Cases reported "Blood Loss, Surgical"

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11/309. Extracorporeal bypass using a centrifugal pump during resection of malignant liver tumors.

    BACKGROUND/AIMS: Total hepatic vascular exclusion (THVE) during extracorporeal bypass is used for hepatic resection in patients with malignant liver tumors. The aim of this study was to determine the efficacy of hepatectomy during total hepatic vascular exclusion using a centrifugal pump (Bio-pump). METHODOLOGY: Fourteen patients with malignant liver tumors who underwent hepatectomy during total hepatic vascular exclusion using the Bio-pump were studied retrospectively. RESULTS: In 3 of 14 patients, insufficient hepatic vascular exclusion was achieved. Six patients underwent tumor resection during total hepatic vascular exclusion, without extracorporeal bypass. In the remaining 5 patients, flow exclusion averaging 1500 ml was achieved with the Bio-pump, and hepatectomy was performed during the procedure. In these 5 patients, the mean operative time and blood loss were 11 hours 38 minutes and 6850 /- 2451 ml. The Bio-pump bypass time, the excluded blood flow and the mean blood pressure were 82 minutes, 1650 ml and 108/53 mmHg, respectively. The arterial ketone body ratio (AKBR) decreased from a pre-operative value of 1.85-0.32 during total hepatic vascular exclusion. CONCLUSIONS: Total hepatic vascular exclusion was useful for hepatectomy in patients with tumor invasion into the hepatic vein and inferior vena cava, or tumor thrombus in the inferior vena cava and right atrium. However, this technique did not decrease blood loss or improve outcome in patients undergoing hepatectomy. ( info)

12/309. laparoscopy extends the indications for liver resection in patients with cirrhosis.

    BACKGROUND: Clinical or biological evidence of liver failure is usually considered a contraindication to open liver surgery as it is associated with a prohibitive risk of postoperative death. methods: This report describes three patients who had resection of a superficial hepatocellular carcinoma suspected either to be ruptured, or at high risk of rupture, using the laparoscopic approach. All three patients had intractable ascites, in two superimposed on active hepatitis. Surgery was per- formed under continuous carbon dioxide pneumoperitoneum with intermittent clamping of the hepatic pedicle. RESULTS: Intraoperative blood loss was between 100 and 400 ml; no blood transfusion was required. The postoperative course was uneventful except for a transient leak of ascites through the trocar wounds. Duration of in-hospital stay was 6-10 days. liver function tests had returned to preoperative values within 1 month of surgery in all patients. CONCLUSION: The laparoscopic approach may enable liver resection in patients with cirrhosis and evidence of liver failure that would contraindicate open surgery. ( info)

13/309. Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy.

    BACKGROUND: Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear. patients AND methods: color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS: Injury to a large branch of the middle hepatic vein adjacent to the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS: patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound. ( info)

14/309. Effect of haemorrhage on plasma propofol concentrations in a patient undergoing orthotopic liver transplantation.

    We report a patient who underwent repeat orthotopic liver transplantation complicated by intraoperative blood loss of more than 59 litre. During liver transplantation, a constant rate propofol infusion was given and plasma samples were obtained throughout the procedure for propofol assay. Before the anhepatic phase of the procedure, plasma propofol concentrations reached a plateau at 1 microgram ml-1, and these concentrations were consistent with those predicted using a pharmacokinetic model. During the anhepatic phase of surgery, serum propofol concentrations increased progressively and exceeded those predicted by the pharmacokinetic model. Large intravascular fluid shifts associated with blood loss and subsequent blood replacement influenced plasma propofol concentrations observed in this patient. ( info)

15/309. antithrombin iii concentrate in the acute phase of thermal injury.

    BACKGROUND: Thermal injury disrupts homeostasis by inducing subclinical disseminated intravascular coagulation, fibrinolysis. and an acquired deficiency of antithrombin iii (ATIII), a natural anticoagulant. As a result, thermally injured patients have a high incidence of hypercoagulability and thrombosis. OBJECTIVE: ATIII (Human) concentrate was given to a thermally injured patient to evaluate safety, and dosage requirements in this setting. DESIGN: The patient was a 40 yr old male with a 68% total burn surface area, right femoral comminuted fracture, and C5-C6 subluxation sustained in a vehicular crash. He received nine infusions of AT III (H) concentrate (100-50 u/kg) within the first four days of injury. RESULT: The ATIII plasma level increased from 45% on admission (normal = 100 /-20%) to 120 /-25% in the next four days. During the 64 day hospitalization, there were 11 grafting procedures with an estimated blood loss (EBL)/procedure: 1140 cc; and EBL/grafted surface area ratio: 0.6 cc cm2. The average time to healing of the meshed autograft was 6.4 days. CONCLUSION: ATIII (H) concentrate can be safely utilized in the acute phase of thermal injury: no excessive bleeding or prolongation of wound healing was documented. ( info)

16/309. DDAVP treatment in a child with von Willebrand disease type 2M.

    von Willebrand disease (vWD) type 2M is characterized by the decreased platelet-dependent function of the von willebrand factor (vWF) that is not caused by the absence of HMW vWF multimers. We report here on a 4-year-old boy with vWD type 2M, who underwent adenotomy and paracentesis after correction of his hemostatic defect by stimulation with DDAVP. The decreased basal levels of vWF Antigen (Ag), ristocetin cofactor activity (RiCoF) and collagen binding activity (CBA) (32%, 14% and 9% respectively) could be stimulated to maximum levels of 69%, 70% and 95% 2 h post DDAVP administration. DDAVP was administered in a dosage of 0.4 microg/kg BW intravenously 30 min prior to surgery. No bleeding occurred intra- and perioperatively. vWF multimer analysis revealed supranormal multimers with an abnormal satellite banding pattern. The typical separation by gel electrophoresis into oligomers with a triplet structure was missing even after stimulation with DDAVP. Thus, the functional hemostatic defect was corrected in this patient after DDAVP administration, although the structural abnormalities of the vWF multimers were still persisting. CONCLUSION: In conclusion, type 2M vWD might be effectively treated with DDAVP administration in cases of elective surgery, dispensing with vWF replacement by pooled blood products. ( info)

