerine lotion were the most effective methods for the hemostasis of hepatic parenchyma.

Tissuelink en cirugía torácica / TissueLink in thoracic surgery

Se presenta la experiencia del uso de TissueLink en pacientes sometidos a cirugía de tórax, particularmente en el manejo quirúrgico de neoplasias del pulmón, mediastino, pared torácica, pleura, entre otros, en quienes se observó mínimo o ningún sangrado, sin morbilidad y buena evolución post operatoria. Se realizaron resecciones completas de nódulos pulmonares periféricos e intraparenquimales, con éxito y sin fuga de aire a nivel pulmonar. Además del uso del TissueLink en lesiones nodulares pulmonares también ha sido utilizado en neoplasias dependientes de otros órganos y estructuras intratorácicas con buenos resultados.

Feasibility and effectiveness of a novel vascular hemostatic device (Chula-clamp) after coronary angiography or percutaneous coronary intervention.

BACKGROUND: Chula-clamp is a newly hydraulic vascular hemostatic device. The advantages of the device are convenience, reusability, and lessen patient discomfort and vascular complication. Furthermore, the device is assembled with a recycled balloon inflator and other locally made components, which make it less expensive than other commercially available hemostatic devices. The present study was conducted to compare the effectiveness of Chula-clamp with standard manual compression. MATERIAL AND METHOD: This is a prospective, quasi-randomized controlled clinical trial comparing effectiveness of Chula-clamp to conventional manual compression for attaining femoral artery hemostasis after coronary angiography (CAG) or percutaneous coronary intervention (PCI). Effectiveness was determined by femoral vascular complications rate. The primary endpoint was severe femoral vascular complications (the formation of a groin hematoma, femoral artery thrombosis, pseudoaneurysm, and arteriovenous fistula). RESULTS: One hundred and forty patients scheduled for percutaneous coronary intervention or coronary angiogram in King Chulalongkorn Memorial hospital were enrolled (70 patients for each group). The baseline characteristics were similar in both groups. There was no serious vascular complication detected in either group. In addition, there was no statistical difference in minor complications at the access site between the two groups. [e.g., swelling (1.4% in standard manual compression group vs. 2.9% in Chula-clamp, p = 0.56) and ecchymosis (8.57% in both groups)]. CONCLUSION: Chula-clamp, a novel hydraulic vascular hemostatic device, is feasible, safe, and effective for femoral artery hemostasis (after CA G or PCI via femoral artery). Its effectiveness is not different from standard manual compression.

Innovadora pinza lumínica / The first claw for the technology of lighting

Se presenta la primera pinza adaptada a la novedosa tecnología de iluminación, mediante diodo ultrabrillante, a fin de lograr la adecuada iluminación de cavidades de dificil acceso y, gracias a su cobertura aislante, permitir la cauterización de vasos sangrantes distales sin lesionar sitios de apoyo accidental.

Manejo exitoso de la hemorragia postparto por acretismo placentario mediante tamponamiento con balón de Bakri / Treatment of postpartum haemorrhage due to placenta accreta with Bakri balloon

Antecedentes: La hemorragia del postparto es una de las complicaciones de mayor morbimortalidad materna. Objetivo: Comunicar el uso exitoso del balón de Bakri en un caso de metrorragia del postparto. Metodología: Se presenta el dispositivo utilizado. Resultado: Control eficiente de la metrorragia postparto por acretismo placentario mediante el uso del balón de Bakri, que permitió conservar el útero. Conclusión: El balón de Bakri es una alternativa no quirúrgica para el control de la hemorragia del postparto.

Efficacy of Femoral Vascular Closure Devices in Patients Treated with Anticoagulant, Abciximab or Thrombolytics during Percutaneous Endovascular Procedures

