Divertículo de Meckel complicado. Experiencia de 15 años en un hospital interzonal / Complicated Meckel's diverticulum. Fifteen years of experiencein an interzonal hospital in the Province of Buenos Aires

Introducción: el divertículo de Meckel es la anomalía congénita más frecuente del tracto gastrointestinal. Puede presentarse con hemorragia, obstrucción intestinal o diverticulitis, complicaciones que disminuyen con la edad, por lo que en el adulto el diagnóstico suele ser incidental. El tratamiento de las complicaciones es quirúrgico, mediante diverticulectomía o resección segmentaria del intestino delgado, dependiendo de sus características morfológicas. Objetivo: analizar nuestra experiencia en el manejo del divertículo de Meckel complicado en un período de 15 años. Diseño: estudio descriptivo, observacional, transversal, retrospectivo. Material y métodos: se revisaron las historias clínicas de los pacientes operados por divertículo de Meckel complicado en el Servicio de Cirugía General del Hospital San Roque durante el periodo 2007-2022. Se registraron datos demográficos, presentación clínica, diagnóstico preoperatorio, tratamiento quirúrgico, complicaciones postoperatorias y hallazgos histopatológicos. Resultados: se incluyeron 25 pacientes, 21 (84%) hombres, 3 menores de 18 años. La presentación clínica fue un síndrome de fosa iliaca derecha en el 80% de los casos, obstrucción intestinal en el 16% y hemorragia en el 4%. En solo 2 casos se realizó el diagnóstico preoperatorio, confirmado mediante tomografía computada. Se realizó diverticulectomía en el 68% de los pacientes y resección segmentaria el 32%. El abordaje fue laparotómico en el 64%, principalmente en el periodo inicial y laparoscópico en el 36%. Hubo una complicación IIIb de Clavien-Dindo en un paciente pediátrico tratado con drenaje percutáneo. En un solo paciente (4%), que se presentó con hemorragia digestiva masiva, se encontró epitelio de tipo gástrico y páncreas ectópico en el divertículo. Conclusiones: En nuestra experiencia el divertículo de Meckel complicado se presentó predominantemente en hombres. La complicación más frecuente en el adulto fue la diverticulitis. El diagnóstico preoperatorio fue infrecuente y realizado por tomografía computada. La diverticulectomía es suficiente en la mayoría de los casos. Actualmente, la laparoscopia es una herramienta segura, rentable y eficiente que permite el diagnóstico y tratamiento oportunos de esta entidad. (AU)

Introduction: Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract. It can present with bleeding, intesti-nal obstruction or diverticulitis, complications that decrease with age, so in adults the diagnosis is usually incidental. Treatment of complications is surgical, through diverticulectomy or segmental resection of the small intestine, depending on its morphological characteristics. Objective: to analyze our experience in the management of complicated Meckel's diverticulum over a period of 15 years. Design: descriptive, observational, cross-sectional, retrospective study. Materials and methods: the medical records of patients operated on for complicated Meckel's diverticulum in the General Surgery Service of the San Roque Hospital during the period 2007-2022 were reviewed. Demo-graphic data, clinical presentation, preoperative diagnosis, surgical treatment, postoperative complications, and histopathological findings were recorded. Results: twenty-five patients were included, 21 (84%) men, 3 under 18 years of age. The clinical presentation was a right iliac fossa syndrome in 80% of cases, intestinal obstruction in 16% and hemorrhage in 4%. In only 2 cases was the preoperative diagnosis made, confirmed by computed tomography. Diverticulectomy was performed in 68% of patients and segmental resection in 32%. The approach was by laparotomy in 64%, mainly in the initial period, and by laparoscopy in 36%. There was a Clavien-Dindo IIIb complication in a pediatric patient treated with percutaneous drain-age. In only one patient (4%), who presented with massive gastrointestinal bleeding, gastric-type epithelium and ectopic pancreas were found in the diverticulum. Conclusions: In our experience, complicated Meckel's diverticulum occurred predominantly in men. The most frequent complication in adults was diverticulitis. Preoperative diagnosis was infrequent and was made by computed tomography. Diverticulectomy is sufficient in most cases. Currently, laparoscopy is a safe, profitable and efficient tool that allows for the timely diagnosis and treatment of this entity. (AU)

Hemorragia digestiva por intususcepción de un lipoma ulcerado en yeyuno / Gastrointestinal bleeding due to ulcerated intussuscepted jejunal lipoma

RESUMEN Los lipomas yeyunales son tumores gastrointestinales benignos e infrecuentes, de origen mesenquimático, compuestos por adipocitos que suelen estar confinados a la submucosa. Generalmente son asintomáticos y se descubren de manera incidental al realizar estudios por imágenes o endoscópicos. Sin embargo, aquellos mayores de 2 cm pueden presentar síntomas como resultado de complicaciones, como intususcepción intestinal, obstrucción o rara vez, hemorragias. Presentamos un caso infrecuente de intususcepción de un lipoma yeyunal ulcerado en un adulto, diagnosticado en el contexto de un cuadro de hemorragia digestiva.

