The use of Arista AH as a local haemostatic agent in distal splenopancreatectomy: report of two cases.

Bleeding is still one of the most feared intraoperative and postoperative complications that can lead to an increase in morbidity, mortality, length of hospital stay and costs. Nowadays, in addition to accurate surgical techniques, several local haemostatic agents are available and can be used in case of oozing bleeding. Herein, we report our experience with a ready-to-use polysaccharide powder in two patients undergoing distal splenopancreatectomy. Bleeding control was achieved in both cases. No patient showed postoperative bleeding, and no other complications were reported.

Effect of early peri-operative arterial lactate concentration level ratios on post-hepatectomy liver failure.

BACKGROUND: Post-hepatectomy liver failure (PHLF) is a serious complication after hepatectomy and a major cause of death. The current criteria for PHLF diagnosis (ISGLS consensus) require laboratory data of elevated INR level and hyperbilirubinemia on or after postoperative day 5. This study aims to propose a new indicator for the early clinical prediction of PHLF. METHODS: The peri-operative arterial lactate concentration level ratios were derived from time points within the 3 days before surgery and within POD1, the patients were divided into two groups: high lactate ratio group (≥ 1) and low lactate ratio group (< 1). We compared the differences in morbidity rates between the two groups. Utilized logistic regression analysis to identify the risk factors associated with PHLF development and ROC curves to compare the predictive value of lactate ratio and other liver function indicators for PHLF. RESULTS: A total of 203 patients were enrolled in the study. Overall morbidity and severe morbidity occurred in 64.5 and 12.8 per cent of patients respectively. 39 patients (19.2%) met the criteria for PHLF, including 15 patients (7.4%) with clinically relevant Post-hepatectomy liver failure (CR-PHLF). With a significantly higher incidence of PHLF observed in the lactate ratio ≥ 1 group compared to the lactate ratio < 1 group (n = 34, 26.8% vs. n = 5, 6.6%, P < 0.001). Multivariable logistic regression analysis revealed that a lactate ratio ≥ 1 was an independent predictor for PHLF (OR: 3.239, 95% CI 1.097-9.565, P = 0.033). Additionally, lactate ratio demonstrated good predictive efficacy for PHLF (AUC = 0.792). CONCLUSIONS: Early assessment of peri-operative arterial lactate concentration level ratios may provide experience in early intervention of complications in patients with hepatocellular carcinoma, which can reduce the likelihood of PHLF occurrence and improve patient prognosis.

Reoperation-requiring postoperative intracranial haemorrhage after posterior fossa craniotomy: Retrospective case-series.

Introduction: Studies report rates of treatment-requiring postoperative intracranial haemorrhage after craniotomy around 1-2%, but do not distinguish between supratentorial and posterior fossa operations. Reports about intracranial haemorrhages' temporal occurrence show conflicting results. Recommendations for duration of postoperative monitoring vary. Research question: To determine the rate, temporal pattern and clinical presentation of reoperation-requiring postoperative intracranial posterior fossa haemorrhage. Material and methods: This retrospective case-series identified cases operated with posterior fossa craniotomy or craniectomy between January 1, 2007 and December 31, 2021 by an electronic search in the patient administrative database, and collected data about patient- and treatment-characteristics, postoperative monitoring, and the occurrence of haemorrhagic and other serious postoperative complications. Results: We included 62 (n = 34, 55% women) cases with mean age 48 (interquartile range 50) years operated for tumours (n = 34, 55%), Chiari malformations (n = 18, 29%), ischemic stroke (n = 6, 10%) and other lesions (n = 3, 5%). One (2%) 66-year-old woman who was a daily smoker operated with decompressive craniectomy and infarct resection, developed a reoperation-requiring postoperative intracranial haemorrhage after 25.5 h. In four (6%) cases, other serious complications requiring reoperation or transfer from the post anaesthesia care unit or regular bed wards to the intensive care unit occurred after 0.5, 6, 9 and 54 h, respectively. Discussion and conclusion: Treatment-requiring postoperative intracranial haemorrhage and other serious complications after posterior fossa craniotomies occur over a wide timespan and are difficult to capture with a standardized postoperative monitoring time. This indicates that the duration of monitoring should be individualized based on assessment of risk factors.

Predictive factors of delayed bleeding after percutaneous nephrolithotomy requiring angioembolization.

