Postoperative Hemorrhage

All patients who had undergone surgery for solitary BM between 2013 and 2019 at the authors’ neuro-oncological university center were entered into a computerized database. Patients with multiple BM and/or leptomeningeal involvement were excluded. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the University Hospital Bonn (No. 250/19). Informed consent was not sought as a retrospective study design was chosen.
Patient characteristics surveyed for further analysis consisted of radiological features, preoperative laboratory values, and BM location, as well as the location of the primary malignancy, the preoperative functional status of the affected patient, and the presence of other systemic metastases. In terms of location, two groups were established for further investigation on the basis of the supra- or infratentorial location of the BM. Infratentorial location was defined as within the cerebellum, and brainstem lesions were excluded from analysis. The functional status of patients undergoing surgery was assessed preoperatively according to the Karnofsky Performance Score (KPS) [8 (link)]. The Charlson Comorbidity Index (CCI) was used to evaluate the comorbidity burden of patients prior to surgery as previously described [3 ]. During a weekly tumor board meeting, all the treatment strategies applied and further investigated were determined individually for each individual patient by interdisciplinary consensus and, if necessary, coordinated with the referring physicians and/or taken into account previous oncological therapies [9 (link)]. In the present study, only patients with indication for surgical therapy were considered and further analyzed resulting in a consecutive cohort of patients with surgically treated BM. After BM resection, patients are transferred to their transferring hospital in order to conduct postoperative oncological treatment [10 (link)].
To evaluate perioperative complication profiles in patients undergoing BM resection, a list of adverse events known as patient safety indicators (PSIs) and hospital-acquired conditions (HACs) was used as previously described [11 ]. These events were established by the Agency for Healthcare Research and Quality and the Center for Medicare and Medicaid Services. The PSIs included occurrences such as pressure ulcers, transfusion reactions, and postoperative hemorrhage, while HACs included screening for pneumonia, fall injuries, and catheter-associated urinary tract infections. Specific to cranial surgeries, complications such as cerebrospinal fluid leakage and postoperative seizures, were classified as cranial-surgery-related complications (CSCs) as previously described [12 (link)]. Any intra- or postoperative adverse events that occurred within 30 days of the initial resection, with or without further surgical interventions, were considered perioperative complications.

This is a retrospective and single-center study. We retrospectively reviewed the records of patients who underwent surgical resection between January 2004 and December 2019 at the Chang Gung Memorial Hospital (CGMH), Taiwan. Post-pancreatoduodenectomy hemorrhage data were collected from the CGMH imaging dataset. This protocol was approved by the CGMH Institutional Review Board and the Ethics Committee. The Ethics Committee waived the requirement for informed consent for this study. All methods in this study were carried out in accordance with the institutional guidelines and regulations of the Chang Gung Medical Foundation. The inclusion criteria were as follows: (a) patients received pancreatoduodenectomy or any periampullary region operation, with GDA ligation; (b) patients had clinical evidence of internal bleeding, with or without a positive finding on the computed tomography (CT) scan with contrast and/or the CTA (CT angiography) scan; (c) patients received angiography. This study excluded (a) patients without GDA ligation, and (b) cases where the patients’ bleeding site was not from the GDA stump.
We used an electronic search method to identify the medical records of patients treated at our hospital. The patients’ medical records and radiological images were retrospectively reviewed in the electronic database of our institution by assessing preoperative characteristics, postoperative hemorrhage, additional interventions, mortality, and postoperative complications (such as hepatic failure, abscess, or infarct).
There is a high prevalence of viral hepatitis in Taiwan; viral hepatitis induces liver cirrhosis (a calculated annual incidence of 2.4%) [13 (link),14 (link)], which subsequently causes portal hypertension and affects the entire liver perfusion. Because liver perfusion via the hepatic artery is sacrificed after TAE and may cause severe post-TAE complications, such as liver infarction, secondary liver abscesses, and hepatic failure, we included underlying liver disease (such as liver cirrhosis and any liver-related surgery) to evaluate their association with post-TAE complications.
All the patients’ vital signs were closely monitored, some through laboratory blood tests (especially in relation to liver function), in the intensive care unit after the TAE procedure. If patients showed any clinical signs or symptoms suggesting re-bleeding, repeated angiography with subsequent embolization was performed. The follow-up duration was measured from the time of surgery until death or after discharge, until 30 June 2022 (more than 6 months). No patient was lost to the follow-up.

All surgery were performed under general anaesthesia by the same surgeon. After the papillae of the submandibular ducts were located, the floor of the mouth was infiltrated with Xylocaine 2% with Epinephrine 1:80,000, and an incision was made to create two mucosal islands containing the papilla. The submandibular duct was freed from anterior to posterior, taking special care to prevent damage to the lingual nerve. The sublingual glands were resected bilaterally to prevent ranula formation. After submucosal re-routing of the submandibular ducts to the oropharynx, the papillae were sutured at the base of the tongue with a single stitch, posterior to the glossopharyngeal plica. Meticulous coagulation was performed. We routinely prescribed a 7-day postoperative course of antibiotics (amoxycilline/clavulanic acid) with 5 days of diclofenac for pain management [5 (link)].
Postoperative management changed in 2006. Before 2006 most patients returned to the ward after surgery. In 2005 a life-threatening complication occurred (airway obstruction due to postoperative haemorrhage), which led to a change in our standard protocol (meticulous bipolar coagulation, local anaesthetics with adrenalin, pre-emptive antibiotics and prolonged intubation with overnight PICU stay). Since 2006 patients were observed overnight at a PICU. Patients remained sedated and (endotracheally) intubated overnight. The next day swelling of the floor of the mouth and tongue was evaluated by a resident ENT by intraoral assessment and in case of absent or minor swelling patients were extubated after weaning.