ABSTRACT Jejunal lipomas are rare benign mesenchymal tumors made up of adipocytes confined to the submucosa layer. They are usually asymptomatic and are incidentally found during imaging or endoscopic tests. Those measuring > 2 cm may become symptomatic as a result of complications as intestinal intussusception, obstruction and bleeding. We herein report a rare case of intussusception of an ulcerated jejunal lipoma in an adult patient, that was diagnosticated in the setting of an intestinal hemorrhage.

Cohorte descriptiva de pacientes adultos con hipertensión portal en una institución de tercer nivel en Colombia / Descriptive cohort of adult patients with portal hypertension at a tertiary care institution in Colombia

Introducción. La hipertensión portal (HTP) se define como una elevación anormal de la presión venosa en el sistema portal que lleva al desarrollo de vías colaterales para desviar el flujo sanguíneo de la zona. Dentro de su etiología están las relacionadas con la cirrosis hepática y otras causas denominadas no cirróticas. El objetivo de este estudio fue evaluar los principales hallazgos demográficos, clínicos y paraclínicos en un grupo de pacientes con HTP, y determinar el uso de ayudas invasivas y no invasivas, y su disponibilidad para el diagnóstico y seguimiento de los pacientes en los centros que no cuentan con laboratorio de hemodinamia hepática, reflejando la dinámica de múltiples escenarios en Colombia. Metodología. Se realizó un estudio descriptivo de corte transversal, retrospectivo, en pacientes atendidos en una institución de tercer nivel del sur de Colombia, entre enero del año 2015 y diciembre del año 2020. Resultados. Se obtuvo una muestra de 61 pacientes en donde la mayoría de casos correspondían a hombres en la séptima década de la vida, procedentes del área urbana. La principal causa de consulta fue el sangrado digestivo (39,3 %), asociado a la presencia de telangiectasias (arañas vasculares) en el 37,2 %, seguido de circulación colateral (31,3 %) e ictericia (19,7 %). En la ecografía abdominal (realizada en el 57,4 % de los pacientes) predominaron la cirrosis (68 %) y la presencia de esplenomegalia (14,2 %), y en lospacientes con Doppler portal (realizado en el 16,4 %) se encontró hígado cirrótico (80 %) y dilatación portal (40 %). Con respecto a los hallazgos en la esofagogastroduodenoscopia predominó la presencia de várices esofágicas y gastritis crónica. Conclusión. El principal motivo de consulta fue el sangrado digestivo, en tanto que la cirrosis fue el antecedente y el hallazgo imagenológico más frecuente, seguido de las várices esofágicas. Se encontró que el uso de paraclínicos, ecografía abdominal, ecografía con Doppler portal y esofagogastroduodenoscopia fueron los más utilizados en el contexto clínico de los pacientes con el diagnóstico de HTP.

Introduction. Portal hypertension (PHT) is defined as an abnormal elevation of venous pressure in the portal system that leads to the development of collateral pathways to divert blood flow from the area. Within its etiology are those related to liver cirrhosis and other so-called non cirrhotic causes. The aim of this study was to evaluate the main demographic, clinical and paraclinical findings in a group of patients with PHT, and to determine the use of invasive and non-invasive aids, and their availability for the diagnosis and follow-up of patients in centers that do not have a hepatic hemodynamics laboratory, reflecting the dynamics of multiple scenarios in Colombia. Methodology. A descriptive, retrospective, cross-sectional, retrospective study was conducted in patients attended in a third level institution in Southern Colombia, between January 2015 and December 2020. Results. A sample of 61 patients was obtained where the majority of cases corresponded to men in the seventh decade of life, from the urban area. The main cause of consultation was digestive bleeding (39.3%), associated with the presence of telangiectasias (spider veins) in 37.2%, followed by collateral circulation (31.3%) and jaundice (19.7%). In abdominal ultrasound (performed in 57.4% of the patients), cirrhosis (68%) and the presence of splenomegaly (14.2%) predominated, and in patients with portal Doppler (performed in 16.4%), cirrhotic liver (80%) and portal dilatation (40%) were found. With respect to the findings in the esophagogastroduodenoscopy, esophageal varices and chronic gastritis were predominant. Conclusion. The main reason for consultation was gastrointestinal bleeding, while cirrhosis was the most frequent history and imaging finding, followed by esophageal varices. It was found that the use of paraclinics, abdominal ultrasound, ultrasound with portal Doppler and esophagogastroduodenoscopy were the most used in the clinical context of patients diagnosed with PHT.

