Management and outcome of patients with acute traumatic subdural hematomas and pre-injury oral anticoagulation therapy

Abstract

Background: Acute subdural hematomas (aSDHs) are found in up to one-third of patients with severe traumatic brain injury and are associated with an unfavorable outcome in the majority of cases. Mortality ranges between 40 and 60%, but was reported to be even higher in patients undergoing oral anticoagulation therapy (OAT) at the time of injury. The objective of this study is to specifically report on the peri-operative management and outcome of patients with aSDH and pre-injury OAT.

Material and Methods: From June 2002 to June 2006, all patients with OAT who underwent surgical treatment of aSDH were retrospectively analysed. Results of pre-operative blood tests, the peri-operative and surgical management and the clinical courses were assessed. Patient outcome is reported according to the Glasgow Outcome Scale (GOS) at 6 months.

Results: Eleven (10.3%) out of 107 patients with aSDH were on OAT. Patients with OAT were significantly older than patients without OAT (72.4 ± 9.3 versus 59.9 ± 17.5 years; p<0.05, Mann–Whitney U-test). Intensity of head trauma was moderate in four and severe in seven patients with a median pre-operative Glasgow Coma Scale (GCS) of 8. Median pre-treatment prothrombin time and international normalized ratio were 23% (range: 10–65%) and 3.3 (range: 1.5–10.6), respectively. Replacement therapy consisted of administration of prothrombin complex concentrates, vitamin K and FFP (fresh frozen plasma). In four patients, antithrombin was additionally given to prevent disseminated intravascular coagulation. Surgical treatment consisted of craniotomy (n=10) or craniectomy (n=1) and hematoma evacuation with intracranial pressure probe placement. Low molecular weight heparin was administered as pharmacological prophylaxis of thrombembolic events in an increasing dose post-operatively. At 6 months, six out of 11 patients survived with a median GOS of 4. All-cause mortality was 45.5%. A pre-operative GCS of ≤ 8 was not associated with an increased risk of mortality (p>0.5, Fisher's exact test). No relevant rebleedings or thrombembolic complications were observed. The mortality rate of patients who did not undergo OAT was 50%.

Conclusion: A large number of patients with aSDH are on pre-injury OAT. Specific replacement therapy facilitates successful clot evacuation without bleeding complications. The overall outcome of these patients does not seem to differ from historical cohorts with aSDH without OAT, but a large prospective multicenter study is warranted to answer that question.     

Outcome of Gastric Bypass Patients

Background: The authors analyzed previously studied outcomes of Roux-en-Y gastric bypass (RYGBP), examined pre-surgical factors of post-surgical outcomes, and examined some of the psychosocial benefits. Methods: A retrospective chart review was conducted of 138 patients who underwent RYGBP between 1997 and 2000. Pre-surgical BMI, cholesterol, blood pressure, creatinine, number of antidepressant/glycemic drugs, and hemoglobin were recorded. Post-surgical follow-up was reviewed to examine changes. Results: Statistically significant changes were found in BMI, hypertension, cholesterol and glycemic control. Surgery was found to reduce creatinine from a pre-surgery average of 1.14 to 1.01 (n=11, p=.0015)). Patients with early post-operative complications (defined as length of stay >6 days or re-hospitalization within 1 month following surgery) had an average BMI of 57.58 (n=23) vs a BMI of 49.9 (n=103) in those who did not experience any complications (p = 0.0004).There was a statistically significant decrease in the rate of anti-depressant use following surgery. 49 patients were on antidepressants before surgery vs 38 following surgery (p=.0016). Conclusion: RYGBP significantly improves hypertension, hyperlipidemia and type II diabetes, and may also improve kidney function. Patients with higher pre-surgical BMIs are at greater risk for postsurgical complications. Postoperative antidepressant use appears to decrease.     

Peptic Ulcer/Stricture After Gastric Bypass: A Comparison of Technique and Acid Suppression Variables

