Maintenance of Multivitamin Supplements After Sleeve Gastrectomy

Introduction

After all bariatric procedures, multivitamin supplements are uniformly prescribed to minimize eventual deficiencies. These supplements are usually maintained long time, even during the whole life after malabsorptive techniques, while these are maintained at least during 1 year after restrictive procedures. Given that sleeve gastrectomy does not alter intestinal absorption, the supplements are possibly unnecessary, once the patient can take an adequate diet.

Patients and Methods

A prospective randomized study of patients undergoing a laparoscopic sleeve gastrectomy was performed. Patients were randomized into two groups: those patients receiving the multivitamin supplement (Multicentrum, Pfizer, 1 tablet/day) during 3 months (group 1) and those receiving the supplement during 12 months (group 2). Laboratory data were recorded: vitamins (D, B12 and folic acid) and oligoelements (calcium, iron, phosphorus, magnesium and zinc) at 3, 6 and 12 months after surgery.

Results

Eighty patients were included, 40 in each group. At 3 months, 7.5 % of the patients presented iron deficiency and 2.5 % ferritin one, similarly in both groups, that was corrected with specific extra iron supplements. At 6 months, one patient (2.5 %) in group 1 presented iron deficiency and one in group 2 vitamin D deficiency (NS). At 12 months, only one patient in group 2 presented vitamin D deficiency, treated with specific supplements.

Conclusion

The maintenance of multivitamin supplements more than 3 months postoperatively seems to be of no benefit. It is preferable monitoring laboratory values and adding specific supplements when necessary.

ClinicalTrials.gov Identifier

NCT02620137

     

Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management

Purpose

The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication.

Methods

We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data.

Results

During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-operative symptoms of GS (1.4 %); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1–114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2 %) after balloon dilatation (n?=?13) or insertion of a covered stent (n?=?2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8 %).

Conclusion

GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation.

     

Concordance of Gleason grading with three-dimensional ultrasound systematic biopsy and biopsy core pre-embedding

Purpose

To determine the value of a three-dimensional (3D) greyscale transrectal ultrasound (TRUS)-guided prostate biopsy system and biopsy core pre-embedding method on concordance between Gleason scores of needle biopsies and radical prostatectomy (RP) specimens.

Methods

Retrospective analysis of prostate biopsies and subsequent RP for PCa in the Jeroen Bosch Hospital, the Netherlands, from 2007 to 2016. Two cohorts were analysed: conventional 2D TRUS-guided biopsies and RP (2007–2013, n = 266) versus 3D TRUS-guided biopsies with pre-embedding (2013–2016, n = 129). The impact of 3D TRUS-guidance with pre-embedding on Gleason score (GS) concordance between biopsy and RP was evaluated using the κ-coefficient. Predictors of biopsy GS 6 upgrading were assessed using logistic regression models.

Results

Gleason concordance was comparable between the two cohorts with a κ = 0.44 for the 3D cohort, compared to κ = 0.42 for the 2D cohort. 3D TRUS-guidance with pre-embedding, did not significantly affect the risk of biopsy GS 6 upgrading in univariate and multivariate analysis.

Conclusions

3D TRUS-guidance with biopsy core pre-embedding did not improve Gleason concordance. Improved detection techniques are needed for recognition of low-grade disease upgrading.

     

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Objective

To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.

Design

Cohort study.

Setting

District hospital.

Patients

Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of?>?20 mm.

Intervention

Fracture fixation with either an intramedullary nail or a plate.

Outcome measurements

Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.

Results

Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.

Conclusion

Severe displacement of the lesser trochanter (>?20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.

Level of evidence

II.

     

Clinical impact of prostate biopsy undergrading in an academic and community setting

Purpose

To evaluate whether the rate of Gleason score (GS) upgrade on final pathology, the rate of positive surgical margins (PSM) and the rate of biochemical recurrence (BCR) after radical prostatectomy (RP) were different if prostate biopsy (PB) was graded by community pathologists (CP) as compared to specialized uro-pathologists (UP).