Value of platelet-albumin-bilirubin index combined with AIMS65 score in predicting the short-term prognosis of patients with liver cirrhosis and acute upper gastrointestinal bleeding / 临床肝胆病杂志

ObjectiveTo investigate the value of platelet-albumin-bilirubin index （PALBI） combined with AIMS65 score in predicting rebleeding and death within 6 weeks after admission in patients with liver cirrhosis and acute upper gastrointestinal bleeding （AUGIB）. MethodsA retrospective study was conducted for 238 patients with liver cirrhosis and AUGIB who were hospitalized in The First Affiliated Hospital of Jinzhou Medical University from February 2021 to October 2022， and all patients were followed up for 6 weeks. According to the prognosis， they were divided into death group with 65 patients and survival group with 173 patients， and according to the presence or absence of rebleeding， they were divided into non-rebleeding group with 149 patients and rebleeding group with 89 patients. General data and laboratory markers （including blood routine， liver/renal function， and coagulation）， and PALBI， AIMS65 score， Child-Turcotte-Pugh （CTP） score， and Model for End-stage Liver Disease （MELD） score were calculated on admission. The independent-samples t test or the Mann-Whitney U test was used for comparison of continuous data between two groups， and the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression model analysis was used to investigate the risk factors for death or rebleeding within 6 weeks after admission in patients with liver cirrhosis and AUGIB. The receiver operating characteristic （ROC） curve and the area under the ROC curve （AUC） were used to investigate the predictive efficacy of each scoring system， and the DeLong test was used for comparison of AUC. ResultsThere were significant differences between the death group and the survival group in hematemesis， past history of varices， albumin （Alb）， total bilirubin （TBil）， international normalized ratio （INR）， creatinine （Cr）， prothrombin time （PT）， systolic blood pressure， PALBI， AIMS65 score， CTP score， and MELD score （all P<0.05）. The multivariate logistic regression analysis showed that hematemesis （odds ratio ［OR］=4.34， 95% confidence interval ［CI］： 1.88‍ ‍—‍ ‍10.05， P<0.001）， past history of varices （OR=3.51， 95%CI： 1.37‍ ‍—‍ ‍8.98， P=0.009）， PALBI （OR=4.49， 95%CI： 1.48‍ ‍—‍ ‍13.64， P=0.008）， and AIMS65 score （OR=3.85， 95%CI： 2.35‍ ‍—‍ ‍6.30， P<0.001） were independent risk factors for death. The ROC curve analysis of each scoring system in predicting survival showed that CTP score， MELD score， PALBI， AIMS65 score， and PALBI combined with AIMS65 score had an AUC of 0.758， 0.798， 0.789， 0.870， and 0.888， respectively， suggesting that PALBI combined with AIMS65 score had a significantly larger AUC than the four scoring systems used alone （all P<0.05）. There were significant differences between the rebleeding group and the non-rebleeding group in hematemesis， history of diabetes， Alb， TBil， INR， Cr， PT， PALBI， AIMS65 score， CTP score， and MELD score （all P<0.05）. The multivariate logistic regression analysis showed that PALBI （OR=2.41， 95%CI： 1.17‍ ‍—‍ ‍4.95， P=0.017） and AIMS65 score （OR=1.58， 95%CI： 1.17‍ ‍—‍ ‍2.15， P=0.003） were independent risk factors for rebleeding. The ROC curve analysis of each scoring system in predicting rebleeding showed that CTP score， MELD score， PALBI， AIMS65 score， and PALBI combined with AIMS65 score had an AUC of 0.680， 0.719， 0.709， 0.711， and 0.741， respectively， suggesting that PALBI combined with AIMS65 score had the largest AUC （all P<0.05）， but with a relatively low specificity. ConclusionPALBI combined with AIMS65 score has a certain value in predicting death within 6 weeks after admission in patients with liver cirrhosis and AUGIB， with a better value than CTP score and MELD score alone. PALBI combined with AIMS65 score has a relatively low value in predicting rebleeding within 6 weeks， with an acceptable accuracy.