Background: Mason's original animal experiments on the gastric bypass (GBP) showed little acid production in the gastric pouch, a finding confirmed in humans. Despite this, GBP in humans is associated with an incidence of ulcer/stricture (U/S) at the gastrojejunostomy of 3 to 20%, with both acid secretion and staple-line dehiscence considered important risk factors or etiologies. Our series of GBP patients was reviewed to determine what technical or management factors, if any, were associated with U/S. Methods: All patients undergoing first time GBP at Dartmouth-Hitchcock Medical Center by one surgeon from June 1991 until June 2000 were reviewed. The incidence of U/S as confirmed on upper endoscopy was determined by retrospective chart review. The technique of surgery, frequency of acid suppressive therapy at discharge, postoperative day of U/S diagnosis by endoscopy, length of follow-up with a member of the multidisciplinary bariatric team, and incidence of staple-line dehiscence were tabulated. Results: 158 patients (72% female, mean BMI 53, mean age 42) underwent GBP.Two gastric stapling methods were used to create the gastric pouch: 4-rows (136 patients) and 8-rows (22 patients). No other technical feature was adjusted in the series. The two patient groups were similar in gender, age, and BMI. Acid suppressive therapy at the time of discharge was similar in each group with U/S (4-rows 64% and 8-rows 50%, p=0.5). U/S developed in 12 (55%) of the 8-row group and in 14 (10%) of the 4-row group (p < 0.001). U/S typically occurred within the first 2 months postoperatively (mean 48 days, SD 40). No patients in our series developed a staple-line dehiscence. Conclusion: U/S occur in the first few months following GBP.Twice the number of gastric staple-lines is associated with over five times the incidence of U/S, whereas post-discharge acid suppressive therapy is not predictive of U/S. Thus, a technique performed to decrease the risk of staple-line breakdown was associated with a much higher incidence of U/S. Staple-line dehiscence is not the etiology of this condition.Therefore, U/S after GBP does not appear to be explained by acid injury. We speculate that local, tissue injury related factors may be more responsible, a speculation that invokes a novel pathophysiologic mechanism for U/S formation following gastrojejunostomy.     

Colles‘骨折固定体位的探讨（附56例疗效分析）

通过对临床实践中正反两方面经验和教训的总结，根据腕部解剖、生理及骨折后的病理特点，分析比较了５６例Ｃｏｌｌｅｓ’骨折患者复位后分别采用腕掌屈前臂旋前位与腕背伸前臂旋后位两种不同固定方法的优劣。结果表明，骨折再移位发生率后者明显低于前者；而功能恢复情况后者明显优于前者（Ｐ＜０．０１）。揭示腕背伸前臂旋后位固定不仅利于骨折复位后的稳定，而且有利于骨折愈合和功能恢复。因此主张摒弃传统的腕掌屈前臂旋前位固定，采用腕背伸前臂旋后位固定。     

Obstructive Symptoms Associated with the 9.75-cm Lap-Band® in the First 24 Hours using the Pars Flaccida Approach

Background: For some patients, especially those with a higher BMI, a non-selective Lap-Band? placement using the pars flaccida approach with application of the small-diameter bands (9.75 and 10 cm) may be too tight or may require significant gastroesophageal junction dissection and thinning. In such a case, the major perioperative complication is acute obstruction immediately after surgery. We review the etiology of obstructive complications that present postoperatively in the first 24 hours. Case Reports: Acute postoperative stoma obstruction (esophageal outlet stenosis) was observed in 5 patients who underwent 9.75-cm Lap-Band? placement for morbid obesity. 2 of these patients had a postoperative upper GI series showing a misplaced band with gastric slippage, and repeat operation was required. 3 patients had gastric obstruction without slippage. Of the latter, 1 patient insisted that the band be removed rather than being replaced with a longer one, and the remaining 2 were managed with conservative treatment, involving extended hospitalization until the edema subsided and the patient slowly regained the ability to swallow. Conclusion: Obstructive symptoms associated with the Lap-Band? using the pars flaccida approach can be addressed conservatively in most patients or by minimally invasive surgery; however we believe that routine use of the 11-cm Lap-Band? for the pars flaccida approach could easily prevent this early complication.     

Late Gastric Pouch Necrosis after Lap-Band<Superscript>®</Superscript>, Treated by an Individualized Conservative Approach

Late band slippage has occurred in nearly 3-10% of patients after laparoscopic adjustable gastric banding (LAGB) with an average delay of 13 months. Band slippage can rarely lead to necrosis of the enlarged pouch, a potentially life-threatening condition. We report a female (BMI 39.92 with co-morbidities) who developed acute outlet obstruction 2 years after LAGB placement. After prompt band deflation, an urgent Gastrografin swallow showed stomach slippage without emptying. At re-operation pouch strangulation was discovered. The pouch appeared to be ill-fated, but as no tear was evident on intra-operative assessment, we decided to simply remove the band and drain. The patient was successfully discharged after 8 days, and the last upper endoscopy showed only a large ulcer in the fundus that was healing. Proper and prompt management of symptomatic patients with stomach slippage, with early operation when acute obstruction is evident, can enable a successful stomach-sparing approach.     