Methods

A consecutive series of patients undergoing RP in our institution between 2005 and 2013 were retrospectively reviewed. Any GS higher or lower in RP specimen as compared to PB GS was defined as GS upgrade or downgrade, respectively. Additionally, stratification for the new ISUP 2014 grading system was performed. Predictors of GS upgrade and PSMs and prognostic parameters for BCR were assessed by stepwise logistic regression models and by multivariable Cox regression analyses, respectively.

Results

A total of 786 patients were available for analysis, and median follow-up was 36 months (1–101 months). A GS upgrade was found in 345 patients (43.9 %) and a GS downgrade in 91 patients (11.6 %). Discordance between PB GS and RP GS was significantly more frequent when grading had been performed by a CP (50.5 % upgrade, 9.0 % downgrade) than by a UP (33.1 % upgrade, 15.7 % downgrade, p < 0.001). CP evaluation was an independent predictor for GS upgrade (odds ratio [OR] 1.91, p < 0.001) and for PSMs (OR 1.69, p = 0.003), as well as an independent predictor of BCR (hazard ratio [HR] 1.65, p = 0.028).

Conclusions

Pathologic evaluation of PBs by a dedicated UP should be recommended to reduce the rate of biopsy undergrading, PSM and BCR after RP.

     

Subcutaneous dissection area contributes less to endoscopic thyroidectomy-related invasiveness

Objective

To clarify the contribution of the subcutaneous area during breast approach endoscopic thyroidectomy (BAET), with regard to invasiveness-related outcomes.

Methods

Seventy-two patients were randomly assigned to two groups: standard dissection and limited dissection. Postoperative pain and inflammatory response were compared between groups.

Results

The groups were well matched except for subcutaneous dissection area (137.11 ± 21.10 vs. 83.69 ± 12.10 cm², p < 0.0001). No significant difference was found with regard to VAS score and postoperative inflammatory response.

Conclusion

Our RCT indicated that the subcutaneous area plays a less important role with regard to BAET-related postoperative pain.

     

Simulation-trained junior residents perform better than general surgeons on advanced laparoscopic cases

Background

Multiple simulation training programs have demonstrated that effective transfer of skills can be attained and applied into a more complex scenario, but evidence regarding transfer to the operating room is limited.

Objective

To assess junior residents trained with simulation performing an advanced laparoscopic procedure in the OR and compare results to those of general surgeons without simulation training and expert laparoscopic surgeons.

Methods

Experimental study: After a validated 16-session advanced laparoscopy simulation training program, junior trainees were compared to general surgeons (GS) with no simulation training and expert bariatric surgeons (BS) in performing a stapled jejuno-jejunostomy (JJO) in the OR. Global rating scale (GRS) and specific rating scale scores, operative time and the distance traveled by both hands measured with a tracking device, were assessed. In addition, all perioperative and immediate postoperative morbidities were registered.

Results

Ten junior trainees, 12 GS and 5 BS experts were assessed performing a JJO in the OR. All trainees completed the entire JJO in the OR without any takeovers by the BS. Six (50 %) BS takeovers took place in the GS group. Trainees had significantly better results in all measured outcomes when compared to GS with considerable higher GRS median [19.5 (18.8–23.5) vs. 12 (9–13.8) p < 0.001] and lower operative time. One morbidity was registered; a patient in the trainees group was readmitted at postoperative day 10 for mechanical ileus that resolved with medical treatment.

Conclusion

This study demonstrated transfer of advanced laparoscopic skills acquired through a simulated training program in novice surgical residents to the OR.

     

Die palmare winkelstabile Plattenosteosynthese bei Extensionsfrakturen des distalen Radius

Objective

Bony healing of dislocated distal radius fractures after open reduction and internal stabilization by locking screws/pins using palmar approach.