Objectives: To investigate the predictive factors of delayed post-percutaneous nephrolithotomy (PCNL) haemorrhage because of arteriovenous fistula (AVF) or pseudoaneurysm (PA) and compare the factors between AVF and PA. Patients and methods: This is a case-control study with a case-to-control ratio of 1:3. Out of 5077 patients who underwent PCNL from April 2015 to April 2018 in three different teaching hospitals, 113 had post-PCNL haemorrhages because of AVF and/or PA. Seventy-two patients met the inclusion criteria and entered the study as cases, while 216 patients without any postoperative complications were selected as controls. Results: Of all 72 studied patients with complications after PCNL, 35 (48.6%) had AVF, and the rest had PA. The regression model revealed that a history of diabetes (odds ratio [OR]: 2.799, 95% confidence interval [CI]: 1.392-5.630, p-value = 0.004) and renal anomalies (OR: 2.929, 95% CI: 1.108-7.744, p-value = 0.03) were associated with developing delayed post-PCNL haemorrhage. However, no differences were seen between AVF and PA regarding selected variables (p-value > 0.05). Conclusion: History of diabetes and renal anomalies were predictive factors for delayed post-PCNL haemorrhage, but no predictive factors were found to differentiate PA and AVF from one another.

BiZact™ tonsillectomy: Predictive factors for post-tonsillectomy haemorrhage from a 1717 case series.

OBJECTIVE: To determine primary and secondary post-tonsillectomy haemorrhage (PTH) rates and identify predictive factors in a cohort of consecutive adult and paediatric BiZact™ tonsillectomy cases. SETTING: Retrospective cohort study. Patients from Flinders Medical Centre, Noarlunga Hospital and private otolaryngology practices who underwent BiZact™ tonsillectomy from 2017 to 2020. DATA COLLECTED: patient age, indication for tonsillectomy, surgeon experience, time and severity of PTH, including return to theatre. Each secondary PTH was graded using the Stammberger classification. Logistic regression was utilised to identify predictors of secondary PTH. RESULTS: One thousand seven hundred and seventeen patient medical records were assessed (658 adults and 1059 children). The primary PTH rate was 0.1%, and secondary PTH rate was 5.9%. The majority of secondary PTH cases were Stammberger grade A (80/102, 78.4%) requiring observation only. Few secondary PTH required medical intervention (grade B; 9/102, 8.8%), return to theatre (grade C; 12/102, 11.8%), or blood transfusion (grade D; 1/102, 1.0%), with no death reported (grade E; 0/102, 0.0%). Recurrent secondary PTH occurred in 8 patients (0.5%). Predictive factors of secondary PTH in children were surgeon experience with trainees having greater chance of PTH (OR 2.502, 95% CI 1.345-4.654; p = .004) and age of child (OR 1.095, 95% CI 1.025-1.170; p = .007). Surgeon experience was a predictive factor for adults (OR 3.804, 95% CI 2.139-6.674; p < .001). CONCLUSIONS: BiZact™ tonsillectomy has a low primary PTH rate, with a secondary PTH rate comparable to other 'hot tonsillectomy' techniques. The majority of PTH events were minor and self-reported. There appears to be a learning curve for trainee surgeons.

Does infection play a role in post-tonsillectomy haemorrhage? A narrative review.

OBJECTIVE: Post-tonsillectomy haemorrhage is an increasingly common cause of morbidity following tonsillectomy. Secondary post-tonsillectomy haemorrhage occurring more than 24 hours after an operation has long been attributed to post-operative infection; however, there is little evidence to support this hypothesis and the associated use of antibiotics in the current literature. METHOD: This study looked at the aetiology and evidence-based management of post-tonsillectomy haemorrhage, and investigated the impact of bacterial infection and antimicrobials on the pathogenesis and clinical course of this complication. RESULTS: A number of peri-operative risk factors for post-tonsillectomy haemorrhage exist, and infective pathologies, including recurrent or chronic tonsillitis and group A streptococcus on blood cultures, may predispose to bleeding. Very few studies have shown a link between post-tonsillectomy haemorrhage and objective markers of infection such as pyrexia, raised inflammatory markers or positive microbiology cultures. The role of antibiotics in secondary post-tonsillectomy haemorrhage remains controversial, and numerous randomised, controlled trials of peri-operative antibiotics have shown no significant difference in bleeding rates between antibiotics and controls. CONCLUSION: Further trials investigating the role of antibiotics and more robust studies investigating the presence of bacterial infection at the time of bleeding may be required to determine the true role of infection in post-tonsillectomy haemorrhage.

Post-operative haemorrhage secondary to cinnamon use. A case report.