Application of valve removal technique in improved endoscopic dacryocystorhinostomy / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To investigate the efficacy of valve removal technology in improved endoscopic dacryocystorhinostomy.METHODS: Prospective randomized controlled study. A total of 92 patients(98 eyes)with nasolacrimal duct obstruction who underwent endoscopic dacryocystorhinostomy in our hospital from November 2020 to September 2022 were selected as the study subjects and they were randomly divided into group A(traditional group)and group B(improved group). The nasal mucosal flap was preserved after incision of the nasal mucosa in group A, the lacrimal sac flap and nasal mucosal flap were trimmed to an appropriate shape after the incision of the lacrimal sac, and the lacrimal sac flap the nasal mucosal flap were matched up. Group B made a “□” shaped incision on the nasal mucosa to remove the complete square nasal mucosa tissue. After the lacrimal sac was incised, the lacrimal sac mucosa was preserved as much as possible, and then the residual nasal mucosa was trimmed to make the lacrimal sac flap close to but not in contact with the residual nasal mucosa. Furthermore, the intraoperative bleeding volume and surgical duration of two groups of patients were recorded, and follow up until 3 mo postoperative. Nasal endoscopy and lacrimal duct flushing examinations were performed at 1 and 3 mo postoperative, respectively. The proliferation of granulation tissue within 5 mm of the ostial postoperative and the therapeutic effect were observed.RESULTS: At 3 mo postoperatively, 6 patients(7 eyes)who were lost to follow-up were excluded. A total of 44 eyes were included in group A, and 47 eyes were included in group B. The bleeding volume [27.00(22.00, 41.00)mL] and the surgical duration [35.00(33.00, 42.00)min] in group B were significantly lower than those in the group A(P&#x0026;#x003C;0.001). At 1 mo postoperatively, granulation tissue hyperplasia was observed within 5 mm of the ostial in 12 eyes of group A. In group B, granulation tissue hyperplasia was observed within 5 mm of the ostial in 1 eye. At 3 mo postoperatively, there were 9 eyes in group A with ostial adhesions but incomplete closure, and 2 eyes with complete closure; group B had 1 eye with mild adhesions at the ostial site and no ostial closure. The postoperative complications in the group B were significantly less than those in the group A(P&#x0026;#x003C;0.05), and the therapeutic effect was better than that in the group A(P&#x0026;#x003C;0.05).CONCLUSION: The application of valve removal technology in improving endoscopic dacryocystorhinostomy not only significantly reduces intraoperative bleeding and surgical duration, but also effectively reduces postoperative complications and improves surgical efficacy.

Risk factors for delayed bleeding after intestinal polypectomy in children / 中国当代儿科杂志

OBJECTIVES@#To investigate the clinical characteristics and risk factors of delayed bleeding after intestinal polypectomy in children, and to provide a theoretical basis for clinical surgical intervention of intestinal polyps.@*METHODS@#A retrospective analysis was conducted on the clinical data of 2 456 children with intestinal polyps who underwent endoscopic high-frequency electrocoagulation loop resection in the Endoscopy Center of Children's Hospital Affiliated to Zhengzhou University from January 2014 to December 2021. According to the presence or absence of delayed bleeding after surgery, they were divided into bleeding group with 79 children and non-bleeding group with 2 377 children. A multivariate logistic regression analysis was used to investigate the risk factors for delayed bleeding. The receiver operating characteristic (ROC) curve was used to investigate the value of various indicators in predicting delayed bleeding.@*RESULTS@#Of all 2 456 children, 79 (3.22%) experienced delayed bleeding, among whom 5 children with severe delayed bleeding underwent emergency colonoscopy for hemostasis and 74 received conservative treatment, and successful hemostasis was achieved for all children. There were significant differences between the bleeding and non-bleeding groups in age, body mass index, constipation rate, location of lesion, time of endoscopic procedure, resection method (P<0.05). Children with a diameter of polyps of 6-10 mm and >20 mm were more likely to develop delayed bleeding after resection (P<0.05). The multivariate logistic regression analysis showed that endoscopic operation time, polyp diameter, and resection method were significantly associated with delayed bleeding (P<0.05). The ROC curve analysis showed that the endoscopic operation time, polyp diameter, and resection method had a good value in predicting delayed bleeding after intestinal polypectomy, with an area under the ROC curve of 0.706, 0.688, and 0.627, respectively.@*CONCLUSIONS@#Endoscopic high-frequency electrocoagulation loop resection has a lower incidence of delayed bleeding in children with intestinal polyps, and the endoscopic operation time, polyp diameter, and resection method are closely associated with the occurrence of postoperative delayed bleeding.

Assessing a cut-off point for the diagnosis of abnormal uterine bleeding using the Menstrual Bleeding Questionnaire (MBQ): a validation and cultural translation study with Brazilian women

ABSTRACT BACKGROUND: Abnormal uterine bleeding (AUB) is a common condition, and the Menstrual Bleeding Questionnaire (MBQ) is used for its assessment. OBJECTIVES: To translate, assess the cut-off point for diagnosis, and explore psychometric properties of the MBQ for use in Brazilian Portuguese. DESIGN AND SETTING: Prospective cohort study including 200 women (100 with and 100 without AUB) at a tertiary referral center. METHODS: MBQ translation involved a pilot-testing phase, instrument adjustment, data collection, and back-translation. Cut-off point was obtained using receiver operating curve analysis. Menstrual patterns, impact on quality of life due to AUB, internal consistency, test-retest, responsiveness, and discriminant validity were assessed. For construct validity, the Pictorial Blood Assessment Chart (PBAC) and World Health Organization Quality of Life - abbreviated version (WHOQOL-BREF) were applied. RESULTS: Women with AUB were older, had higher body mass indices, and had a worse quality of life during menstruation. Regarding the MBQ's psychometric variables, Cronbach's alpha coefficient was > 0.70 in all analyses, high intraclass correlation coefficient was found in both groups; no ceiling and floor effects were observed, and construct validity was demonstrated (correlation between MBQ score, PBAC score, and clinical menstrual cycle data). No difference between MBQ and PBAC scores were perceived after the test-retest. Significant differences were found between MBQ and PBAC scores before and after treatment. An MBQ score ≥ 24 was associated with a high probability of AUB; accuracy of 98%. CONCLUSION: The MBQ is a reliable questionnaire for Brazilian women. The cut-off ≥ 24 shows high accuracy to discriminate AUB.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Acute normovolemic hemodilution and intraoperative autotransfusion