Indications

Extraarticular distal radius fractures type A2/A3, simple extra- and intraarticular fractures type C1 according to the AO classification, provided a palmar approach is possible.

Contraindications

Forearm soft tissue lesions/infections. As a single procedure if a volar approach not possible.

Surgical technique

Palmar approach to the distal radius and fracture. Open reduction. Palmar fixation of the plate to radial shaft with single screw. After fluoroscopy, distal fragments fixed using locking screws.

Postoperative management

Below-the-elbow cast for 2 weeks. Early exercise of thumb and fingers, wrist mobilization after cast removal. Complete healing after 6–8 weeks.

Results

Ten patients averaged 100?% range of motion of the unaffected side after 43±21 months. No complications observed. DASH score averaged 12±16 points; Krimmer wrist score was excellent in 7, good in 2, and fair in one.

     

Iodine Status After Bariatric Surgery—a Prospective 10-Year Report from the Swedish Obese Subjects (SOS) Study

Context

Bariatric surgery can lead to nutrient deficiencies. Gastric by-pass (GBP) entails restriction and malabsorption, whereas, vertical banded gastroplasty (VBG) is only restrictive.

Objective

The objective of this study is to study whether GBP-patients develop iodine deficiency from malabsorption, and if GBP- and VBG-patients develop lower 24-h urinary iodine excretion (24-UIE) than obese non-operated controls (OB-controls) due to lower iodine intake.

Design

The Swedish Obese Subjects (SOS) study is a prospective, non-randomized study of 4047 obese patients included 1987–2001, who chose bariatric surgery or non-surgical treatment. SOS-groups were compared at baseline, after 2 and 10 years and with population-based subsamples (MONICA-controls).

Patients

One hundred eighty-eight GBP-patients were matched with 188 VBG-patients and 188 OB-controls and with three subgroups from 412 MONICA-controls.

Main Outcome Measurements

Primary outcome was 24-UIE. Secondary outcomes were iodine intake, iodine supplementation, TSH, FT4, and thyroid morbidity.

Results

At baseline, median 24-UIE was higher in GBP-patients, VBG-patients and OB-controls than in MONICA-controls (214, 201, 203 and 137 μg/day, p < 0.001). At 10 years, 24-UIE in GBP-patients (161 μg/day) and VBG-patients (149 μg/day) was lower compared with baseline (p < 0.01) and OB-controls (189 μg/day, p < 0.01), but similar to 24-UIE in MONICA-controls (137 μg/day). The 10-year-dietary iodine intake was similar in GPB-patients and OB-controls, but higher in VBG-patients. Iodine supplementation was taken by 0–9% in SOS-groups.

Conclusion

After surgery, GBP- and VBG-patients did not suffer from iodine deficiency, but both groups had lower iodine status than OB-controls. Dietary supplements recommended after bariatric surgery do not need to include iodine, in iodine sufficient countries.

Trial Registration

clinicaltrials.gov: NCT01479452

     

A simplified surgical technique for recurrent inguinal hernia repair following total extraperitoneal patch plastic

Purpose

To present a new and alternative method for surgical treatment of recurrent inguinal hernia after total extraperitoneal patch plastic (TEP).

Methods

From January 2005 to September 2015, 35 patients (34 male, 1 female; mean age 65 ± 12.6 years) with recurrent inguinal hernia following TEP were operated at the Kliniken Essen-Mitte using a simplified method consisting of re-fixation of the primary mesh to the inguinal ligament by an anterior approach.

Results

The mean operating time was 47 ± 22 min. All complications were minor with an overall incidence of 6%. After a mean follow-up of 54 months one re-recurrence was observed.

Conclusions

This Simplified Hernia Repair is safe and avoids additional foreign body implantation. Therefore, it is our method of choice for recurrent inguinal hernias after TEP.