INTRODUCTION: Herbal medicine plays a significant role in modern medicine. The difficulty in integrating the two, lies in the unknown quantities of active ingredients in herbal remedies. This proved true in this clinical scenario. The quantity of coumarin, in the form of cinnamon ingested by this patient over ten months is unknown. The only quantifiable measure was the derangement in his extrinsic coagulation pathway. PRESENTATION OF CASE: A 49-year-old male with a history of celiac disease presented with haematochezia secondary to a malignant adenocarcinoma of the transverse colon. The patient underwent a laparoscopic subtotal colectomy and on the second post-operative day, he was noted to have peritonitis and a positive Fox sign. Diagnostic laparoscopy confirmed intraabdominal bleeding. Over the next four days, the patient's haemoglobin plummeted from 17.4 g/dL to 8.0 g/dL. Investigations revealed an INR of 1.59, which led to further questioning into dietary practices. The patient admitted he had been taking Ceylon cinnamon one tablespoon daily for ten months in the period leading up to surgery. DISCUSSION: Coumarin is a chemical compound readily available in food items such as cinnamon. Coumarin possesses the ability to inhibit vitamin K epoxide reductase complex 1 which is responsible for the recycling of vitamin K. This impedes the gamma-carboxylation of coagulation factors II, VII, IX, X. Vitamin K antagonism can manifest as a prolonged INR and normal activated partial thromboplastin time. CONCLUSION: Bleeding diathesis secondary to dietary coumarin is a rare but dangerous phenomenon that emphasizes the need for a thorough interrogation into a patient's dietary history.

Eventos adversos postquirúrgicos asociados con características sociodemográficas y de salud en un hospital de tercer nivel / Postoperative adverse events associated with sociodemographic and health-related characteristics in a tertiary hospital

Objetivo: analizar los eventos adversos postquirúrgicos (EAP) de pacientes sometidos a una intervención quirúrgica en un hospital de tercer nivel. Métodos: estudio descriptivo, observacional y ambispectivo. Se incluyeron pacientes sometidos a cirugía cuyo registro de quirófanos estuviera completo (n= 322). Se realizó un muestreo por conveniencia en un hospital mexicano. Se utilizó una cédula de recolección de datos de la historia clínica y se efectuaron llamadas telefónicas de seguimiento postquirúrgico. Se analizó el riesgo mediante razón de momios y la asociación mediante la prueba de Chi cuadrado y regresión logística binaria, considerando un intervalo de confianza de 95% y significancia estadística < 0,05. Resultados: se incluyeron 274 pacientes (85,1%). La edad media fue de 55 años (DE: 16,37), el 51,5% era mujer, el 67% se hallaba en nivel de pobreza y un 70,5% presentaba ≥ 1 comorbilidades, siendo las más comunes: hipertensión (40,5%) y diabetes (29,9%). El 38% de los pacientes tuvo sobrepeso y el 29% obesidad grado I. Un 21,9% desarrolló ≥ 1 EAP, siendo los más frecuentes las infecciones del sitio quirúrgico (39,1%) y las infecciones de vías urinarias (23%). Se calculó un OR de 10,1 más riesgo de presentar un EAP según se prolonga la estancia hospitalaria (IC95% 2,003-50,924), y un OR de 4,70 veces más riesgo ante una cirugía urgente (IC95% 2,558-8,977). A mayor índice de masa corporal se hallaron más complicaciones neuroquirúrgicas (p= 0,045), hemorragias y reingresos (p< 0,001). Conclusiones: existen factores de riesgo de aparición de EAP como estancias hospitalarias prolongadas, ser intervenido de urgencia y tener un alto índice de masa corporal.(AU)

Objective: to analyse the postoperative adverse events (PAE) in patients undergoing a surgical intervention in a third level hospital. Methods: a descriptive, observational and ambispective study, including patients undergoing surgery, with a complete surgical record (n= 322). Convenience sampling was conducted in a Mexican hospital. A data collection card was used in clinical records, and post-surgical follow-up phone calls were made. Risk was analysed through odd ratios, and there was association analysis through Chi square test and binary logistic regression, considering a 95% confidence interval and < 0,05 for statistical significance. Results: the study included 274 patients (85.1%). Their mean age was 55 years (SD: 16.37), 51.5% were female, 67% were at poverty level, and 70.5% presented ≥ 1 comorbidities, with hypertension (40.5%) and diabetes (29.9%) as the most common. A 38% of the patients had excess weight, and 29% presented Obesity Grade I. A 21.9% developed ≥ 1 PAE; the most frequent were surgical site infections (39.1%) and urinary infections (23%). It was calculated that the OR for the risk of presenting a PAE was 10.1 higher when the hospital stay was prolonged (CI95% 2.003-50.924), and there was an OR of 4.70 times more risk when faced with emergency surgery (CI95% 2.558-8.977). More neurosurgical complications p= 0.045), haemorrhages and readmissions (p< 0,001) were found with a higher body mass index. Conclusions: there are factors of risk for developing PAE, such as prolonged hospital stays, undergoing an emergency surgery, and presenting a high body mass index.(AU)

