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Old June 13th, 2011
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Default Excessive bleeding following circumcision.

A thread to collate article abstracts, official statements and the like regarding excessive bleeding in boys following circumcision.

The need for blood transfusions following circumcision puts boys at risk of diseases which are not being adequately tested for in donor blood and tissues, for example, hepatitis ( see this thread http://www.foreskin-restoration.net/...ead.php?t=7757 ).

"Survey of current prophylaxis practices and bleeding characteristics of children with severe haemophilia A in US haemophilia treatment centres"

http://www.ncbi.nlm.nih.gov/pubmed/21539695

Quote:
Haemophilia. 2011 May 4. doi: 10.1111/j.1365-2516.2011.02554.x. [Epub ahead of print]
Survey of current prophylaxis practices and bleeding characteristics of children with severe haemophilia A in US haemophilia treatment centres.
Ragni MV, Fogarty PJ, Josephson NC, Neff AT, Raffini LJ, Kessler CM.
Source

Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA Department of Medicine, University of California, San Francisco, CA Department of Medicine, University of Washington, Seattle, WA Department of Medicine, Vanderbilt University, Nashville, TN Department of Pediatrics, Children's Hospital of Philadelphia, PA Department of Medicine and Pathology, Georgetown University Medical Center, Washington, DC, USA.
Abstract

Summary.   Every other day (qod) factor VIII prophylaxis prevents joint bleeds in children with severe haemophilia A. Although three times weekly or qod prophylaxis is recommended by the National Hemophilia Foundation (NHF), how widely these practices have been adopted is not known. We sought to define current prophylaxis practices at US haemophilia treatment centres (HTCs). An email survey was distributed to US HTCs, utilizing web-based membership rosters of the Centers for Disease Control (CDC) and the Hemostasis Thrombosis Research Society (HTRS). Of 62 HTCs responding, prophylaxis is initiated on a three times weekly schedule in 29 (46.8%), twice weekly in 13 HTCs (21.0%) and once weekly in 20 HTCs (32.2%). Central venous catheters are used to infuse factor prophylactically at 55 HTCs (88.7%), including in 100% of children initiating prophylaxis at 19 HTCs (30.6%) and in 50% of those at 41 HTCs (66.1%), but avoided altogether at seven HTCs (11.3%). Prophylaxis is initiated after one or more bleeds in 56 HTCs (90.3%), but after the first bleed in only 28 HTCs (25.2%). Among 226 newborns with severe haemophilia A in 62 HTCs, 1.82 births/HTC/year, the median age at first bleed, excluding circumcision, is 7 months. Of the 113 (53.5%) newborns who underwent circumcision, 62 (54.9%) bled. Despite a recommended standard of three times weekly prophylaxis, over half of surveyed HTCs do not follow these guidelines, and nearly one-third begin prophylaxis on a once weekly schedule to delay or avoid the need for central venous access.

© 2011 Blackwell Publishing Ltd.

PMID:
21539695
[PubMed - as supplied by publisher]

Keywords:

central venous catheter; children; circumcision; haemophilia A; prophylaxis

Last edited by Minuteman; November 3rd, 2011 at 23:30.
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Old June 18th, 2011
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Default Re: Excessive bleeding following circumcision.

"A simple technique to control bleeding after Plastibell circumcision"

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080088/

Emphasis added:

Quote:
Ann R Coll Surg Engl. 2010 April; 92(3): 261–262.
doi: 10.1308/003588410X12664192075134f.

PMCID: PMC3080088
Copyright © 2010 by the Annals of The Royal College of Surgeons of England

A simple technique to control bleeding after Plastibell circumcision

Abid Qazi, Nadeem Haider, and David Crabbe
Department of Paediatrics, Leeds General Infirmary, Leeds, UK
Correspondence to David Crabbe, Consultant Paediatric Surgeon, C Floor, Clarendon Wing, Leeds General Infirmary, Leeds LS2 9NS, UK E: Email: david.crabbe@leedsth.nhs.uk

BACKGROUND
The Plastibell technique is commonly used to circumcise infants in the community for cultural and religious reasons.[1] Bleeding occurs in 3–10% of cases in reported series,[2,3] although this may be reduced by careful technique.[1] Bleeding usually arises from the frenulum; however, as the frenular vessels are hidden inside the Plastibell, the site of the bleeding is unclear and external compression is ineffective. We describe a simple technique to control frenular bleeding after Plastibell circumcision.

