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Endoscopic polidocanol foam sclerobanding for the treatment of grade Ⅱ-Ⅲ internal hemorrhoids:A prospective,multi-center,randomized study

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World Journal of Gastroenterology 2024年第38期30卷 3326-3335页

作者： chun-ying qu Fei-Yu Zhang Yi Zhang Ming-Ming Li Zheng-Hong Li Mei-Hong Cai Lei-Ming Xu Feng Shen Wen Wang Wu-Lian Lin Feng-Yu Gao Hao Zhang Guang-Yu Chen Department of Gastroenterology&Endoscopy Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghai 200092China Department of Gastroenterology The 900th Hospital of the People’s Liberation Army Joint Service Support ForceFuzhou 350025Fujian ProvinceChina Department of Endoscopy Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao UniversityJinan 250014Shandong ProvinceChina Department of Endoscopy Baoshan People’s Hospital of Yunnan ProvinceBaoshan 678000Yunnan ProvinceChina Department of Gastroenterology Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghai 200092China

BACKGROUND Endoscopic rubber band ligation(ERBL)is a nonsurgical technique for the treatment of symptomatic internal hemorrhoids but is limited by recurrence and post-procedural *** To evaluate satisfaction,long-term recurrence,and post-procedural pain in managing internal hemorrhoids using a combination of polidocanol foam sclerotherapy and *** This was a prospective,multicenter,randomized study.A total of 195 consecutive patients diagnosed with grade II-III internal hemorrhoids were enrolled from four tertiary hospitals and randomly divided into a cap-assisted endoscopic polidocanol foam sclerobanding(EFSB)or an ERBL *** patients were followed-up for 12 ***-based severity and post-procedural pain were assessed using a hemorrhoid severity score(HSS)and a visual analog scale(VAS).Continuous variables were reported as medians and interquartile *** One hundred and ninety-five patients were enrolled,with 98 in the EFSB *** was lower in the EFSB group than in the ERBL group at 8 weeks[4.0(3.0-5.0)vs 5.0(4.0-6.0),P=0.003]and 12-month[2.0(1.0-3.0)vs 3.0(2.0-3.0),P<0.001]of *** prolapse recurrence rate was lower in the EFSB group at 12 months(11.2%vs 21.6%,P=0.038).Multiple linear regression analysis demonstrated that EFSB treatment[B=-0.915,95%confidence interval(CI):−1.301 to−0.530,P=0.001]and rubber band number(B=0.843,95%CI:0.595-1.092,P<0.001)were negatively and independently associated with the VAS score 24 hours *** median VAS was lower in the EFSB group than in the ERBL[2.0(1.0-3.0)vs 3.0(2.0-4.0),P<0.001].CONCLUSION Cap-assisted EFSB provided long-term satisfaction and effective relief from the recurrence of prolapse and pain 24 hours post-procedure.

关键词： Internal hemorrhoids Endoscopic therapy Polidocanol foam Sclerotherapy Rubber band ligation Sclerobanding

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Comparison between air and carbon dioxide insufflation in the endoscopic submucosal excavation of gastrointestinal stromal tumors

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World Journal of Gastroenterology 2012年第48期18卷 7296-7301页

作者： Wei-Bin Shi Zi-Hao Wang chun-ying qu Yi Zhang Han Jiang Min Zhou ying Chen Lei-Ming Xu Department of General Surgery Xinhua HospitalSchool of MedicineShanghai Jiaotong University Digestive Endoscopic Diagnosis and Treatment Center Xinhua HospitalSchool of MedicineShanghai Jiaotong University Shanghai Key Laboratory of Pediatric Digestion and Nutrition