Introducing day case thyroid lobectomy at a tertiary head and neck centre.

BACKGROUND: Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre. METHODS: We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery's 5th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service. RESULTS: In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre. CONCLUSIONS: Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

Secondary bleeding following proctological surgery: Rare but potentially severe.

PURPOSE: Haemorrhage following proctological surgery is one of the complications with the greatest potential for severity. The aim of this work was to assess the frequency and risk factors of haemorrhage requiring hospitalization during 30-days postoperatively. METHODS: A retrospective cohort review of all surgeries performed in a Parisian department of medico-surgical proctology between January 2016 and June 2018 was performed. Demographic and surgical data were collected for patients who were hospitalized for postoperative haemorrhage. Their analysis was conducted as a single analysis followed by multivariate analysis. RESULTS: A total of 7533 surgeries were performed on 6727 patients. The mean patient age was 42.6 (±14.3) years and 67.2% were males. Postoperative haemorrhage occurred in 111 patients (1.5%) with a total of 123 haemorrhagic episodes (12 relapses) within a mean of 6 (±5.5) days. In therapeutic terms, 28.5% of haemorrhages required transfusion, 37.4% required haemostasis in the operating theatre and 14.6% required haemostasis under local anaesthesia. Using multivariate analysis, haemorrhage was more frequent after haemorrhoid surgery and in the case of anticoagulant treatment, particularly direct oral anticoagulants, and if the ASA score was equal to 3. Active smoking was associated with a decreased risk of haemorrhage. CONCLUSION: Haemorrhage requiring hospitalization occurred in 1.5% of cases following proctological surgery, 52.8% were severe and recurred in 10.8% of cases. The study also specified certain risk factors for haemorrhage and demonstrated the protective effect of active smoking.

[Application of combined intracapsular and extracapsular hypothermic plasma tonsillectomy in reducing intraoperative and postoperative hemorrhage in children with OSA].

Objective:The aim of this study is to explore the application and advantages of combined intrathecal and extrathecal hypothermic plasma tonsillectomy in reducing intraoperative and postoperative hemorrhage in OSA children. Method:We retrospectively reviewed 726 cases who were diagnosed as OSA. All patients were divided into two groups according to the surgical method: 320 cases by total tonsillectomy and 406 cases by combined extracapsular and intracapsular tonsillectomy. The intro operative bleeding volume, post operative haemorrhage data as time, location and degree in the two groups were compared. Result:There was no statistical difference in the intro operative bleeding volume in the two groups [（9.3±4.6） mL]vs [（7.6±3.5） mL], t=12.687, P=0.235. Two patients who underwent combined extracapsular and intracapsular tonsillectomy presented with post operative haemorrhage, the total post operative haemorrhage rate was significantly decreased that in the total tonsillectomy group（14 cases）（χ²=10.779, P=0.001）. The 2 patients in combined extracapsular and intracapsular tonsillectomy group were secondary haemorrhage, with location in the upper pole and medium, grade A haemorrhage; while in the 14 cases in in the total tonsillectomy group, there were 2 cases presented with primary haemorrhage and 12 cases with secondary haemorrhage; with regard to location of haemorrhage, 1 in the upper pole, 2 in the medium, 11 in the lower pole; 5 cases presented with grade A haemorrhage, 8 with grade B haemorrhage and 1 with grade C haemorrhage. The haemorrhage rate at 7 days after surgery （χ²=5.697, P=0.017）, at the lower pole（χ²=11.961, P=0.001） and grade B（χ²=8.097, P=0.004） were all significantly decreases in the combined extracapsular and intracapsular tonsillectomy group. Conclusion:Plasma tonsillectomy combined with intrathecal and extrathecal hypothermic tonsillectomy is a safe and effective method, which has obvious advantages in reducing the postoperative hemorrhage, especially the secondary hemorrhage of Subtonsillar Pole.

Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy.

OBJECTIVES: Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management. METHODS: We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days. RESULTS: Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group. CONCLUSIONS: Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.

Application of combined intracapsular and extracapsular hypothermic plasma tonsillectomy in reducing intraoperative and postoperative hemorrhage in children with OSA / 临床耳鼻咽喉头颈外科杂志

The aim of this study is to explore the application and advantages of combined intrathecal and extrathecal hypothermic plasma tonsillectomy in reducing intraoperative and postoperative hemorrhage in OSA children. We retrospectively reviewed 726 cases who were diagnosed as OSA. All patients were divided into two groups according to the surgical method: 320 cases by total tonsillectomy and 406 cases by combined extracapsular and intracapsular tonsillectomy. The intro operative bleeding volume, post operative haemorrhage data as time, location and degree in the two groups were compared. There was no statistical difference in the intro operative bleeding volume in the two groups [（9.3±4.6） mL]vs [（7.6±3.5） mL], =12.687, =0.235. Two patients who underwent combined extracapsular and intracapsular tonsillectomy presented with post operative haemorrhage, the total post operative haemorrhage rate was significantly decreased that in the total tonsillectomy group（14 cases）（χ²=10.779, =0.001）. The 2 patients in combined extracapsular and intracapsular tonsillectomy group were secondary haemorrhage, with location in the upper pole and medium, grade A haemorrhage; while in the 14 cases in in the total tonsillectomy group, there were 2 cases presented with primary haemorrhage and 12 cases with secondary haemorrhage; with regard to location of haemorrhage, 1 in the upper pole, 2 in the medium, 11 in the lower pole; 5 cases presented with grade A haemorrhage, 8 with grade B haemorrhage and 1 with grade C haemorrhage. The haemorrhage rate at 7 days after surgery （χ²=5.697, =0.017）, at the lower pole（χ²=11.961, =0.001） and grade B（χ²=8.097, =0.004） were all significantly decreases in the combined extracapsular and intracapsular tonsillectomy group. Plasma tonsillectomy combined with intrathecal and extrathecal hypothermic tonsillectomy is a safe and effective method, which has obvious advantages in reducing the postoperative hemorrhage, especially the secondary hemorrhage of Subtonsillar Pole.

Application of combined intracapsular and extracapsular hypothermic plasma tonsillectomy in reducing intraoperative and postoperative hemorrhage in children with OSA / 临床耳鼻咽喉头颈外科杂志

Objective@#The aim of this study is to explore the application and advantages of combined intrathecal and extrathecal hypothermic plasma tonsillectomy in reducing intraoperative and postoperative hemorrhage in OSA children. @*Method@#We retrospectively reviewed 726 cases who were diagnosed as OSA. All patients were divided into two groups according to the surgical method: 320 cases by total tonsillectomy and 406 cases by combined extracapsular and intracapsular tonsillectomy. The intro operative bleeding volume, post operative haemorrhage data as time, location and degree in the two groups were compared. @*Result@#There was no statistical difference in the intro operative bleeding volume in the two groups [（9.3±4.6） mL]vs [（7.6±3.5） mL], t=12.687, P=0.235. Two patients who underwent combined extracapsular and intracapsular tonsillectomy presented with post operative haemorrhage, the total post operative haemorrhage rate was significantly decreased that in the total tonsillectomy group（14 cases）（χ²=10.779, P=0.001）. The 2 patients in combined extracapsular and intracapsular tonsillectomy group were secondary haemorrhage, with location in the upper pole and medium, grade A haemorrhage; while in the 14 cases in in the total tonsillectomy group, there were 2 cases presented with primary haemorrhage and 12 cases with secondary haemorrhage; with regard to location of haemorrhage, 1 in the upper pole, 2 in the medium, 11 in the lower pole; 5 cases presented with grade A haemorrhage, 8 with grade B haemorrhage and 1 with grade C haemorrhage. The haemorrhage rate at 7 days after surgery （χ²=5.697, P=0.017）, at the lower pole（χ²=11.961, P=0.001） and grade B（χ²=8.097, P=0.004） were all significantly decreases in the combined extracapsular and intracapsular tonsillectomy group. @*Conclusion@#Plasma tonsillectomy combined with intrathecal and extrathecal hypothermic tonsillectomy is a safe and effective method, which has obvious advantages in reducing the postoperative hemorrhage, especially the secondary hemorrhage of Subtonsillar Pole.