TECHNIQUE
Resuscitation is imperative. Babies often present after several hours of continued bleeding and blood transfusion may be necessary. To assess the wound, the penis is stabilised by gentle traction on the Plastibell. A strip of ribbon gauze 1 cm wide and 1–2 cm long is introduced between the Plastibell ring and the dorsal aspect of the glans using a dissecting forceps. The gauze pushes the ventral aspect of the glans against the ring and compresses the frenular vessels (Fig. 1). Bleeding should stop immediately. The gauze usually falls out when the child passes urine. The temptation to pack an excessive length of gauze should be resisted or the urethral meatus will be obstructed.

DISCUSSION
In the UK, infants are rarely circumcised in hospital. Many hospital practitioners are unfamiliar with the Plastibell device and, consequently, infants with post-Plastibell circumcision bleeding tend to be transferred to paediatric surgeons for exploration under general anaesthetic. We feel that this can be avoided in most of the cases by using the technique described.

References
1. Mahomed A, Zaparackaite I, Adam S. Improving outcome from Plastibell™ cir cumcisions in infants. Int Braz J Urol. 2009;35:310–4. [PubMed]
2. Ben Chaim J, Livne PM, Binyamini J, Hardak B, Ben-Meir D, Mor Y. Complications of circumcision in Israel: a one year multicenter survey. Isr Med Assoc J. 2005;7:368–70. [PubMed]
3. Palit V, Menebhi DK, Taylor I, Young M, Elmasry Y, Shah T. A unique service in UK delivering Plastibell circumcision: review of 9-year results. Pediatr Surg Int. 2007;23:45–8. [PubMed]
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  #3  
Old June 18th, 2011
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Default Re: Excessive bleeding following circumcision.

I'm inclined to say that all bleeding following circumcision is excessive, since the procedure never needed to happen in the first place to justify the bloodshed.
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Old June 19th, 2011
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Default Re: Excessive bleeding following circumcision.

Seems to me that these "gentlemen" need to keep their barbaric traditions within the confines of their own countries and STOP spreading them to countries like the UK and the U.S.A.
It is quite obvious that this is exactly what they are doing. I fear one day this will work against them.
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Old June 23rd, 2011
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Default Re: Excessive bleeding following circumcision.

"Improving outcome from Plastibell circumcisions in infants"

These British authors chose to publish in a Brazilian journal.

http://www.brazjurol.com.br/may_june...ng_310_314.htm

Emphasis Added:

Quote:
IMPROVING OUTCOME FROM PLASTIBELL™ CIRCUMCISIONS IN INFANTS

ANIES MAHOMED, INDRE ZAPARACKAITE, SAM ADAM

Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, United Kingdom

ABSTRACT

Circumcisions are among the most frequently performed operations in children and numerous techniques are employed often with varying results. Use of the Plastibell™ (Hollister Incorporated, Illinois, USA), under local anesthetic, is popular for cultural and religious circumcisions but is not without its problems. Complications of Plastibell™ (slippage, migration, bleeding and serious infection) have been reported. Described is a prospective series of cases in which modifications to the standard Plastibell™ technique were utilized to improve outcomes, in particular, the risk of bleeding.

Key words: circumcision; infant; complications
Int Braz J Urol. 2009; 35: 310-4

INTRODUCTION

The authors have undertaken cultural circumcisions under local anesthetic in infants for several years utilizing different techniques. From our earlier experience of the classic Plastibell™ technique (unpublished) where the string tie, which is packaged with the device was used, complications of Plastibell™ slippage with consequent bleeding was encountered (1). Over the last 4 years, an amended approach has been adopted as the procedure of choice. Described are details of the technical modifications and the resultant outcome.