Abstract Autologous blood transfusion can be achieved through different techniques, including by the patient donating blood before surgery (pre-deposit), collecting blood from the patient immediately before the operation and replacing the volume with colloids or plasma expanders (acute normovolemic hemodilution) or through the salvage of lost blood, during or immediately after surgery, and its retransfusion after washing (intraoperative or postoperative recovery). We will focus on the two methods used intraoperatively that are of fundamental importance in the management and conservation of the patient's own blood.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Management of critical bleeding

Abstract The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Preoperative Phase - Preoperative management of the patient's anemia

Abstract Managing anemia before surgery is extremely important as it is a clinical condition that can significantly increase surgical risk and affect patient outcomes. Anemia is characterized by a reduction in the number of red blood cells or hemoglobin levels leading to a lower oxygen-carrying capacity of the blood. Proper treatment requires a multifaceted approach to ensure patients are in the best possible condition for surgery and to minimize potential complications. The challenge is recognizing anemia early and implementing a timely intervention to correct it. Anemic patients are more susceptible to surgical complications such as increased infection rates, slower wound healing and increased risk of cardiovascular events during and after surgery. Additionally, anemia can exacerbate existing medical conditions, causing greater strain on organs and organ systems. To correct anemia and optimize patient outcomes, several essential measures must be taken with the most common being identifying and correcting iron deficiency.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Preoperative Clinical and Laboratory Assessment of the Patient

Abstract The preoperative clinical and laboratory evaluations of the patient is an essential step to ensure the safety and success of any surgical procedure. This assessment aims to identify any underlying medical conditions and risk factors and determine suitability for surgery. With this step, the medical team can adapt the care plan to meet each patient's specific needs, increasing the chances of a successful procedure. Good clinical assessment and comprehensive laboratory testing, when integrated into a Patient Blood Management approach, are invaluable in promoting safety of care, reducing transfusion risks, improving surgical outcomes, and optimizing resource utilization. This approach not only elevates the quality of care, but is also aligned with evidence-based practice and patient-centered principles, making it an essential component of the perioperative process.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Intraoperative hemostasis and volume replacement

Abstract Hemostasis plays a critical role in surgical procedures and is essential for a successful outcome. Advances in hemostatic agents offer new approaches to controlling bleeding thereby making surgeries safer. The appropriate choice of these agents is crucial. Volume replacement, another integral part of Patient Blood Management (PBM), maintains adequate tissue perfusion, preventing cellular damage. Individualization in fluid administration is vital with the choice between crystalloids and colloids depending on each case. Colloids, unlike crystalloids, increase oncotic pressure, contributing to fluid retention in the intravascular space. Understanding these aspects is essential to ensure safe and effective surgery, minimizing complications related to blood loss and maintaining the patient's hemodynamic status.

The Efficacy of Tranexamic Acid in Reducing Perioperative Drainage in Cardiac Surgery with Cardiopulmonary Bypass

ABSTRACT Introduction: Although cardiopulmonary bypass procedures remain a critical treatment option for heart disease, they come with risks, including hemorrhage. Tranexamic acid is known to reduce morbidity and mortality in surgical hemorrhage. Objective: This study aimed to evaluate the efficacy of tranexamic acid, which is routinely used to treat hemorrhage, in decreasing the amount of intraoperative and postoperative drainage. Method: A total of 80 patients who underwent cardiac surgery with cardiopulmonary bypass were included in this retrospective study. Forty patients who received tranexamic acid during the operation were assigned to Group 1, while 40 patients who did not receive tranexamic acid were assigned to Group 2. Patient data were collected from the hospital computer system and/or archive records after applying exclusion criteria, and the data were recorded. Statistical analyses were then performed to compare the data. Results: Age, sex, height, weight, body surface area, flow, and ejection fraction percentages, preoperative hematological parameters, and intraoperative variables (except tranexamic acid) were similar between the groups (P>0.05). However, there were statistically significant differences between the groups in terms of intraoperative (through the heart-lung machine) and postoperative red blood cell transfusion rates, intraoperative and postoperative bleeding drainage amounts, as well as postoperative hematocrit, hemoglobin, platelet, and red blood cell levels (P<0.05). Conclusion: We concluded that intraoperative and postoperative use of tranexamic acid in patients who underwent coronary artery bypass grafting with cardiopulmonary bypass has positive effects on hematological parameters, reducing blood product use, and bleeding drainage amount.

