1305 Ureteral Stenting in Conservative Management of Grade IV Blunt Renal Injury

Post-traumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. A 16-year-old male sustained a motor vehicle accident. Brought after 30 minutes to emergency department, upon arrival he was fully conscious, complaining of severe right hypochondrial and loin pain, abdomen was tender and guarded over the right side, urinary catheter inserted revealed gross haematuria, the patient was resuscitated accordingly, fast ultrasound scan showed minimal fluid collection in the Morison's pouch, the right kidney was swollen with perinephric fluid collection and poor cortico-medullary differentiation. Urgent CT scan findings were deep avulsion of the right kidney. The Patient was planned for conservative management, admitted to high dependency ward, CT scan repeated, and the size of urinoma increased compared to the initial CT, so he was planned for retrograde pyelography and ureteric stenting. Intra-operatively the right ureter was canulated, contrast injected. The pelvi-ureteric junction was intact, extravasation of contrast in the upper pole of the kidney. The right ureter was stented using a size 6 multiloop stent, with the tip directed into the upper pole calyx. The Patient showed dramatic improvement, haematuria cleared and the patient was discharged well after 12 days and the stent was removed after 6 weeks. Despite the improvements with nonoperative management, complications are described and include delayed hemorrhage, delayed massive hematuria and renal scaring with loss of function. Ureteric stenting is playing a major part in the conservative management of high-grade renal injury particularly grade IV type.

HIPTCN: Prospective Observational Study of Hypocoagulated Head Trauma Patients with Normal Admission Computed Tomography Scan

Introduction: Our national protocol for traumatic brain injury dictates that hypocoagulated patients with mild trauma and initial tomography scan with no intracranial traumatic changes must be hospitalized for 24 hours and do a post-surveillance tomography scan. The main goal of this study was to evaluate the clinical relevance of these measures.Material and Methods: A prospective observational study was undertaken in four hospitals. Adult hypocoagulated traumatic brain injury patients with a normal tomography scan were included. The main outcomes evaluated were rate of delayed intracranial hemorrhage, rate of admission in a neurosurgical department, rate of complications related with surveillance and rate of prolonged hospitalization due to complications. An analysis combining data from a previously published report was also done.Results: A total of 178 patients were included. Four patients (2.3%) had a delayed hemorrhage and three (1.7%) were hospitalized in a neurosurgery ward. No cases of symptomatic hemorrhage were identified. No surgery was needed, and all patients had their anticoagulation stopped. Complications during surveillance were reported in seven patients (3.9%), of which two required prolonged hospitalization.Discussion: The rate of complications related with surveillance was higher than the rate of delayed hemorrhages. The initial period of in-hospital surveillance did not convey any advantage since the management of patients was never dictated by neurological changes. Post-surveillance tomography played a role in deciding about anticoagulation suspension and prolongation of hospitalization.Conclusion: Delayed hemorrhage is a rare event and the need for surgery even rarer. The need for in-hospital surveillance should be reassessed.

Tonsillectomy Outcomes for Coblation Versus Bipolar Diathermy Techniques in Adult Patients: A Systematic Review and Meta-Analysis

Introduction and Aims: There is no consensus on the optimal tonsillectomy technique in adult patients. The study aims to identify all studies comparing the outcomes of coblation versus bipolar diathermy in adult patients undergoing tonsillectomy. Methods: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary outcomes were hemorrhage and postoperative pain. Secondary outcome measures included return to theatre, analgesia, intraoperative bleeding, diet, tonsillar healing, and operation time. Fixed-effects modeling was used for the analysis. Results: Six studies were identified enrolling a total of 1824 patients. There were no significant differences in terms of reactionary hemorrhage (OR = 1.81, P = .51), delayed hemorrhage (OR = 0.72, P = .20), or postoperative pain (mean difference = −0.15, P = .45); however, there is a general trend favuring coblation. For secondary outcomes, no significant differences noted in terms of intraoperative bleeding, diet, and cases returning to theatre. Analgesia administration was either insignificant or higher in the coblation group. The coblation group had longer operation time and greater healing effect on tonsillar tissue. Conclusions: There were no significant differences in outcomes for coblation and bipolar diathermy for adult tonsillectomy patients in this systematic review and meta-analysis.