MATERIALS AND METHODS

A retrospective analysis of a prospectively held database containing details of infant cultural circumcisions performed under local anesthetic between 04/05 and 01/09 was undertaken. Three senior surgeons at a university affiliated tertiary pediatric institution were involved and a standard operative approach was utilized in all cases. Demographic and outcome parameters were studied to assess the impact of the technical amendments on patient performance.

CIRCUMCISION TECHNIQUE

The operation is performed by a surgeon and assistant standing at opposite ends of the patient who is placed across the operating table. The assistant abducts the hips and the external genitalia area is cleansed with an antiseptic solution. A standard ring block with 0.5% lignocaine in a dose of 1 mg/kg is applied to the base of the penis. Once anaesthetized, the foreskin is comprehensively freed from the underlying glans, which is calibrated with an appropriately sized Plastibell™ device (PD), Figure-1. Sizes between 1.2 and 1.7 cm were utilized.

The foreskin is returned to its anatomical position then grasped between 2 hemostatic clips to either side of the dorsal midline before the intervening foreskin is crushed and divided to a depth of 1 cm. This maneuver widens the preputial opening and facilitates placement of the PD. To prevent proximal displacement of the internal (preputial) layer by the PD it is important for the two layers at the apex of the cut to be approximated with a suture (4/0 silk) (Figure-2). This suture is left to a 6 cm length and held on a hemostat to aid later retraction of the foreskin over the PD.

A pre-moistened PD is introduced through the widened foreskin opening until it cups the glans. The orientation of the device should be with the handles at 90 degrees to the penile frenulum to minimize injury to this structure during detachment from the ring.
The next step draws an appropriate amount of foreskin over the PD and is achieved with a bimanual manoeuvre involving forward traction on the 3 hemostats with simultaneous gentle downward pressure on the handle of the PD) (Figure-3). The surgical assistant applies two sequential silk 0 ligatures around the neck of the PD taking care to avoid knot overlap.

Finally, a check confirming position and integrity of the ligatures is performed after which the foreskin is divided approximately 2 mm distal to the ring (Figure-4).

Hemostasis is checked just prior to discharge about 30 minutes later. Parents are sent home with a pack containing surgeon contact details, advice on analgesia and information on commonly encountered problems. To save on costs, routine postoperative visits are not scheduled.

RESULTS

Between 04/2005 and 01/2009, 130 infants underwent cultural circumcision by the modified Plastibell™ technique. Age ranged from 4 to 359 days with a mean of 82.37 days. There were no instances of post circumcision bleeding or infection requiring hospitalization however, 2 cases with suspected infections were reviewed and the diagnosis excluded. Three further cases were admitted within a month of the procedure for retained PD requiring removal. Two of these were managed in the Accident and Emergency Department and one required removal under a short general anesthetic. A single case where parents were unhappy with the completeness of circumcision had a revision under a general anesthetic within a year of initial surgery.