Emicizumab prophylaxis in people with hemophilia A and inhibitors: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as prophylaxis has demonstrated promising results. OBJECTIVES: We aimed to compare the bleeding endpoints between PwHAi on BPA and those on emicizumab prophylaxis. DESIGN AND SETTING: Systematic review of interventions and meta-analysis conducted at the Universidade Federal de Goiás, Goiânia, Goiás, Brazil. METHODS: The CENTRAL, MEDLINE, Scopus, and LILACS databases were searched on February 21, 2023. Two authors conducted the literature search, publication selection, and data extraction. The selected publications evaluated the bleeding endpoints between PwHAi on emicizumab prophylaxis and those on BPA prophylaxis. The risk of bias was evaluated according to the Joanna Briggs Institute criteria. A meta-analysis was performed to determine the annualized bleeding rate (ABR) for treated bleeds. RESULTS: Five publications (56 PwHAi) were selected from the 543 retrieved records. Overall, bleeding endpoints were lower during emicizumab prophylaxis than during BPA prophylaxis. All the publications had at least one risk of bias. The only common parameter for the meta-analysis was the ABR for treated bleeds. During emicizumab prophylaxis, the ABR for treated bleeds was lower than during BPA prophylaxis (standard mean difference: −1.58; 95% confidence interval −2.50, −0.66, P = 0.0008; I2 = 68.4%, P = 0.0031). CONCLUSION: Emicizumab was superior to BPA in bleeding prophylaxis in PwHAi. However, both the small population size and potential risk of bias should be considered when evaluating these results. SYSTEMATIC REVIEW REGISTRATION: CRD42021278726, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278726.

Ligadura de la arteria lingual: estrategia para hemorragias por lesión de la arteria en la base de la lengua: informe de dos casos / Lingual Artery Ligation: Strategy for Bleeding from Artery Injury at the Base of the Tongue: Report of Two Cases

La hemorragia producida por lesión de la arteria lingual en la base de la lengua por cirugías o por tumores es infrecuente. La mayor frecuencia en la indicación de abordajes transorales para tratar diferentes patologías que afectan la orofaringe requiere que el equipo quirúrgico tenga experiencia en el manejo de esta complicación. La ligadura de la arteria lingual en el cuello es una técnica quirúrgica muy eficaz para solucionar la hemorragia, pero es importante conocer las posibles variantes anatómicas que puede tener la arteria en su trayecto cervical. Debido a su baja incidencia se propone como objetivo describir dos casos clínicos de pacientes que tuvieron hemorragias graves por lesión de la arteria lingual en la base de la lengua, producidas por daño quirúrgico y por erosión por tumor. [AU]

The bleeding caused by injury to the lingual artery at the base of the tongue due to surgery or tumors is infrequent. The increased frequency in the indication of transoral approaches to treat different pathologies affecting the oropharynx requires the surgical team to have experience in managing this complication. Ligation of the lingual artery in the neck is a very effective surgical technique to solve the bleeding; however, it is essential to be aware of the possible anatomical variants the artery may have in its cervical trajectory. Due to its low incidence, we propose to describe two clinical cases of patients who had severe bleeding due to a lesion of the lingual artery at the base of the tongue, produced by surgical damage and erosion due to a tumor. [AU]

Hemorragia digestiva alta / Upper Gastrointestinal Bleeding

Introducción: La hemorragia digestiva alta tiene una elevada morbimortalidad. La endoscopía digestiva alta es el estudio de elección para su diagnóstico y tratamiento. Objetivo: Describir la conducta ante la hemorragia digestiva alta. Métodos: Para la revisión bibliográfica se consultaron artículos científicos indexados en idioma español e inglés, relacionados con la hemorragia digestiva, publicados en las bases de datos PubMed, SciELO, Medline y Cochrane, pertenecientes a autores dedicados al estudio de este tema. Desarrollo: La hemorragia digestiva alta se clasifica, según la etiología de origen, en variceal y no variceal. La mayoría de los pacientes con hemorragia digestiva alta el sangrado se autolimita. La causa más habitual es la úlcera péptica, pero en caso de sangrado masivo la etiología más frecuente es la variceal. El empleo precoz de la terlipresina en los pacientes con hemorragia digestiva alta variceal mejora el control del sangrado y disminuye la mortalidad. Se debe hacer uso de escalas validadas de estratificación del riesgo: escala de riesgo de Rockall (tiene como propósito principal predecir la mortalidad y riesgo de resangrado del paciente) y la escala de Glasgow-Blatchford). Conclusiones: Sospechar la presencia de hemorragia digestiva alta, estratificar su riesgo e instaurar el manejo inicial y apropiado constituye una prioridad para el médico de urgencia(AU)