AIM:To evaluate the safety and efficacy of CO2 insufflation compared with air insufflation in the endoscopic submucosal excavation(ESE) of gastrointestinal stromal ***:Sixty patients were randomized to undergo endoscopic submucosal excavation,with the CO2 group(n = 30) and the air group(n = 30) undergoingCO2 insufflation and air insufflation in the ESE,*** end-tidal CO2 level(pETCO2) was observed at 4 time points:at the beginning of ESE,at total removal of the tumors,at completed wound management,and 10 min after ***,the patients' experience of pain at 1,3,6 and 24 h after the examination was registered using a visual analog scale(VAS).RESULTS:Both the CO2 group and air group were similar in mean age,sex,body mass index(all P > 0.05).There were no significant differences in PetCO2 values before and after the procedure(P > 0.05).However,the pain scores after the ESE at different time points in the CO2 group decreased significantly compared with the air group(1 h:21.2 ± 3.4 vs 61.5 ± 1.7;3 h:8.5 ± 0.7 vs 42.9 ± 1.3;6 h:4.4 ± 1.6 vs 27.6 ± 1.2;24 h:2.3 ± 0.4 vs 21.4 ± 0.7,P < 0.05).Meanwhile,the percentage of VAS scores of 0 in the CO2 group after 1,3,6 and 24 h was significantly higher than that in the air group(60.7 ± 1.4 vs 18.9 ± 1.5,81.5 ± 2.3 vs 20.6 ± 1.2,89.2 ± 0.7 vs 36.8 ± 0.9,91.3 ± 0.8 vs 63.8 ± 1.3,respectively,P < 0.05).Moreover,the condition of the CO2 group was better than that of the air group with respect to anal ***:Insufflation of CO2 in the ESE of gastrointestinal stromal tumors will not cause CO2 retention and it may significantly reduce the level of pain,thus it is safe and effective.

关键词： Carbon dioxide insufflation Endoscopic submucosal excavation Gastrointestinal tract Stromal tumor Treatment

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Antifibrotic effect of N-acetyl-seryl-aspartyl-lysyl-proline on bile duct ligation induced liver fibrosis in rats

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World Journal of Gastroenterology 2012年第37期18卷 5283-5288页

作者： Lei Zhang Lei-Ming Xu Yuan-Wen Chen Qian-Wen Ni Min Zhou chun-ying qu Yi Zhang Digestive Endoscopic Diagnosis and Treatment Center Xinhua HospitalSchool of MedicineShanghai Jiaotong UniversityShanghai 200092China

AIM:To investigate the preventive effect of N-acetyl-seryl-aspartyl-lysyl-proline (AcSDKP) on bile duct ligation (BDL)induced liver fibrosis in rats. METHODS:Liver fibrosis in rats was induced by BDL and AcSDKP was infused subcutaneously for 2 wkvia a osmotic minipump (Alzet 2ML4) immediately after BDL operation. After scarifying, serum and liver specimens were collected. Hematoxylin and eosin staining, Sirius red staining, enzyme linked immunosorbent assay, Western blot or real-time polymerase chain reaction were used to determinate liver functions, histological alterations, collagen deposition, mRNA expression of markers for fibroblasts, transforming growth factor-β1 (TGF-β1) and bone morphogenetic protein-7 (BMP-7). RESULTS:When compared to model rats, chronic exogenous AcSDKP infusion suppressed profibrogenicTGF-β1 signaling, α-smooth muscle actin positivity (α-SMA), fibroblast specific protein-1 (FSP-1) staining and collagen gene expression. Col Ⅰ, Col Ⅲ, matrix metalloproteinase-2, tissue inhibitors of metallopro-teinase-1 and tissue inhibitors of metalloproteinase-2 mRNA expressions were all significantly downregulated by AcSDKP infusion (2.02 ± 1.10vs 14.16 ± 6.50, 2.02 ± 0.45vs 10.00 ± 3.35, 2.91 ± 0.30vs 7.83 ± 1.10, 4.64 ± 1.25 vs 18.52 ± 7.61, 0.46 ± 0.16 vs 0.34 ± 0.12, respectively, P < 0.05). Chronic exogenous AcSDKP infusion attenuated BDL-induced liver injury, inflammation and fibrosis. BDL caused a remarkable increase in alanine transaminase, aspartate transaminase, total bilirubin, and prothrombin time, all of which were reduced by AcSDKP infusion. Mast cells, collagen accumulation, α-SMA, TGF-β1, FSP-1 and BMP-7 increased. The histological appearance of liver specimens was also improved. CONCLUSION:Infusion of exogenous AcSDKP attenu-ated BDL-induced fibrosis in the rat liver. Preservation of AcSDKP may be a useful therapeutic approach in the management of liver fibrosis.