COMMENTS

One of the commonest complications of cultural circumcisions is bleeding and rates as high as 35% have been quoted in the literature (2). Outcomes from Plastibell™ circumcisions are reported to be better although bleeding is still a significant problem (3-6). From the authors earlier experience with the classic Plastibell™ approach bleeding was problematic and therefore a series of subtle modifications were introduced to reduce this risk. The most significant of these was substitution of the pre-packed string tie with silk 0 ligatures. Neither Plastibell™ slippage nor bleeding were encountered in the current series and we are of the opinion that silk 0 ligatures offer superior knotting and hemostatic qualities as compared to the string. Furthermore, it is likely that application of a double ligature and the avoidance of knot overlap afforded protection against Plastibell™ slippage. Although ring separation times were not specifically studied in this series, it is our opinion that the caliber of silk 0 is such that it allows for a gradual separation of the ring. This tended to occur anytime between 5 to 12 days post application allowing adequate time for sealing of the circumcision margins. It is also possible that the use of finer sutures might predispose to wound dehiscence, retraction and sepsis from premature separation.
Another potential source of bleeding with the standard Plastibell™ technique is from the inner/preputial layer at the apex of the dorsal slit especially when this is forced proximally by the PD. This problem can be averted by a stitch applied to this point to approximate internal and external layers of foreskin. If the suture is left to adequate length, the apex of the cut can be retracted over the ring and distal to the hemostatic ligature hence excluding this as a cause for bleeding.
A less critical reason for hemorrhage is injury to the frenulum by the sharp edges of the handle of the PD when detaching from the ring. This hazard is minimized by ensuring that PD orientation is such that the handle is perpendicular to the frenulum when applying the hemostatic ligatures.
Adequate foreskin excision is fundamental to a successful circumcision and suboptimal excision will result in parental dissatisfaction and certain come back. It is often the case that too little rather than too much is taken. However, the problem can be minimized if at the time of ligature application, adequate foreskin is drawn over the PD. The technique of applying opposing pressure to the handle of the PD and the hemostats works well as the operator is able to adjust the length of foreskin to be sacrificed. Surgeons working solo may have serious difficulty with ensuring adequate circumcision as critical to this step is the application of the ligatures by a skilled assistant when instructed to do so by the operator. Rarely, despite this manoeuvre, instances of incomplete circumcision as was our experience with one case may occur. At particular risk are patients with a large amount of prepubic fat with partially recessed penises and mature judgment here is vital to a satisfactory outcome. Clearly where there is doubt on the amount of skin to be excised cases should be deferred until later in life or alternatively performance under a general anesthetic might be considered. Absolute contraindications to cultural circumcisions include; buried penis, hypospadias and epispadias.
Ring retention around the corona was the most frequent complication in this series and has been documented by others (6). We suspect that this may be due to the application of excessive tension on the foreskin during PD placement and in combination with this and contrary to the opinion of others, to be due to a selection of a smaller rather than a larger PD (7,8). Calibration with a suitably sized PD device is therefore crucial and erring on a slightly larger than smaller device would seem sensible. The PD usually detaches within 12 days and a surgical assessment is mandatory if separation has not occurred by day 15. Retained rings can be removed under sedation by simply applying traction on the device. However, if this fails it may be necessary to divide the ring with a pair of strong scissors. Very rarely this may require a general anesthetic.
With this series, we have demonstrated that with modifications to the original Plastibell™ technique that infant circumcision can be offered with relatively few complications. The most frequent of these is post circumcision bleeding which can be reduced substantially.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Hollister Plastibell: Available from: http://www.cir clist.com [<----!!!].
2. Williams N, Kapila L: Complications of circumcision. Br J Surg. 1993; 80: 1231-6.
3. Shah T, Raistrick J, Taylor I, Young M, Menebhi D, Stevens R: A circumcision service for religious reasons. BJU Int. 1999; 83: 807-9.
4. Manji KP: Circumcision of the young infant in a developing country using the Plastibell. Ann Trop Paediatr. 2000; 20: 101-4.
5. Holman JR, Lewis EL, Ringler RL: Neonatal circumcision techniques. Am Fam Physician. 1995; 52: 511-8, 519-20.
6. Lazarus J, Alexander A, Rode H: Circumcision complications associated with the Plastibell device. S Afr Med J. 2007; 97: 192-3.
7. Sörensen SM, Sörensen MR: Circumcision with the Plastibell device. A long-term follow-up. Int Urol Nephrol. 1988; 20: 159-66.
8. Mousavi SA, Salehifar E: Circumcision Complications Associated with the Plastibell Device and Conventional Dissection Surgery: A Trial of 586 Infants of Ages up to 12 Months. Adv Urol. 2008: 606123.

____________________
Accepted after revision:
February 5, 2009

_______________________
Correspondence address:
Dr. Anies Mahomed
Department of Paediatric Surgery
Royal Alexandra Children’s Hospital
Eastern Road, Brighton
BN2 5BE, United Kingdom
Fax: + 1273 523-120
E-mail: anies.mahomed@bsuh.nhs.uk

EDITORIAL COMMENT

Circumcision performed by Plastibell™ method is a well-proven method, which compares well with standard open circumcision with respect to results and complications. This is an interesting paper with modifications of standard Plastibell technique. The authors should be commended of such low complication rates
The application of suture to the apex of the cut seems to be a practical technique where the inner layer has some chance of bleeding. This is a reasonable modification to reduce bleeding complications. The author’s claim for silk sutures to have superior knotting techniques and allows more secure hemostasis is probably true but should be substantiated by evidence.
I do not think the slippage of the ring was a major problem in the largest Plastibell series and though tying two silk ligatures theoretically should provide additional safety - it is probably unnecessary.
There are few important distinctions when comparing this paper with one of the largest series from Bradford - firstly the procedure was performed by nurses with consultant urologist available in Hospital in case of any problem. Secondly, the maximum age in that series was 14 weeks (the present series max age is 359 days). Penile block was used along with ring block for local anesthesia whereas only ring block was used in the present series.