Introduction: Upper gastrointestinal bleeding presents high morbidity and mortality. Upper gastrointestinal endoscopy is the study of choice for its diagnosis and treatment. Objective: To describe the management of upper gastrointestinal bleeding. Methods: For the bibliographic review, the consultation was carried out of scientific articles indexed in Spanish and English, related to gastrointestinal bleeding, published in the databases PubMed, SciELO, Medline and Cochrane, belonging to authors dedicated to the study of this subject. Development: Upper gastrointestinal bleeding is classified, according to the etiology of origin, into variceal and nonvariceal. In most patients with upper gastrointestinal bleeding the bleeding as such is self-limiting. The most common cause is peptic ulcer; however, in the case of massive bleeding, the most frequent etiology is variceal. Early use of terlipressin in patients with variceal upper gastrointestinal bleeding improves bleeding control and decreases mortality. Validated risk stratification scales should be used: Rockall risk scale (its main purpose is to predict patient mortality and risk of bleeding recurrence) and the Glasgow-Blatchford scale. Conclusions: Suspecting the presence of upper gastrointestinal bleeding, stratifying its risk, as well as instituting initial and appropriate management, are a priority for the emergency physician(AU)

Primary Anorectal Melanoma: Case Report and Review of a Rare Neoplasm

Primary anorectal melanoma is a rare malignant melanocytic neoplasm; its principal manifestation is rectal bleeding. It has an ominous prognosis with a five-year survival rate of 10%. The case of a 56-year-old woman with rectal bleeding and the sensation of a rectal mass is presented. A polypoid lesion, resected transanally, was documented in the distal rectum during the colonoscopy. The histological study confirmed a primary anorectal melanoma.

El melanoma anorrectal primario es una neoplasia melanocítica maligna poco frecuente, su principal manifestación es el sangrado rectal. Tiene un pronóstico ominoso con una tasa de sobrevida del 10% a 5 años. Se presenta el caso de una mujer de 56 años con rectorragia y sensación de masa rectal. Durante la colonoscopia se documentó una lesión polipoide en el recto distal, que se resecó por vía transanal. El estudio histológico confirmó la presencia de un melanoma anorrectal primario.

Uso de anticoagulantes parenterales en pacientes con síndromes coronarios / Use of parenteral anticoagulants in patients with coro nary syndromes

Resumen El tratamiento anticoagulante, en conjunto con la anti agregación, cumple un rol de suma importancia en el tratamiento de los síndromes coronarios agudos. Su uso está asociado a reducción de nuevos eventos isquémicos, trombosis del stent e incluso menor morta lidad. No obstante, en la práctica clínica existe una gran heterogeneidad en su utilización, llevando a resultados subóptimos en el tratamiento. Este trabajo ofrece una revisión narrativa sobre el uso de anticoagulantes parenterales en pacientes con sín dromes coronarios agudos, dependiendo del escenario clínico, así como también de la estrategia de revascula rización implementada y el riesgo hemorrágico. Se abordan los diferentes esquemas anticoagulantes disponibles en síndromes coronarios agudos con y sin elevación del segmento ST, basados en la evidencia ac tualizada hasta la fecha. Finalmente, se desarrollan herramientas para la es tratificación del riesgo de sangrado y su manejo tera péutico.

Abstract Anticoagulant treatment, together with antiplatelet therapy, plays an important role in the treatment of acute coronary syndromes. Its use is associated with a reduction in new ischemic events, stent thrombosis, and lower mortality. However, in clinical practice there is great heterogene ity in its use, leading to suboptimal results in treatment. This paper conducts a narrative review on the use of parenteral anticoagulants in patients with acute coronary syndromes, depending on the clinical scenario, as well as the revascularization strategy used and the bleeding risk. The different anticoagulant schemes available in acute coronary syndromes with and without segment ST elevation are addressed, based on the updated evidence. Finally, evidence-based strategies for risk stratifi cation for bleeding and therapeutic management are developed.

Serie de casos de sangrado intraluminal postoperatorio en colectomía izquierda / Case series of postoperative intraluminal bleeding in left colectomy