17/309. Successful use of recombinant VIIa (Novoseven) and endometrial ablation in a patient with intractable menorrhagia secondary to FVII deficiency.

    menorrhagia is a well-recognized complication of inherited bleeding disorders. In the past, the only viable option for women who were unresponsive to medical therapy was hysterectomy. Endometrial ablation has been recently developed as an alternative therapy for these patients and is associated with decreased morbidity. We report the successful use of activated recombinant factor vii (FVIIa) and endometrial ablation in the treatment of excessive menstrual blood loss in a 34-year-old women with severe factor vii (FVII) deficiency. Recombinant FVIIa (40 microg/kg) was administered pre-operatively and every 6 h (20 microg/kg) for 24 h postoperatively. The procedure was uncomplicated with a 200 ml surgical blood loss. FVIIa was used because it allowed FVII replacement with a recombinant product and also has the ability to bind to tissue factor expressed at the site of vascular injury, resulting in site-specific thrombin generation. We believe that endometrial ablation with recombinant VIIa should be considered in patients with severe FVII deficiency and menorrhagia unresponsive to medical therapy. ( info)

18/309. postoperative complications of repeat hepatectomy for liver metastasis from colorectal carcinoma.

    BACKGROUND/AIMS: When a repeat hepatectomy is possible, it is the most effective treatment modality for recurrent colorectal liver metastasis. The aim of this study was to evaluate the surgical risks of repeat hepatectomy for liver metastasis from colorectal carcinoma. METHODOLOGY: Between 1986 and 1996, 60 patients with hepatic metastasis from colorectal carcinoma underwent surgery in the Department of Surgery I, Oita Medical University. Ten of them underwent a repeat hepatectomy. The cases of these 10 patients were studied retrospectively; in particular, postoperative complications and intraoperative blood loss were compared between the initial and second operation. RESULTS: During the second surgery, recurrence was detected adjacent to the hepatic stump in 9 of the 10 patients. During the initial surgery, 6 underwent non-anatomic resections, and 4 had anatomic resection, including 1 extended lobectomy, 1 lobectomy, and 2 segmentectomies. For the second surgery, 3 had anatomic resections, including 2 lobectomies, and 1 segmentectomy, and 7 underwent non-anatomic resections. There were no mortalities during the initial or second operation. There was no morbidity following the initial surgeries and 7 postoperative complications (intraabdominal abscess, 4 cases; biloma, 3 cases) following the second surgeries. Mean blood loss during the second operation (1044 mL) was significantly greater than during the initial operation (561 mL). CONCLUSIONS: The present results show that repeat hepatectomy for recurrent liver metastasis from colorectal carcinoma resulted in significantly greater intraoperative blood loss and postoperative complications than those of the initial surgeries. The blood loss and complications in the second operation, the one for the recurrence, were directly associated with the fact that the recurrence was so close to the hepatic stump. Since the resection line in the second surgery was adjacent to the hepatic hilus, resection of the lesion caused much more injury to the main bile duct and main portal vein than that caused by the. ( info)

19/309. Transient myocardial ischemia may occur following subendometrial vasopressin infiltration.

    A case of transient myocardial ischemia following subendometrial vasopressin infiltration in intractable intra-operative postpartum bleeding due to placenta accreta is described. In our experience, the rate of this side effect is one in 14 patients (rate of 7.1%). We believe that the benefits of the treatment outweigh the risks, since the uterus was saved in all 14 patients. Nevertheless, this case emphasises that extreme precaution is needed with subendometrial vasopressin infiltration. It should be emphasised that the needle must not be within a blood vessel because intravascular injection of vasopressin solution can precipitate acute arterial hypertension, bradycardia and even death. We suggest that local vasopressin infiltration into the placental site is indicated in cases of intractable bleeding at cesarean section after other conventional obstetric and pharmacological maneuvers have failed. ( info)

20/309. Does ketamine have preemptive effects in women undergoing abdominal hysterectomy procedures?

    ketamine may produce "preemptive" analgesia when administered before surgically induced trauma. Therefore, we hypothesized that pre- versus postincisional administration of ketamine would improve pain control after abdominal hysterectomy procedures. Eighty-nine patients were randomly assigned to one of three treatment groups according to a placebo-controlled, double-blinded protocol: Group 1 (placebo) received saline 0.04 mL/kg IV immediately before and after surgery; Group 2 (preincision), received ketamine 0.4 mg/kg IV before skin incision and saline at the end of the operation; and Group 3 (postincision), received saline before skin incision, and ketamine 0.4 mg/kg IV was given after skin closure. The general anesthetic technique was standardized in all three treatment groups. During the first postoperative hour, Group 3 experienced significantly less pain than Groups 1 and 2, as assessed by using both visual analog and verbal rating scales. There were no significant differences between Groups 1 and 2 with respect to pain scores, postoperative opioid analgesic requirements, and incidence of postoperative nausea and vomiting. We conclude that a single dose of ketamine 0.4 mg/kg IV fails to produce preemptive analgesic effects. Implications: Even though ketamine 0.4 mg/kg IV has short-lasting acute analgesic effects, it failed to produce a preemptive effect when given before abdominal hysterectomy procedures. ( info)
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