     

Arthroscopic popliteus bypass graft for posterolateral instabilities of the knee

Objective

An arthroscopic technique for the reconstruction of the posterolateral corner combined with posterior cruciate ligament (PCL) reconstruction was developed.

Indications

Posterolateral rotational instabilities of the knee. Combined lesions of the PCL, the popliteus complex (PLT) and the posterolateral corner. Isolated PLT lesions lacking static stabilizing function.

Contraindications

Neuromuscular disorders; knee deformities or fractures; severe posterolateral soft tissue damage.

Surgical technique

Six arthroscopic portals are necessary. Using the posteromedial portal, resect dorsal septum with a shaver. Visualize the PCL, the lateral femoral condyle and the posterolateral recessus with the PLT. Dissect the popliteomeniscal fibers; retract PLT until sulcus popliteus is visualized. Drill a 6-mm tunnel anteriorly into the distal third of the sulcus popliteus. Visualize femoral footprint of the PLT and place an anatomical drill tunnel. Pull the popliteus bypass graft into the knee and fix with bioscrews. Fix the reconstructed PCL. In cases of additional LCL injury, reconstruct LCL with autologous graft.

Postoperative management

Partial weight-bearing for 6 weeks, range of motion exercises, quadriceps-strengthening exercises on postoperative day 1. Full extension allowed immediately with flexion limited to 20° for 2 weeks, to 45° for up to week 4, and to 60° up to week 6. Use a PCL brace for 3 months, running and squatting exercises allowed after 3 months.

Results

In the 35 patients treated, no technique-related complications. After 1 year, 12 patients had a mean Lysholm Score of 88.6 (± 8.7) points and a side-to-side difference in the posterior drawer test of 2.9 (± 2.2) mm (preoperative 13.3 [± 1.9] mm).

Conclusion

Low complication risk and good and excellent clinical results after arthroscopic posterolateral corner reconstruction.

     

Laparoscopic inguinal hernioplasty after robot-assisted laparoscopic radical prostatectomy

Purpose

To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series.

Results

The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence.

Conclusions

Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.

     

Vitamin D Deficiency Before Bariatric Surgery: Should Supplement Intake Be Routinely Prescribed?

Background

Before bariatric surgery, we demonstrate a 96% rate of vitamin D deficiency in morbidly obese French patients: should supplement intake be routinely prescribed? We conducted a prospective observational study to demonstrate the prevalence of vitamin D deficiency in morbidly obese patients awaiting bariatric surgery.

Methods

Clinical and biological data were collected on 50 successive patients.

Results

Data showed vitamin D deficiency in 96% (25-OH vitamin D = 31 ± 13 nmol/l), with a cut-point of 50 nmol/l. Secondary hyperparathyroidism was found in 44% of patients with hypovitaminosis D (parathyroid hormone (PTH), 59?±?24 pg/ml). Impaired PTH level concerned 89% of this group, considering the cut-point at 30 pg/ml. No significant correlation appeared between vitamin D and calcium or phosphate levels.

Conclusions

Before surgery, we demonstrated a higher incidence of vitamin D deficiency in morbidly obese French patients as compared to the general population. The incidence was also higher than previous American studies. Screening for hypovitaminosis D may routinely be considered in morbid obesity. Long-term observation is, however, needed to assess the advantages and potential side effects of systematic vitamin D supplements.

     

The learning curve of lateral access lumbar interbody fusion in an Asian population: a prospective study

Purpose

Lateral access lumbar interbody fusion (LLIF) is a minimally invasive technique that has an increasing popularity. It offers unique advantages and circumvents risk of certain serious complications encountered in other conventional spinal approaches. This study provides a statistical analysis defining the lateral access learning curve in the Asian population.

Methods

This prospective study included 32 consecutive patients who underwent LLIF from April 2012 to August 2014. The surgeries were performed by two senior spine surgeons and follow-up was conducted at 6 weeks, 3, 6, 9 months and 1 year post-operation.

