Intraoperative blood loss may be associated with myocardial injury after non-cardiac surgery

BACKGROUND

This study aimed to evaluate the association between intraoperative blood loss and myocardial injury after non-cardiac surgery (MINS), which is a severe and common postoperative complication.

METHODS

We compared the incidence of MINS based on significant intraoperative bleeding, defined as an absolute hemoglobin level < 7 g/dL, a relative hemoglobin level less than 50% of the preoperative measurement, or need for packed red cell transfusion. We also estimated a threshold for intraoperative hemoglobin level associated with MINS.

RESULTS

We stratified a total of 15,926 non-cardiac surgical patients with intraoperative hemoglobin and postoperative cardiac troponin (cTn) measurements according to the occurrence of significant intraoperative bleeding; 13,416 (84.2%) had no significant bleeding while 2,510 (15.8%) did have significant bleeding. After an adjustment with inverse probability weighting, the incidence of MINS was higher in the significant bleeding group (35.2% vs. 16.4%; odds ratio, 1.58; 95% confidence interval, 1.43-1.75; p < 0.001). The threshold of intraoperative hemoglobin associated with MINS was estimated to be 9.9 g/dL with an area under the curve of 0.643.

CONCLUSION

Intraoperative blood loss appeared to be associated with MINS. Further studies are needed to confirm these findings.

CLINICAL REGISTRATION

The cohort was registered before patient enrollment at https://cris.nih.go.kr (KCT0004244).

CO2 artificial pneumothorax on coagulation and fibrinolysis during thoracoscopic esophagectomy

BACKGROUND

CO2 artificial pneumothorax creates a sufficient operative field for thoracoscopic esophagectomy. However, it has potential complications and continuous CO2 insufflation may impede coagulation and fibrinolysis. We sought to compare the effects of CO2 artificial pneumothorax on perioperative coagulation and fibrinolysis during thoracoscopic esophagectomy.

METHODS

We investigated patients who underwent thoracoscopic esophagectomy with (group P, n = 24) or without CO2 artificial pneumothorax (group N, n = 24). The following parameters of coagulation-fibrinolysis function: intraoperative bleeding volume; serum levels of tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), thromboelastogram (TEG), D-Dimer; and arterial blood gas levels were compared with two groups.

RESULTS

Group P showed higher levels of PaCO2, reaction time (R) value and kinetics (K) value, but significantly lower pH value, alpha (α) angle and Maximum Amplitude (MA) value at 60 minutes after the initiation of CO2 artificial pneumothorax than group N ((P < .05, all). The t-PA level after CO2 insufflation for 60 minutes was significantly higher in group P than in group N (P < .05), but preoperative levels were gradually restored on cessation of CO2 insufflation for 30 min (P > .05). There was no significant difference in D-dimer.

CONCLUSION

CO2 artificial pneumothorax during thoracoscopic esophagectomy had a substantial impact on coagulation and fibrinolysis, inducing significant derangements in pH and PaCO2.

TRIAL REGISTRATION

The study was registered at the Chinese clinical trial registry (ChiCTR1800019004).

Vancomycin prophylaxis for revision hip arthroplasty in penicillin and cephalosporin sensitive patients: Is dose adjustment necessary in accordance with blood loss and fluid replacement?

OBJECTIVE

The aims of this study were (1) to investigate the changes in the serum concentration of prophylactically administrated vancomycin in the perioperative period of revision hip arthroplasty in penicillin/cephalosporin-allergic patients, (2) to assess whether the postoperative re-administration of vancomycin is needed, and (3) to determine the relationships of vancomycin serum concentration with blood loss, body weight, and fluid replacement in such patients.