Management of Anticoagulation and Colonoscopy

Purpose of review Patients undergoing colonoscopy frequently require antithrombotic therapy for underlying cardiovascular disease. Antithrombotic therapy increases the risk of bleeding during or after colonoscopy, particularly when more invasive procedures are required. However, the risk of thrombosis—with possibly devastating consequences—is increased if antithrombotic agents are held. This review will highlight existing data on the balance of procedural and patient risk factors to guide endoscopists on the management of periprocedural antithrombotic therapy. Recent findings Diagnostic colonoscopy has long been established to be low risk for hemorrhage even in patients on antithrombotic therapy, while colonoscopy with interventions—including polypectomy—is viewed as high risk requiring interruption of antithrombotic therapy when possible. Recent data, however, has challenged these practices and suggests that a more nuanced perspective may be necessary. For example, a recent randomly controlled trial found no difference in immediate or delayed hemorrhage between patients on dual antiplatelet therapy versus aspirin and placebo after polypectomy. Further, increasing data are emerging to suggest that small polypectomy (< 1 cm) is safe without interruption of anticoagulation with the use of cold snare polypectomy. Summary In patients undergoing colonoscopy, the risk of hemorrhage must be weighed against the risk of thrombosis in patients with cardiovascular disease on antithrombotic agents. In general, low-risk procedures do not require interruption of antithrombotic agents, while high-risk procedures in low-risk patients require holding antithrombotic therapy. High-risk procedures in high-risk patients require individualized decision-making with increasing data helping to support which procedures can safely be performed.

Five-year results of randomized bioactive versus bare metal coils in the treatment of intracranial aneurysms: the Matrix and Platinum Science (MAPS) Trial

BackgroundNo randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix2 coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years.MethodsA total of 626 patients were randomized to BMCs or Matrix2 coils. Detailed methods and 1-year results have been published previously.ResultsOf 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix2 coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (P<0.0001) and with aneurysm hemorrhage after treatment (P<0.008). Repeat aneurysmal hemorrhage after treatment, but before hospital discharge, occurred in three patients treated for acutely ruptured aneurysms. Additionally, two patients treated for unruptured aneurysms experienced a first hemorrhage during follow-up. All five hemorrhages resulted from aneurysms with Raymond III residual aneurysm filling persisting after initial treatment. After 5 years follow-up, 2/626 (0.3%) patients are known to have had target aneurysm rupture following hospital discharge. The annualized rate of delayed hemorrhage after coiling was 2/398/5=0.001 (0.1%) per year for unruptured aneurysms and 0 for ruptured aneurysms.ConclusionsAfter 5 years Matrix2 coils were non-inferior to BMCs but no benefit was demonstrated. Post-treatment residual angiographic aneurysm filling (Raymond III) is strongly associated with TAR (P<0.0001) and post-treatment aneurysmal hemorrhage (P=0.008).

Efficacy and safety of cold vs hot snare polypectomy for small (5-9 mm) colorectal polyps: a multicenter randomized controlled trial

Background and aims: Currently available resection techniques for small polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). We aimed to compare CSP vs HSP in 5-9 mm polyps in terms of complete resection and adverse events rates. Methods: Multicenter, randomized trial conducted in 7 Spanish centers between February-November 2019. Patients with ≥1 5-9mm polyp were randomized to CSP or HSP, regardless of morphology or pit pattern. After polyp removal, two marginal biopsies were submitted to a single pathologist blind to polyp histology. Complete resection was defined as the only finding of normal mucosa or burn artifacts in the biopsies. Abdominal pain was only assessed in patients without <5mm or >9mm polyps. Results: A total of 496 subjects were randomized; 237 (394 polyps) to CSP and 259 (397 polyps) to HSP. Complete polypectomy rates were 92.5% with CSP and 94% with HSP (difference 1.5%, 95%CI: 4.9% to -1.9%). Intraprocedural bleeding appeared in 3 (0.8%) CSPs and 7 (1.8%) HSPs (p=0.34). One (0.3%) lesion per group presented delayed hemorrhage. Post-colonoscopy abdominal pain presented similarly in both groups 1 hour after the procedure (18.8% in CSP vs 18.4% in HSP), but, after 5 hours, it was higher in HSP group (5.9% vs 16,5%, p=0.02). CSP presented a higher proportion of asymptomatic patients 24h after the procedure than HSP, 97% vs 86.4% (p=0.01). Conclusions: We observed no differences in complete resection and bleeding rates between CSP and HSP. CSP reduces the intensity and duration of post-colonoscopy abdominal pain (ClinicalTrials.gov number: NCT03783156).