关键词： N-acetyl-seryl-aspartyl-lysyl-proline Liverfibrosis Transformating growth factor-β1 α -smoothmucle actin Bone morphological protein-7 Fibroblastspecific protein-1 Epithelial-mesenchymal transition

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Combining protein arginine methyltransferase inhibitor and antiprogrammed death-ligand-1 inhibits pancreatic cancer progression

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World Journal of Gastroenterology 2020年第26期26卷 3737-3749页

作者： Nan-Nan Zheng Min Zhou Fang Sun Man-Xiu Huai Yi Zhang chun-ying qu Feng Shen Lei-Ming Xu Department of Gastroenterology Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghai 200092China

BACKGROUND Immunotherapy targeting programmed death-1(PD-1)or programmed deathligand-1(PD-L1)has been shown to be effective in a variety of malignancies but has poor efficacy in pancreatic ductal adenocarcinoma(PDAC).Studies have shown that PD-L1 expression in tumors is an important indicator of the efficacy of *** cells usually evade chemotherapy and host immune surveillance by epigenetic *** arginine methylation is a common posttranslational *** arginine methyltransferase(PRMT)1 is deregulated in a wide variety of cancer types,whose biological role in tumor immunity is *** To investigate the combined effects and underlying mechanisms of anti-PD-L1 and type I PRMT inhibitor in pancreatic cancer in *** PT1001B is a novel type I PRMT inhibitor with strong activity and good selectivity.A mouse model of subcutaneous Panc02-derived tumors was used to evaluate drug efficacy,toxic and side effects,and tumor growth in *** flow cytometry,we determined the expression of key immune checkpoint proteins,detected the apoptosis in tumor tissues,and analyzed the immune *** staining for cellular proliferation-associated nuclear protein Ki67,TUNEL assay,and PRMT1/PD-L1 immunofluorescence were used to elucidate the underlying molecular mechanism of the antitumor *** Cultured Panc02 cells did not express PD-L1 in vitro,but tumor cells derived from Panc02 transplanted tumors expressed *** therapeutic efficacy of anti-PD-L1 mAb was significantly enhanced by the addition of PT1001B as measured by tumor volume(1054.00±61.37 mm3 vs 555.80±74.42 mm3,P<0.01)and tumor weight(0.83±0.06 g vs 0.38±0.02 g,P<0.05).PT1001B improved antitumor immunity by inhibiting PD-L1 expression on tumor cells(32.74%±5.89%vs 17.95%±1.92%,P<0.05).The combination therapy upregulated tumorinfiltrating CD8+T lymphocytes(23.75%±3.20%vs 73.34%±4.35%,P<0.01)and decreased PD-1+leukocytes(35.77%±3.30%vs 6.48%±1.08%,

关键词： Protein arginine methyltransferase Programmed death-ligand-1 blockade Pancreatic cancer Combination therapy Tumor microenvironment Pancreatic ductal adenocarcinoma

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Electroacupuncture at Sensitized Acupoints Relieves Somatic Referred Pain in Colitis Rats by Inhibiting Sympathetic-Sensory Coupling to Interferewith 5-HT Signaling Pathway

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Chinese Journal of Integrative Medicine 2024年第2期30卷 152-162页

作者： YANG ying qu Jin-yu GUO Hua ZHOU Hai-ying RUAN Xia PENG ying-chun SHEN Xue-fang XIONG Jin WANG Yi-li School of Clinical Medicine Chengdu Medical CollegeChengdu(610500)China Department of Rehabilitation Medicine the First Affliated Hospital of Chengdu Medical CollegeChengdu(610500)China Department of Rehabilitation Medicine West China HospitalSichuan University/West China School of NursingSichuan UniversityChengdu(610041)China Department of Neurology the First Affiliated Hospital of Chengdu Medical CollegeChengdu(610500)China