Dr. Victor Palit
Yorkshire Deanery
Royton, Oldham, Lancashire
United Kingdom
E-mail: victorpalit@yahoo.co.uk
PubMed Citation / Link

Int Braz J Urol. 2009 May-Jun;35(3):310-3; discussion 313-4 / http://www.ncbi.nlm.nih.gov/pubmed?t...20in%20infants

Last edited by Minuteman; August 20th, 2011 at 07:46.
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Old August 20th, 2011
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Default Re: Excessive bleeding following circumcision.

Cross-referenced information ( http://www.foreskin-restoration.net/...3475#post63475 ):

Blood transfusions were the 5th most common procedure performed on children in U.S. hospitals in 2009 (~109,400 procedures, 146.8 discharges per 10,000 population).

Source: AHRQ (2011) STATISTICAL BRIEF #118 Hospital Stays for Children, 2009 http://www.hcup-us.ahrq.gov/reports/...iefs/sb118.jsp
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Old September 3rd, 2011
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Default Re: Excessive bleeding following circumcision.

"Scientists Use Stem Cells for Blood 'Self-Transfusion'" HealthDay News 1 September 2011.

http://liveweb.archive.org/http://ww...ry_116037.html

Quote:
Though preliminary, process might help those too ill to donate blood before needing a transfusion
URL of this page: http://www.nlm.nih.gov/medlineplus/n...ry_116037.html (*this news item will not be available after 11/30/2011)

By Randy Dotinga
Thursday, September 1, 2011

THURSDAY, Sept. 1 (HealthDay News) -- Researchers report that they used stem cells to create cultured red blood cells and then successfully injected the blood cells back into the human donor who provided the stem cells in the first place.

The findings raise the possibility of creating individualized blood supplies without making people donate their own blood for storage before they need a transfusion, a potentially dicey situation if someone is ill.

The researchers said that the cultured red blood cells created with the help of stem cells from the donor -- and then inserted back into the donor -- lived about as long as regular blood cells normally do.

The study, the first to show that red blood cells created from stem cells can survive in the human body, is "a major breakthrough for the transplant community," Dr. Luc Douay, senior study author and a professor of hematology at Universite Pierre et Marie Curie in Paris, said in a news release from the American Society of Hematology.

"There is a dire need for an alternative source of transfusable blood products, especially with the risk of infection from emergent new viruses that comes with traditional transfusion," Douay explained. "Producing red blood cells in culture is promising since other efforts to create alternative sources have not yet been as successful as once hoped."

However, one expert said the research isn't quite as exciting as it may sound.

Creating red blood cells from your own stem cells is "going to be an extremely complex process, extremely expensive, not very convenient and uncommonly used," explained Dr. Paul Holland, a blood banking specialist and a clinical professor of medicine and pathology at the University of California, Davis Medical Center.

"Most people who need a transfusion need it now, and they use blood from donors that's already there," he said. One exception might be if someone has a condition that makes it difficult to match his or her blood to other donors and it's dangerous to draw and save their own blood, he said.

The findings appear in the Sept. 1 issue of the journal Blood.

SOURCES: Paul Holland, M.D., clinical professor, medicine and pathology, University of California, Davis Medical Center; American Society of Hematology, news release, Sept. 1, 2011
HealthDay
Copyright (c) 2011 HealthDay. All rights reserved.
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Old November 3rd, 2011
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Default Re: Excessive bleeding following circumcision.