Introducción: El sangrado digestivo intraluminal postoperatorio es una entidad poco frecuente y su manifestación clínica no difiere de la hemorragia digestiva baja de otra etiología. A pesar de que su presentación más habitual es la hematoquecia autolimitada en la primera deposición, en un discreto porcentaje puede requerir transfusiones, tratamiento endoscópico, hemodinámico, o incluso cirugía. Objetivo: Analizar los pacientes con sangrado digestivo intraluminal postoperatorio tratados en un centro de alta complejidad y realizar una revisión bibliográfica del tema. Diseño: Estudio retrospectivo, descriptivo. Material y métodos: Pacientes con sangrado anastomótico durante el post operatorio inmediato de una colectomía izquierda, operados en el Servicio de Cirugía General y Coloproctología desde enero del 2017 a diciembre del 2021. Las variables estudiadas fueron edad, sexo, anticoagulación y su causa, descenso de hemoglobina, cirugía realizada y su indicación, vía de abordaje, configuración de la anastomosis, electividad de la cirugía, complicaciones, días de internación y manejo terapéutico. Resultados: Se incluyeron 4 pacientes con una edad media de 72 (rango 54-87) años y una distribución por sexo de 1:1. En todos la colectomía izquierda fue programada y en 3 el abordaje fue laparoscópico. La anastomosis fue termino-terminal con sutura mecánica circular. Todos los pacientes presentaron sangrado en las primeras 24 horas postoperatorias. El tratamiento fue decidido de acuerdo a la condición hemodinámica: en los 2 pacientes con estabilidad hemodinámica fue suficiente el tratamiento conservador con reanimación y transfusiones. Los otros 2 que presentaron inestabilidad hemodinámica requirieron manejo intervencionista con endoscopía rígida, videocolonoscopía y cirugía. Conclusión: El sangrado intraluminal es una complicación poco frecuente de la anastomosis colorrectal que requiere manejo intervencionista solo en los pacientes que presentan inestabilidad hemodinámica. (AU)

Introduction: Postoperative intraluminal gastrointestinal bleeding is a rare entity and its clinical manifestation does not differ from lower gastro-intestinal bleeding of another etiology. Despite the fact that its most common presentation is self-limited hematochezia at the first stool, in a small percentage it may require transfusions, endoscopic or hemodynamic management, or even surgery. Aim: To analyze the patients with postoperative intraluminal gastrointestinal bleeding treated in a tertiary center and to carry out a bibliographic review of the subject. Design: Retrospective descriptive study. Material and methods: Patients with immediate postoperative anastomotic bleeding from a left colectomy, operated on at the General Surgery and Coloproctology Service from January 2017 to December 2021 were included. The variables recorded were age, sex, anticoagulation and its cause, decrease in hemoglobin, procedure performed and its indication, surgical approach, type of anastomosis, electiveness of surgery, complications, hospital stay and management. Results: Four patients with a mean age of 72 (range 54-87) years and a 1:1 gender distribution were included. All procedures were elective and 3 laparoscopic. All anastomoses were performed end-to-end with a circular stapler. All patients presented bleeding in the first 24 postoperative hours. The treatment was decided according to the hemodynamic condition; patients with hemodynamic stability (2) received medical treatment while those with hemodynamic instability (2) required interventional management with rigid endoscopy, colonoscopy and surgery. Conclusion: Intraluminal bleeding is a rare complication of colorectal anastomosis that requires interventional management only in patients with hemodynamic instability. (AU)

Manejo das irregularidades menstruais secundárias ao uso de contraceptivos ­ análise das recomendações atuais / Management of menstrual irregularities secondary to contraceptive use ­ analysis of current recommendations

As irregularidades menstruais representam uma série de desordens na quantida- de, duração, frequência ou regularidade do sangramento uterino. Entre suas cau- sas destaca-se o sangramento secundário ao uso de anticoncepcionais, uma razão frequente de descontinuidade dos contraceptivos, podendo aumentar as taxas de gestações não planejadas. Boa parte dos contraceptivos pode levar a mudanças no padrão de sangramento uterino, e a abordagem inicial do sangramentos irregula- res inclui a avaliação de outras possíveis causas, o reforço do uso correto da medi- cação, a tranquilização da paciente quanto à benignidade do quadro e à tendência a melhora com a continuidade do uso. Os anti-inflamatórios podem ser usados como estratégia inicial, e, não havendo resposta satisfatória, há alternativas espe- cíficas para cada método. Este trabalho visa identificar as recomendações atuais sobre o manejo do sangramento anormal decorrente de contraceptivos, por meio de revisão narrativa de estudos publicados sobre o tema nos últimos vinte anos.

Abnormal uterine bleeding represents a series of disorders in the amount, du- ration, frequency and or regularity of uterine bleeding. Among its causes, uterine bleeding secondary to the use of contraceptives stands out as a frequent reason for contraceptive discontinuity, which could lead to unplanned pregnancies. Most contraceptives can cause changes in the pattern of uterine bleeding, and the ini- tial approach of the abnormal bleeding includes assessing other possible cau- ses, reinforcing the correct use of medication, and reassuring the patient about the benignity of the condition and the tendency to improve with the continuity of the treatment. Anti-inflammatory drugs can be used as an initial strategy, and, if there is no satisfactory answer, there are specific alternatives for each contracep- tive method. This work aims to identify them current recommendations on the management of abnormal bleeding resulting from contraceptives use, through a narrative review of studies published on the subject in the last twenty years.