Objective:To investigate whether electroacupuncture(EA) at sensitized acupoints could reduce sympathetic-sensory coupling(SSC) and neurogenic inflammatory response by interfering with 5-hydroxytryptamine(5-HT)ergic neural pathways to relieve colitis and somatic referred pain,and explore the underlying ***:Rats were treated with 5% dextran sodium sulfate(DSS) solution for 7 days to establish a colitis *** rats were randomly divided into the control and model groups according to a random number table(n=6).According to the Research on Rat Acupoint Atlas",sensitized acupoints and non-sensitized acupoints were *** were randomly divided into the control,model,Zusanli-EA(ST 36),Dachangshu-EA(BL 25),and Xinshu(BL 15) groups(n=6),as well as the control,model,EA,and EA+GR113808(a 5-HT inhibitor)groups(n=6).The rats in the control group received no *** was administered on 2 days after modeling using the stimulation pavameters:1 mA,2 Hz,for 30 min,with sparse and dense waves,for 14 consecutive ***113808 was injected into the tail vein at 5 mg/kg before EA for 10 min for 7 consecutive *** sensitivity was assessed with von Frey *** weight and disease activity index(DAI) scores of rats were *** and eosin staining was performed to observe colon *** was analyzed by immunofluorescence *** staining was performed to detect 5-HT and substance P(SP) *** calcitonin gene-related peptide(CGRP) in skin tissue and tyrosine hydroxylase(TH) protein levels in DRG were detected by Western *** levels of hyaluronic acid(HA),bradykinin(BK),prostaglandin I2(PGI2) in skin tissue,5-HT,tryptophan hydroxylase 1(TPH1),serotonin transporters(SERT),5-HT 3 receptor(5-HT3R),and 5-HT 4 receptor(5-HT4R) in colon tissue were measured by enzyme-linked immunosorbent assay(ELISA).Results:BL 25 and ST 36 acupoints were determined as sensitized acupoints,and BL 1

关键词： electroacupuncture sensitized acupoints sympathetic-sensory coupling 5-hydroxytryptamine neurogenic inflammation somaticreferredpain

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Effect of photodynamic therapy with(17R,18R)-2-(1-hexyloxyethyl)-2-devinyl chlorine E6 trisodium salt on pancreatic cancer cells in vitro and in vivo

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World Journal of Gastroenterology 2018年第46期24卷 5246-5258页

作者： Yu-Jie Shen Jia Cao Fang Sun Xiao-Lei Cai Ming-Ming Li Nan-Nan Zheng chun-ying qu Yi Zhang Feng Shen Min Zhou ying-Wei Chen Lei-Ming Xu Department of Gastroenterology Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

AIM To investigate the antitumor effects and underlying mechanisms of(17 R,18 R)-2-(1-hexyloxyethyl)-2-devinyl chlorine E6 trisodium salt(YLG-1)-induced photodynamic therapy(PDT) on pancreatic cancer in vitro and in *** YLG-1 is a novel photosensitizer extracted from spirulina. Its phototoxicity, cellular uptake and localization, as well as its effect on reactive oxygen species(ROS) production, apoptosis, and expression of apoptosis-associated proteins were detected in vitro. An in vivo imaging system(IVIS), the Lumina K imaging system, and mouse models of subcutaneous Panc-1-bearing tumors were exploited to evaluate the drug delivery pathway and pancreatic cancer growth in *** YLG-1 was localized to the mitochondria, and the appropriate incubation time was 6 h. Under 650 nm light irradiation, YLG-1-PDT exerted a potent cytotoxic effect on pancreatic cancer cells in vitro, which could be abolished by the ROS scavenger N-acetyl-L-cysteine(NAC). The death mode caused by YLG-1-PDT was apoptosis, accompanied by upregulated Bax and cleaved Caspase-3 and decreased Bcl-2 expression. The results from the IVIS images suggested that the optimal administration route was intratumoral(IT) injection and that the best time to conduct YLG-1-PDT was 2 h post-IT injection. Consistent with the results in vitro, YLG-1-PDT showed great growth inhibition effects on pancreatic cancer cells in a mouse *** YLG-1 is a potential photosensitizer for pancreatic cancer PDT via IT injection, the mechanisms of which are associated with inducing ROS and promoting apoptosis.