"Using Drug for Prevention Might Help in Hard-to-Treat Hemophilia" HealthDay News 2 November 2011

http://liveweb.archive.org/http://ww...ry_118257.html

Excerpt:

Quote:
For some patients, using medicine to stave off, not just treat bleeds, could decrease joint damage

WEDNESDAY, Nov. 2 (HealthDay News) -- A compound currently used to stop bleeding episodes in a subset of hard-to-treat hemophilia patients also seems to be effective in preventing bleeds before they start.

Although this study, published in the Nov. 3 edition of the New England Journal of Medicine, was a small one and didn't last long, the results do raise the possibility that, over time, this type of use will also prevent the much-feared joint damage that is a hallmark of the condition.

"This study shows that it is at least possible to keep these people relatively healthy, without bleeds, by using chronic prophylactic [preventive] agents," said Dr. Thomas Harrington, director of the Adult Hemophilia and Adult Sickle Cell programs at the University of Miami Miller School of Medicine. He was not involved with the study.

The research was funded by Baxter BioScience, which makes FEIBA (Factor VIII Inhibitor Bypassing Activity), the agent tested in this trial.

Most people with hemophilia have a genetic defect in a clotting factor known as factor VIII. This results in excessive bleeding and bruising either as the result of traumas -- even small ones -- or sometimes occurring spontaneously.

About half of the bleeds occur in the joints and can lead to painful and debilitating joint disease.

Clotting factor concentrates that contain factor VIII are extremely effective both to stop bleeds when they happen (called "on-demand" treatment) and to prevent bleeds when given three or so times a week.

The problem is that about one-third of hemophilia patients develop antibodies to factor VIII, meaning the compound just stops working.

So-called "bypassing agents" have been developed for patients who have factor VIII inhibitors, but these aren't nearly as effective and have only been used on an on-demand basis.

The authors designed this study to see if bypassing agents might prevent bleeds in this subset of patients in the same way that factor VIII concentrates successfully prevent bleeds in people without inhibitors.
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Old December 16th, 2011
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Default Re: Excessive bleeding following circumcision.

"NIH-supported study finds no benefit for a liberal transfusion strategy after hip-fracture surgery" NIH News 14 December 2011.

http://www.nih.gov/news/health/dec2011/nhlbi-14.htm

Excerpt:

Quote:
"Blood transfusions can save lives, but they are not without risks," said Susan B. Shurin, M.D., acting director of the National Heart, Lung, and Blood Institute, the institute within NIH that supported the research. "Knowing when to perform blood transfusions may help patients avoid unnecessary medical procedures, and their associated risks, and help conserve our limited blood supply."
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Old December 17th, 2011
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Default Re: Excessive bleeding following circumcision.

From Turkey:

Yilmaz D, Akin M, Ay Y, Balkan C, Celik A, Ergün O, Kavakli K (2010) A single centre experience in circumcision of haemophilia patients: Izmir protocol Haemophilia. 2010 Nov;16(6):888-91. doi: 10.1111/j.1365-2516.2010.02324.x Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20491959

Quote:
Haemophiliacs and their families consider that circumcision is a very important step to become a member of society and it is a social obligation for men in Turkey. Although bleeding risk is high, almost all haemophiliacs would like to be circumcised in Turkish society. The aim of this study was to evaluate our experience in circumcision of haemophilia patients and define efficacy, safety and complication rates of our protocol, called 'Izmir protocol'. In this study, we retrospectively reviewed medical records of 50 patients with haemophilia who underwent circumcision at our hospital according to Izmir protocol between 1996 and 2009. Oral tranexamic acid and fibrin glue were used in all children. One hour before the operation, first dose of factor concentrate was given. After reaching a plasma factor level of around 90-100%, the prepuce was incised circumferentially and excised using Gomco clamp or open technique under general anaesthesia. Intermittent injections of factor concentrate were given every 12 for 48 h. While the first two doses were given at higher amount to achieve or continue plasma factor level at 90-100%, in the last three doses, the aim was to maintain the plasma factor level at 50-60%. Forty-eight hours after the circumcision, patients were discharged. Three patients (6%) showed bleeding complication and all were resolved easily. All had at least one excuse from the protocol (Lower doses of factor concentrates was used in 2, tranexamic acid was not used in 2). Izmir protocol is safe, cheap and easy to carry out.
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