METHODS

This study consisted of 29 patients (20 females, 9 males; mean age=63.3 years; age range=45-79 years) with a history of penicillin/cephalosporin allergy undergoing revision hip arthroplasty secondary to aseptic loosening or periprosthetic fractures. Serum vancomycin levels were measured (1) before administration of vancomycin, (2) at the time of skin incision, (3) every 1,5 hours thereafter until the end of the operation, (4) during the skin closure, and (5) after three and 12 hours from the initial dosage. Data regarding body weight, amounts of intraoperative blood loss, fluid and blood replacements and postoperative wound drainage were recorded.

RESULTS

The average blood loss, fluid replacement, and drain volume were 1280.3±575.8 (500-2700) mL, 2922.6±768.8 (1700-4600) mL, and 480.2±163.7 (200-850) mL, respectively. The mean levels of serum vancomycin were 46.3±21.8 (14.1-80.7) mg/L at the time of skin incision, 17.9±4.7 (9.4-30.9) and 9.8±2.2 (4.3-13.8) mg/L after 1.5 and 3 hours from the beginning of the surgery and 5.1±1.1 (2.9-6.8)mg/L after 12th hour postoperatively. The measured vancomycin levels were below the effective serum concentrations (< 5 mg/L) for 18 patients at 12 hours the administration of the first dose. A moderate level negative correlation between the blood loss/body weight ratio and vancomycin levels was found (p=0.004, r=-0.493). Predictive ROC curve analysis resulted in determining a blood loss volume higher than 1150 ml and a blood loss/body weight ratio higher than 18,5 is significant to estimate the vancomycin level below the minimum effective serum level at 12th hour postoperatively (AUC=0.793±0.16, p=0.009, AUC=0.753) 26±0.12, p=0.025, respectively).

CONCLUSION

Evidence from this study has indicated vancomycin concentration at 12th hour is below the effective level in most patients. Thus, earlier repetitive infusion of vancomycin seems to be necessary in penicillin/cephalosporin-allergic patients undergoing revision hip arthroplasty, especially in those with high blood loss.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Effectiveness and safety of the use of antifibrinolytic agents in total-knee arthroplasty: A meta-analysis

BACKGROUND

Antifibrinolytic agents have been successfully used to reduce blood transfusion demand in patients undergoing elective knee arthroplasty. The purpose of this study was to investigate different antifibrinolytic agents for patients undergoing total-knee arthroplasty (TKA).

METHODS

We searched the randomized controlled trials assessing the effect of antifibrinolytic agents on TKA in MEDLINE, PubMed, Embase, and the Cochrane Library. Participants are divided into antifibrinolytic agent group and control group under TKA. Double extraction technology is used and the quality of its methodology is evaluated before analysis. Outcomes analyzed included blood loss, number of blood transfusions, rates of blood transfusion, and deep vein thrombosis (DVT).

RESULTS

A total of 28 randomized controlled trials involving 1899 patients were included in this study. Compared with the control group, the antifibrinolytic agents group exhibited significantly reduced the amounts of total blood loss (weighted mean difference [WMD] with 95% confidence interval [CI]: -272.19, -338.25 to -206.4), postoperative blood loss (WMD with 95% CI: -102.83, -157.64 to -46.02), average units of blood transfusion (risk ratio with 95% CI: 0.7, 0.12 to 0.24), and average blood transfusion volumes (WMD with 95% CI: -1.34, -1.47 to -1,21). Antifibrinolytic agents significantly reduced the rate of blood transfusions and did not increase the occurrence risk of intraoperative blood loss and DVT. Several limitations should also be acknowledged such as the heterogeneity among the studies.

CONCLUSION

The application of antifibrinolytic agents can significantly reduce blood loss and blood transfusion requirements. Additionally, these agents did not increase the risk of DVT in patients undergoing TKAs.