Results

The breakpoint in operating time occurred at the 22nd level operated, from a mean of 71 min in the early phase group to a mean of 42 min in the steady state group. LLIF at L4/5 level is technically more demanding but technically feasible as competency is achieved.

Conclusions

During the learning process, there was no compromise of perioperative or clinical outcomes. It should be feasibly incorporated into a spine surgeon’s repertoire of procedures for the lumbar spine.

     

Rekonstruktion des medialen patellofemoralen Ligaments mit autologer Grazilissehne in patellarseitig implantatfreier Technik

Objective

Anatomic reconstruction of the medial patellofemoral ligament using autologous gracilis tendon in an implant-free technique on the patellar side to regain patellofemoral stability.

Indications

Recurrent dislocations, primary dislocation with high risk of recurrence, and dislocations with (osteo-)chondral flake fractures. As combined approach together with other procedures (trochleoplasty, tibial tubercle osteotomy). Revisions.

Contraindications

As an isolated procedure in patients with high degrees of trochlear dysplasia, chronic dislocation of the patella, and patellofemoral maltracking without instability.

Surgical technique

Harvesting of the gracilis tendon. Drilling of a V-shaped tunnel with a special aiming device in anatomic position on the medial side of the patella. Drilling of a femoral tunnel in anatomic position under fluoroscopic control. Passage of the graft, arthroscopic-guided tensioning, and femoral fixation with a biodegradable interference screw.

Postoperative management

Partial weight bearing (20 kg) for 1–2 weeks. No limitation in range of motion. No orthosis. Specific sports allowed after approximately 3 months.

Results

Perioperative complications associated specifically with the technique were observed in 1.0?% (7 of 729 cases). In a series of 72 consecutive cases from May 2010 to October 2010, the following were recorded after 4.0 ± 0.1 years: recurrent dislocations in 3.2?%, a Tegner activity score of 5.1 ± 1.8, and subjective satisfaction in 92?% (follow-up rate 87.5?%). No fracture of the patella was seen in any of our patients.

     

Task Shifting: The Use of Laypersons for Acquisition of Vital Signs Data for Clinical Decision Making in the Emergency Room Following Traumatic Injury

Importance

In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care.

Objective

To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients.

Design

We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention.

Setting

The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi.

Participants

All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014).

Intervention

Lay people were trained to take and record vital signs.

Main outcomes and measures

The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis.

Results

Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded.

Conclusions and relevance

The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.

     

A national benchmark for the initial assessment of men with LUTS: data from the 2010 Royal College of Physicians National Audit of Continence Care

Objective

To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in men.

Design

Retrospective survey of male patients with UI in primary and acute hospital (AH) care as part of a national audit.

Setting

NHS AH and primary care (PC) trusts.

Sample

Twenty-five men <65 years old and 25 men ≥65 years old from each participating site.

Methods

All NHS trusts in England, Wales Northern Ireland and Channel Islands were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous, and access to the web tool was password protected for confidentiality.

Results

Data were returned by 80 % (128/161) of acute trusts and 52 % (75/144) of PC trusts in England, and 71 % (10/14) of combined trusts from Northern Ireland, Wales and the Channel Islands including data on 559 men <65 and 1271 65+ from 141 sites within acute hospitals and 445 men <65 and 826 men 65+ in PC, a total of 3101 participants.

Conclusion

The majority of men seen within the NHS with LUTS do not receive management according to evidence-informed NICE guidelines; in general, older men are less likely to receive care that meets guideline standards than younger men.

     

Operative Behandlung der ulnaren Seitenbandläsion am Daumengrundgelenk

Objective

Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.

Indications

Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.

Contraindications

Abrasions, wound-healing disturbance, skin disease, osteoarthritis.

Surgical technique

Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.

Postoperative treatment

Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.

Results

Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery

Background

Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery.

Objective

To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery.

Methods

From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days.

Results

The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions.

Conclusions

Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.