Bilateral thalamic stroke after tonsillectomy in a patient with collateral extracranial anastomosis - case report.

Haemorrhage remains the most frequent and serious complication of tonsillectomy. When bleeding is recurrent, gushing, and ceases spontaneously, pseudoaneurysm of the injured artery in the proximity of the tonsillar bed should be suspected. Haemorrhage related to pseudoaneurysm occurs most commonly in the first 30 days after surgery. It can sometimes be excessive and requires a revision procedure such as external carotid artery (ECA) ligation or embolisation. During those procedures, ECA should be checked for possible anastomoses, otherwise the bleeding may persist despite the intervention. We report an unusual case of a patient with recurrent post-tonsillectomy haemorrhage due to pseudoaneurysm of the facial artery, which persisted after ECA ligation because of the presence of collateral occipital-vertebral anastomosis. Due to the recurrence of bleeding episodes, endovascular treatment was implemented. However, the embolisation was complicated by bilateral thalamic stroke with unclear mechanism. This case highlights the importance of anastomosis between ECA and the vertebrobasilar system, both in recurrence of significant post-tonsillectomy bleeding and in potential thromboembolic complications. Therefore, ECA ligation should always be accompanied by exclusion of possible anastomoses. In cases of non-life-threatening bleeding, embolisation seems to be the proper and more selective therapy.

Complications after surgery for benign prostatic enlargement: a population-based cohort study in Ontario, Canada.

OBJECTIVES: To examine the complication rates after benign prostatic enlargement (BPE) surgery and the effects of age, comorbidity and preoperative medical therapy. DESIGN: A retrospective, population-based cohort study using linked administrative data. SETTING: Ontario, Canada. PARTICIPANTS: 52 162 men≥66 years undergoing first BPE surgery between 1 January 2003 to 31 December 2014. INTERVENTION: Medical therapy preoperatively and surgery for BPE. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was overall 30-day postoperative complication rates. Secondary outcomes included BPE-specific event rates (bleeding, infection, obstruction, trauma) and non-BPE specific event rates (cardiovascular, pulmonary, thromboembolic and renal). Multivariable analysis examined the association between preoperative medical therapy and postoperative complication rates. RESULTS: The 30-day overall complication rate after BPE surgery was 2828 events/10 000 procedures and increased annually over the study period. Receipt of preoperative α-blocker monotherapy (relative rate (RR) 1.05; 95% CI 1.00 to 1.09; p=0.033) and antithrombotic medications (RR 1.27; 95% CI 1.22 to 1.31; p<0.0001) was associated with increased complication rates. Among the ≥80-year-old group, the rate of complications increased by 39% from 2003 to 2014 (RR 1.39; 95% CI 1.21 to 1.61; p<0.0001). The mean duration of medical and conservative management increased by a mean of 2.1 years between 2007 and 2014 (p<0.0001 for trend). CONCLUSIONS: Thirty-day complication rates after BPE surgery have increased annually between 2003 and 2014. Preoperative medical therapy with alpha blockers or antithrombotics was independently associated with higher rates of complications. Over this time, the duration of conservative therapy also increased.

Risk factors for bleeding after dental extractions in patients over 60 years of age who are taking antiplatelet drugs.

The aim of this retrospective, single-centre study was to identify the risk factors for bleeding after dental extractions in patients aged over 60 who were being treated with antiplatelet drugs. A total of 338 patients who fulfilled the inclusion criteria were enrolled, and their personal and clinical details, and complications with bleeding after extraction, were retrieved and recorded. There were 182 men and 156 women (mean (SD) age 72 (8) years). A total of 469 teeth were extracted, with a mean (SD) of 1.4 (0.6) teeth/patient. Seventy-seven patients (23%) developed mild, and 55 (16%) severe, bleeding postoperatively. No patient developed a major cardiovascular or cerebrovascular event. We calculated the significance of the association of different variables with the occurrence of postoperative haemorrhage using a multivariate stepwise logistic regression model. The presence of three or more coexisting conditions, a complicated tooth extraction, and the use of two antiplatelet drugs were independent risk factors, while discontinuation of antiplatelet treatment four or more days before the tooth was extracted was a protective factor. This suggests that clinicians should assess the thrombotic risk associated with the interruption of antiplatelet drugs as well as the risk of bleeding for each patient before dental extraction. Strong and effective measures for haemostasis may be preferred over blind discontinuation of antiplatelet drugs. This study is registered in the Chinese Clinical Trial Registry (No. ChiCTR1800014355).