关键词： Photodynamic therapy Pancreatic neoplasm (17R,18R)-2-(1-hexyloxyethyl)-2-devinyl chlorine E6 trisodium salt Antitumor effect

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Feasibility and efficacy of endoscopic purse-string suture-assisted closure for mucosal defects induced by endoscopic manipulations

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World Journal of Gastroenterology 2023年第4期29卷 731-743页

作者： Ming-Ming Li Yi Zhang Fang Sun Man-Xiu Huai Fei-Yu Zhang chun-ying qu Feng Shen Zheng-Hong Li Lei-Ming Xu Department of Gastroenterology Xinhua HospitalShanghai Jiaotong University School of MedicineShanghai 200092China

BACKGROUND Large or transmural defects induced by gastrointestinal endoscopic manipulations are difficult to close,although complete closure is recommended for better *** purse-string assisted suturing(EPSS)has been used in clinical practice and has proven to be an effective and safe technique for the closure of large mucosal ***,details regarding the efficacy of endoscopic pre-purse-string suture(P-EPSS)are unknown,especially that it offers several advantages over conventional EPSS(C-EPSS).AIM To elucidate the outcomes of EPSS-assisted closure in different clinical situations,and evaluate the efficacy of *** This retrospective observational study included a total of 180 patients who underwent closure assisted by P-EPSS(n=63)or C-EPSS(n=117)between July 2014 and June *** P-EPSS and C-EPSS groups were compared and the intergroup differences in aspects such as the lesion size,location,and morphology,incidence of complete closure,intraoperative perforation,and delayed adverse events were *** on the features and clinical course of cases with adverse events were collected for further *** Patients with lesion size larger than 3 cm,lesions located at the fundus of stomach,or submucosal tumors originating from the deep mucosa were more likely to undergo P-EPSS-assisted *** P-EPSS group showed a significantly higher proportion of intraoperative perforation(56%vs 17%)and a much shorter procedure time(9.06±6.14 min vs 14.84±7.25 min).Among adverse events,the incidence of delayed perforation(5%vs 4%;P=0.82)and delayed bleeding(3%vs 4%;P=0.96)did not differ significantly between the *** analysis revealed that lesions with incomplete closure[odds ratio(OR)=21.33;95%confidence interval(CI):5.45-83.45;P<0.01]or size greater than 3 cm(OR=3.14;95%CI:1.08-9.18;P=0.039)showed a statistical tendency to result in an increase in delayed adverse *** The present study revealed that EPSS

关键词： Endoscopic purse-string suture Mucosal defect Endoscopic full-thickness resection Endoscopic submucosal dissection

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Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration

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World Journal of Gastroenterology 2019年第36期25卷 5505-5514页

作者： Wen-Guang Wu Lu-Cui Qin Xiao-Ling Song Ming-Ning Zhao Wen-Jie Zhang Jun Gu Hao Weng ying-Bin Liu Yi Zhang chun-ying qu Lei-Ming Xu Xue-Feng Wang Department of General Surgery and Laboratory of General Surgery Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine Shanghai 200092 China Department of Operating Room Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine Shanghai 200092 China Shanghai Key Laboratory of Biliary Tract Disease Research Shanghai 200092 China Department of Gastroenterology Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine Shanghai 200092 China

BACKGROUND Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown. AIM To explore the feasibility and effectiveness of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China. METHODS This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated. RESULTS Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60 (93.8%) cases and successful diagnosis in 59 (92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation, and no post-ERCP pancreatitis occurred. CONCLUSION Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.