OBJECTIVE: This study assessed the outcomes of using vascular closure devices following percutaneous transfemoral endovascular procedures in the patients who were treated with heparin, abciximab or thrombolytics (urokinase or t-PA) during the procedures. MATERIALS AND METHODS: From March 28, 2003 to August 31, 2004, we conducted a prospective and randomized study in which 1,676 cases of 1,180 patients were treated with one of the two different closure devices (the collagen plug device was Angio-SealTM; the suture-mediated closure device was The Closer STM) at the femoral access site after instituting percutaneous endovascular procedures. Among the 1,676 cases, 108 cases (the drug group) were treated with heparin only (n = 94), thrombolytics only (n = 10), heparin and thrombolytics (n = 3), or abciximab and thrombolytics (n = 1) during the procedures; 1,568 cases (the no-drug group) were treated without any medication. We compared the efficacy and complications between the two groups. Of the drug group, 42 cases underwent arterial closures with the collagen plug devices and 66 cases underwent arterial closures with the suture-mediated closure devices. We also compared the efficacy and complications between these two groups. RESULTS: The immediate hemostasis rates were 92.9% (1,456/1,568) in the no-drug group and 91.7% (99/108) in the drug group. Early complications occurred in four cases of the drug group. These included two episodes of rebleeding with using the Closer S, which required manual compression for at least 10 minutes, and two episodes of minor oozing with using one Angio-Seal and one Closer S, which required two hours of additional bed rest. There was no late complication. So, the total success rates were 90.8% (1,423/1,568) in the no-drug group and 88.0% (95/108) in the drug group. These results were not significantly different between the two groups (p = 0.34). In the drug group, the difference of the successful hemostasis rate between the collagen plug devices and the suture-mediated devices was also not statistically significant (92.9% vs. 84.8%, respectively; p = 0.21). CONCLUSION: Arterial closure of the femoral access site with using vascular closure devices is both safe and effective, even in the patients who received heparin, abciximab or thrombolytics.

Prospective Comparison of Collagen Plug (Angio-SealTM) and Suture-Mediated (the Closer STM) Closure Devices at Femoral Access Sites

OBJECTIVE: Rapid and effective hemostasis at femoral puncture sites minimizes both the hospital stay and patient discomfort. Therefore, a variety of arterial closure devices have been developed to facilitate the closure of femoral arteriotomy. The objective of this prospective study was to compare the efficacy of two different closure devices; a collagen plug device (Angio-Seal) and a suture-mediated closure device (the Closer S). MATERIALS AND METHODS: From March 28, 2003 to August 31, 2004, we conducted a prospective study in which 1, 676 cases of 1, 180 patients were treated with two different types of closure device. Angio-Seal was used in 961 cases and the Closer S in 715 cases. The efficacy of the closure devices was assessed, as well as complications occurring at the puncture sites. RESULTS: Successful immediate hemostasis was achieved in 95.2% of the cases treated with Angio-Seal, and in 89.5% of the cases treated with the Closer S (p < 0.05). The rates of minor and major complications occurring between the two groups were not significantly different. In the Closer S group, we observed four major complications (0.6%), that consisted of one massive retroperitoneal hemorrhage (surgically explored) and three pseudoaneurysms. In the Angio-Seal group, we observed three major complications (0.3%) that consisted of one femoral artery occlusion, one case of infection treated with intravenous antibiotics and one pseudoaneurysm. CONCLUSION: The use of Angio-Seal was found to be more effective than that of the Closer S with regard to the immediate hemostasis of the femoral puncture sites. However, we detected no significant differences in the rate at which complications occurred.

Manejo de la sonda de taponamiento esófago-gástrico / Management of esophagogastric balloon

El taponamiento con balón esofagogástrico es una medida terapéutica antigua de fácil acceso para el control de hemorragia digestiva, por varices esofagogástrica. Actúa por compresión directa en el sitio de sangrado. Suele ser efectivo (70-80 por ciento) de los casos, para el manejo inicial de los pacientes. El 15 al 30 por ciento de los pacientes presentan complicaciones graves (neumonía aspirativa, ruptura del esófago, obstrucción de la vía área). Los cuidados de enfermería apuntan a disminuir la incidencia de complicaciones

Ligaduras hemostáticas en la inercia uterina postcesárea / Hemostatic sutures in uterine, postcesarea inertia

El presente informe describe una nueva técnica con base en ligaduras hemostáticas sobre el músculo uterino, las cuales se utilizan en los casos de inercia uterina con la finalidad de coadyuvar en la contracción de este órgano después del alumbramiento, estas ligaduras pueden ser utilizadas tanto en la cesárea como en el parto. La indicación precisa es cuando aún después de haber recurrido a métodos habituales como: masaje, comprensión del útero y la metrorragia persiste. Se informan 69 casos en los cuales se aplicaron ligaduras hemostáticas, de los cuales sólo en un caso no se controló la hemorragia y fue necesario practicar histerectomía. En los restantes 68 se logró evitar la histerectomía con el uso de las suturas hemostáticas

Tecnica hemostatica en adenomectomia prostatica extracapsular / Prostatic technique in extracapsular prostatic adenomectomy

Los autores describen una experiencia con una técnica hemostática de adenomectomía vesicocapsular de abordaje extracapsular. Fueron intervenidos 117 pacientes; el sangrado intraoperatorio fue de 100 a 250 ml (promedio de 150 ml) y los pacientes no necesitaron transfusión sanguínea. De acuerdo con estos resultados las operaciones se acompañaron de menor sangrado intra y postoperatorio. Se evitaron las transfusion es sanguíneas y por lo tanto sus posibles complicaciones