Postoperative hemorrhage

Endoscopic treatment and risks

When removing large neoplasms using endoscopic submucosal dissection (ESD), the patient must be prepared as seriously as for traditional open surgery. The main threats of such procedures are organ wall perforation and massive bleeding.

If bleeding does occur, in the vast majority of cases it can be stopped using endoscopic techniques directly during the procedure. In the postoperative period, proton pump inhibitors (PPIs) form the basis of conservative management. Their administration must be continued uninterrupted until complete healing and scarring of the mucosal defect.

Nonspecific thrombosis prevention

Prescribing specific anticoagulant therapy to correct hemostasis is always associated with the risk of hemorrhagic complications, especially in the early postoperative period. Therefore, nonspecific prevention methods aimed at combating venous stasis play a crucial role. Their main advantage is that they do not increase the risk of bleeding at all while significantly enhancing the efficacy of pharmacological thromboprophylaxis.

Basic measures include:

• Early mobilization of the patient after surgery.
• Therapeutic exercises (physical therapy), including lower extremity exercises and the use of a "foot pedal" for passive contraction of the calf muscles.
• Mechanical methods: elastic compression of the legs, sequential intermittent pneumatic compression, and calf muscle electrical stimulation.

Complications in spinal surgery

Spine surgery has its own spectrum of early complications, where postoperative bleeding can lead to fatal neurological consequences.

• Epidural hematoma. Occurs with insufficient intraoperative hemostasis. If the accumulated blood compresses the spinal nerve roots, emergency reoperation is required to remove the clots and achieve definitive hemostasis.
• Spinal cord ischemia. Requires continuous hemodynamic monitoring (blood pressure, heart rate), minimal traction on the dural sac and spinal nerve root, and medical management if abnormalities occur.
• Implant-related problems. Insertion of an inappropriately sized (larger) screw can cause pedicle fracture, requiring screw revision into an adjacent vertebra. During the first 4–5 months, before bone union is achieved, the risk of rod fracture is high. This threatens secondary spinal deformity, chronic pain, and progressive neurological deficit. To prevent screw malposition, careful sizing and intraoperative fluoroscopy or CT control are necessary.
• Infections. Require antibiotic therapy based on microbiological sensitivity and surgical debridement. The decision to retain or remove hardware is always strictly individualized.

Epidemiology of ulcer bleeding

Despite advances in modern surgery, the incidence of ulcer gastroduodenal bleeding in the Russian Federation remains steadily high at 90–160 cases per 100,000 population, with no clear downward trend. Moreover, due to the frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs), the number of hospitalizations for complicated peptic ulcer disease (bleeding and perforation) is steadily increasing.

According to 2022 statistics:

• 47,483 patients were admitted to hospitals.
• Surgical activity was 12.1% (5,746 patients operated on).
• Overall mortality was recorded at 5.87%, while postoperative mortality reached 16.92%.

The decline in overall mortality observed in recent years is associated with the introduction of modern endoscopic and endovascular hemostasis methods, as well as the high efficacy of modern antiulcer drug regimens.

Class and exam questions

What else to study on this topic

• Patient selection criteria for endoscopic submucosal dissection (ESD)
• Endoscopic and endovascular methods for stopping gastrointestinal bleeding
• Mechanisms of spinal cord ischemia during surgical interventions
• Types of implant instability in spinal surgery
• Management tactics for patients with infectious processes in the surgical site

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.