关键词： Bilioenteric Roux-en-Y anastomosis Single balloon enteroscopy Multidisciplinary cooperation Hepaticojejunostomy Pancreaticoduodenectomy

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Reinforcement of High Impact Polystyrene by Aramid Nanoparticle Fillers Prepared via an In situ Bottom-up Approach

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Chinese Journal of Polymer Science 2024年第8期42卷 1167-1176页

作者： Xiang-Jun Gong Zhi-Ping Zhao Chang-Mei Sun ying Zhang Rong-Jun qu ying Wang School of Chemistry and Materials Science Ludong UniversityYantai 264025China

In this work,aramid nanoparticles(ANPs)were prepared in dimethyl formamide(DMF)solution containing high impact polystyrene(HIPS)via a bottom-up *** electron microscopy(TEM)images showed that the obtained ANPs were evenly distributed in the HIPS matrix without any *** composition of the ANPs,i.e.,poly(p-phenyl-p-phenylenediamine)(PPTA),was confirmed by Fourier transform infrared spectroscopy(FTIR),X-ray photoelectron spectroscopy(XPS)and X-ray diffractometer(XRD).The ANP/HIPS composites,obtained after ethanol precipitation,were added to neat HIPS as fillers to fabricate ANP/HIPS composite *** surface roughness and the glass transition temperature(T_g)of the sheets were characterized by atomic force microscope(AFM)and differential scanning calorimetry(DSC),*** with neat HIPS,the mechanical properties of the composite sheet were significantly improved,and the Young's modulus increased from 246.55 MPa to 2025.12 MPa,the tensile strength increased from 3.07 MPa to 29.76 MPa,and the toughness increased from 0.32 N/mm^2 to 3.92 N/mm^2,with an increase rate of 721%,869%and 1125%,***,the thermal stability of the composites improved with the increase in ANP content.

关键词： High impact polystyrene PPTA nanoparticle Reinforce Mechanical property

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Effects of medical adhesives in prevention of complications after endoscopic submucosal dissection

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World Journal of Gastroenterology 2013年第17期19卷 2704-2708页

作者： Yi Zhang ying Chen chun-ying qu Min Zhou Qian-Wen Ni Lei-Ming Xu Department of Digestive Endoscopy Xinhua Hospital School of Medicine Shanghai Jiaotong University Shanghai Key Laboratory of Pediatric Digestion and Nutrition

AIM:To evaluate the use of medical adhesive spray in endoscopic submucosal dissection (ESD). METHODS:Patients who underwent ESD between January 2009 and June 2012 (n = 173) were enrolled in the prospective randomized study. Two patients undergoing surgery due to severe intraoperative hemorrhage and failed hemostasis were excluded, and the remaining 171 patients were randomly divided into two groups:group A (medical adhesive group, n = 89) and group B (control group, n = 82). In group A, a medical adhesive spray was evenly applied after routine electrocoagulation and hemostasis using hemostatic clip after ESD. Patients in group B only treated with routine wound management. Intraoperative and postoperative data were collected and compared. RESULTS:In all 171 patients, ESD was successfully completed. There was no significant difference in the average treatment time between groups A and B (59.4 min vs 55.0 min, respectively). The average length of hospital stay was significantly different between group A and B (8.89 d vs 9.90 d, respectively). The incidence of intraoperative perforation was 10.1% in group A and 9.8% in group B, and was not significantly different between the two groups. In all cases, perforations were successfully managed endoscopically and with conservative treatment. The incidence of postoperative delayed bleeding in group A was significantly lower than that in group B (0.00% vs 4.88%, respectively). CONCLUSION:ESD is an effective minimally invasive treatment for gastrointestinal precancerous lesions or early-stage gastrointestinal cancer. Medical adhesive spray is effective in preventing delayed bleeding after ESD, and can thus reduce the average length of hospital stay.

关键词： Endoscopic submucosal dissection Medical adhesive Early-stage gastrointestinal cancer Postoperative delayed bleeding Intraoperative hemorrhage

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