Silastic Ring Vertical Gastric Bypass: Evolution of an Open Surgical Technique,and Review of 1,588 Cases

Background: Silastic ring vertical gastric bypass (SRVGBP) has evolved from a stapled (SSRVGBP) to a transected (TSRVGBP), and finally to a transected pouch with jejunal interposition (TSRVGBP with J-I). The creation of the gastroenterostomy evolved from a hand-sewn to a stapled and finally to a combined stapled and hand-sewn anastomosis. The circumference of the ring was increased from 5.5 to 6.0 cm. We address the effect of these modifications on surgical outcome. Method: The records of 1,588 consecutive patients (mean BMI of 44.5) since 1990 who had a SRVGBP were indentified from a prospective data-base of all patients undergoing bariatric operations. 205 patients with a prior bariatric operation were excluded from the review, leaving 1,383 patients who had a primary SRVGBP. Results: In the 193 SRVGBP patients, there was 1 gastric leak (0.5%) and 64 gastrogastric fistulas (33.2%). In the 165 TSRVGBP patients, there were 4 gastric leaks (2.4%) and 14 gastrogastric fistulas (8.5%). In the 1,025 patients with TSRVGBP with JI, there were 8 gastric leaks (0.8%) and no gastro-gastric fistulas. In the TSRVGBP with J-I, 367 patients had a hand-sewn, 16 a stapled, and 642 a combined stapled and hand-sewn anastomosis. Stricture rate was 3.8%, 31%, and 2.6% respectively. There were 7 ring migrations (0.7%), all in the totally hand-sewn group. Ring removal was necessary in 20 (5%) with a 5.5-cm and 4 (0.74%) with a 6.0-cm ring. Conclusion: TSRVGBP with J-I with a combined stapled and hand-sewn gastrojejunal anastomosis using a 6.0-cm ring decreased the incidence of complications, and is our current technique.     

The Elite II™ Bariatric Surgery Retractor System: A Recent Addition to the Bariatric Surgeon's Tool Chest

Background: A good surgical retractor is essential for facilitating bariatric surgery. Recently,Thompson Surgical Instruments designed a new system specifically for bariatric surgical procedures. Methods: The Elite II^™ Bariatric Retractor system was evaluated in 50 successive bariatric surgical patients. We had the opportunity to modify and improve several major components. We report our experience with this modified retractor system. Results: This system proved to be safe, easy to use, durable, and useful in patients of all BMIs, following modifications and improvements to standard parts. Conclusion: This new bariatric retractor system is an improvement over prior bariatric retractor systems being used.     

The Micropouch Gastric Bypass: Technical Considerations in Primary and Revisionary Operations

Background: Roux-en-Y gastric bypass is an effective procedure for the long-term control of morbid obesity. An eventual revisionary operation, however, is necessary for some patients (0.8-29%). Redo procedures are required for pouch enlargement, stapleline dehiscence, or marginal ulceration. In 1994, the micropouch gastric bypass (MBG) was developed to eliminate the need for a repeat operation. Its design was based on two anatomical principles: 1) The fundus is elastic, aperistaltic, and may significantly dilate over time; 2) The proximal magenstrasse contains a high concentration of parietal cells, which potentiates the risk for marginal ulceration or gastroesophageal reflux after vertical pouch restriction. Construction of a micropouch limited to the gastric cardia avoids using the fundus and proximal lesser curvature, but requires a greater mobilization of the stomach and its peritoneal attachments. Methods: Between February 1994 and February 2000, 1,120 patients underwent the MGB as a primary or revisionary operation.The fundus was mobilized completely, including transection of the left phreno-esophageal and gastrophrenic ligaments. The transected pouch was limited to the gastric cardia with 1 cm of fundus incorporated into the gastrojejunostomy stoma (GJS). Results: There were 10 anastomotic leaks at the GJS (0.9%). All leaks sealed following surgical drainage or parenteral nutrition. One patient required re-operation (0.09%) for a dilated pouch and marginal ulceration. An additional patient (0.09%) developed a gastrogastric fistula secondary to a pharmacobezoar and stomal stenosis. Conclusion: With an appreciation for the finer anatomy of the proximal stomach and intra-abdominal esophagus, the micropouch can be constructed safely in both primary and redo procedures. The MGB, now in its seventh year, is durable and has, with rare exception, eliminated pouch enlargement, staple-line separation, reflux esophagitis, and marginal ulceration.