Measured versus Estimated Blood Loss: Interim Analysis of a Prospective Quality Improvement Study

Estimated blood loss (EBL) is an increasingly important factor used to predict outcomes, such as morbidity and mortality, length of stay, and readmissions, after major abdominal operations. However, blood loss is difficult to estimate, with frequent under- and overestimations, consequences of which can be potentially dangerous for individual patients and confounding for scoring systems relying on EBL. We hypothesized that EBL is often inaccurate and have prospectively enrolled consecutive patients undergoing major elective intra-abdominal operations. Actual hemoglobin levels were measured and used to calculate the measured blood loss (MBL), which was compared with the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common, followed by colectomy (n = 3), hepatectomy (n = 3) and gastrectomy (n = 2), biliary excision and reconstruction (n = 2), combined gastrectomy + colectomy (n = 1), radical nephrectomy (n = 1), open cholecystectomy (n = 1), pancreatic debridement (n = 1), and exploratory laparotomy (n = 1). aEBL overestimated MBL by 192 mL (143%) on average. The aEBL was significantly greater than the MBL (P = 0.004), whereas the sEBL was significantly less than the MBL (P = 0.009). In conclusion, surgeons significantly underestimate and anesthesiologists significantly overestimate EBL. This finding impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL.

Institutional First 100 Case Experience and Outcomes of Robotic Hepatectomy for Liver Tumors

The nascent robotic approach for hepatic resections is gaining momentum in the United States because it offers solutions to the known limitations of laparoscopic approach. Herein, we report our initial experience and short-term outcomes of the first 100 robotic hepatectomies. With Institutional Review Board approval, all patients undergoing robotic hepatectomy were prospectively followed up. Patient demographics, operative outcomes, complications, and 30-day readmissions were collected and analyzed. Data are presented as median (mean ± SD). One hundred consecutive patients underwent robotic hepatectomy. Patients were aged 62 (63 ± 13.6) years, 66 per cent were women, and BMI was 29 (29 ± 6.4) kg/m². In all, 76 per cent of the hepatectomies were undertaken for malignancy [metastatic colorectal cancer (28%), hepatocellular carcinoma (21%), and intrahepatic cholangiocarcinoma (15%)], and 20 per cent for benign lesions; 66 per cent of patients underwent nonanatomical partial hepatectomies, 17 per cent right hepatectomies, 16 per cent left hepatectomies, and 1 per cent trisegmentectomy. Operative time was 233 (268 ± 109.3) minutes, and the estimated blood loss was 123 (269 ± 322.1) mL. Conversion to "open" approach was necessary in one patient. The length of stay was 3 (5 ± 4.6) days. There were no intraoperative complications. Twelve patients experienced postoperative complications. Six patients required readmission to the hospital within 30 days of discharge. Robotic hepatectomy is safe and feasible with favorable short-term outcomes. The robotic system enhances application of minimally invasive surgery for complex hepatobiliary operations.

Mini-fluid challenge test predicts stroke volume and arterial pressure fluid responsiveness during spine surgery in prone position: A STARD-compliant diagnostic accuracy study

The study was designed to verify if mini-fluid challenge test is more reliable than dynamic fluid variables in predicting stroke volume (SV) and arterial pressure fluid responsiveness during spine surgery in prone position with low-tidal-volume ventilation.Fifty patients undergoing spine surgery in prone position were included. Fluid challenge with 500 mL of colloid over 15 minutes was given. Changes in SV and systolic blood pressure (SBP) after initial 100 mL were compared with SV, pulse pressure variation (PPV), SV variation (SVV), plethysmographic variability index (PVI), and dynamic arterial elastance (Eadyn) in predicting SV or arterial pressure fluid responsiveness (15% increase or greater).An increase in SV of 5% or more after 100 mL predicted SV fluid responsiveness with area under the receiver operating curve (AUROC) of 0.90 (95% confidence interval [CI], 0.82 to 0.99), which was significantly higher than that of PPV (0.71 [95% CI, 0.57 to 0.86]; P = .01), and SVV (0.72 [95% CI, 0.57 to 0.87]; P = .03). A more than 4% increase in SBP after 100 mL predicted arterial pressure fluid responsiveness with AUROC of 0.86 (95% CI, 0.71-1.00), which was significantly higher than that of Eadyn (0.52 [95% CI, 0.33 to 0.71]; P = .01).Changes in SV and SBP after 100 mL of colloid predicted SV and arterial pressure fluid responsiveness, respectively, during spine surgery in prone position with low-tidal-volume ventilation.

Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes

BACKGROUND

Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes.

METHODS

We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors.

RESULTS

The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay.

CONCLUSION

Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.

Analysis of risk factors for concurrent pulmonary infection after operation for colon cancer

PURPOSE

To investigate the risk factors for concurrent pulmonary infection after radical operation for colon cancer, providing a reference for the prevention and treatment of this condition.

METHODS

A total of 486 patients subjected to radical operation for colon cancer in Shanghai Hudong Hospital from December 2014 to December 2017 composed the study group. Their clinicopathologic data and postoperative follow-up were reviewed, including gender, age, body mass index (BMI), preoperative albumin (ALB), preoperative hemoglobin (Hb), hypertension (HBP), diabetes mellitus (DM), smoking history, preoperative pulmonary ventilation dysfunction, tumor size, lymph node metastasis, operative time, intraoperative blood loss, blood transfusion and surgical method. Univariate and multivariate analyses were applied to investigate the risk factors influencing concurrent pulmonary infection after radical operation for colon cancer. The severity of pulmonary infection was assessed using the Clavien-Dindo classification system, and the severity ≥ Grade II suggested that postoperative pulmonary infection (POPI) occurred.

RESULTS

Among 486 patients, 20 (4.12%) patients suffered from POPI, including 17 (3.50%) cases of Grade II infection, 2 (0.41%) cases of Grade IIIa infection and 1 (0.21%) case of Grade IVa infection. Univariate analysis showed that POPI was associated with age (≥75 years), gender (male), DM, smoking history, preoperative pulmonary function impairment and blood transfusion. Multivariate analysis indicated that age, preoperative pulmonary ventilation dysfunction, DM and blood transfusion were independent risk factors for POPI.

CONCLUSIONS

Age, preoperative respiratory function impairment, DM and blood transfusion are considered as independent risk factors for pulmonary infection after radical operation for colon cancer.

Serotonin-Modulating Antidepressants and Risk of Bleeding after Trauma

Serotonin-modulating antidepressants have been associated with increased risk of gastrointestinal bleeding and increased blood loss during elective surgery. This study sought to investigate the effect of preinjury selective-serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) use on transfusion requirements after trauma, and to evaluate whether resumption of SSRI/SNRI after trauma may worsen bleeding risk. This was a retrospective matched-cohort study evaluating patients with solid organ injury. Preinjury SSRI/SNRI users were matched to non-SSRI/SNRI users based on age, preinjury aspirin use, Injury Severity Score, and abdominal Abbreviated Injury Severity Score. The primary endpoint was transfusion requirement during hospitalization. The absolute need for transfusion was higher in SSRI/SNRI users throughout hospitalization (50.9% vs 37.3%, P = 0.02). After logistic multivariate analysis, SSRI/SNRI users were more likely to require transfusion at 24 hours (odds ratio (95% confidence interval): 2.73 (1.41, 5.29), P = 0.003), but this difference did not persist for overall hospitalization (odds ratio (95% confidence interval): 1.32 (0.74, 2.36), P = 0.35). Fewer patients restarted on SSRI/SNRI therapy within 72 hours required packed red blood cell transfusion compared with those who were restarted later or not at all (43.2% vs 60.3%; P = 0.04). Preinjury use of serotonin-modulating antidepressants led to an increased requirement of blood transfusions after solid organ injury. Although clinicians should weigh bleeding risk before reinitiation of SSRI/SNRI, the results of this study indicate that reasonable efforts to restart these medications after stabilization do not result in further risk for transfusion.

The Efficacy of Tranexamic Acid on Blood Loss from Lumbar Spinal Fusion Surgery: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

The efficacy of tranexamic acid to control blood loss from lumbar spinal fusion surgery remains controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on blood loss from lumbar spinal fusion surgery.

METHODS

We searched PubMed, Embase, Web of Science, EBSCO, and the Cochrane Library databases through March 2018 for randomized controlled trials assessing the effect of tranexamic acid on blood loss from lumbar spinal fusion surgery. A meta-analysis was performed using the random-effect model.

RESULTS

Six randomized controlled trials involving 394 patients were included in the meta-analysis. Overall, compared with control group for lumbar spinal fusion surgery, tranexamic acid significantly reduced intraoperative blood loss (standard mean difference [Std. MD] -0.32; 95% confidence interval [CI] -0.58 to -0.06; P = 0.02), and drain (Std. MD -1.12; 95% CI -1.59 to -0.64; P < 0.00001) but had no remarkable influence on hemoglobin (Std. MD -0.10; 95% CI -0.56 to 0.37; P = 0.68) and hematocrit (Std. MD -0.34; 95% CI -1.08 to 0.40; P = 0.37) 1 day after surgery and transfusion (risk ratio 0.44; 95% CI 0.16-1.19; P = 0.11). Duration of hospitalization was found to be shortened by tranexamic acid (Std. MD -1.00; 95% CI -1.68 to -0.32; P = 0.004).

CONCLUSIONS

Tranexamic acid has an important ability to decrease intraoperative blood loss and hospitalization for lumbar spinal fusion surgery.

FIBTEM as a predictor of intra- and postoperative blood loss in revision total hip arthroplasty: A prospective observational study

Revision total hip arthroplasty (THA) may cause intra- and postoperative massive bleeding. This prospective observational study evaluated if the maximum clot firmness of FIBTEM (MCFFIB) could act as a predictor of perioperative massive bleeding in revision THA.Fifty-eight adult patients undergoing revision THA were included. Pre- and postoperative MCFFIB, hematological and hemostatic laboratory data, as well as the amount of intra- and postoperative blood loss (IBL and PBL) were obtained.The change rate (MCFFIB-C) between the pre- and postoperative MCFFIB had a significant correlation with IBL (ρ = 0.431, P = .001). Moreover, PBL had a significant correlation with MCFFIB-C (ρ = 0.292, P = .026). The MCFFIB-C cut-off value of ≥ 29% showed the highest sensitivity and specificity for predicting IBL ≥ 1000 mL or PBL ≥500 mL. The incidence of red blood cell transfusion in the postoperative period was higher in patients showing MCFFIB-C ≥ 29% (34% vs 8%, P = .015).The change rate between pre- and postoperative MCFFIB values was correlated well with the amount of IBL or PBL. Moreover, particular change rate of MCFFIB could predict massive bleeding in revision THA.

[LIVER CYSTIC ECHINOCOCCOSIS LAPAROSCOPIC TREATMENT EFFECTIVENESS]

The main goal of the research was to study echinococcosis liver cyst laparoscopic treatment's effectiveness. The retrospective analysis of liver echinococcosis cyst surgical treatment in the period from 2003 to 2013 years was conducted. 348 patients underwent surgical treatment, among them 283 patients - laparoscopic procedure, 65 - open surgery. Medial age was 42,3±7,9 years. Female - 214, male - 134. 249 patients underwent laparoscopic partial (conservative) cystectomy, 34 - laparoscopic radical cystectomy with liver resection, 3 (1%) - conversion. 47 patients underwent partial (conservative) cystectomy using open approach. 18 - radical cystectomy using either typical or atypical hemihepatectomy. A long term analysis of 226 (79,8%) patients in a period from 6 month to 7 years was conducted. Comparison of the results revealed the advantage of laparoscopic operations. It was manifested in less blood loss, duration of the procedure, pain syndrome, and a smaller number of bed-days. Infections of the residual cavity after open surgery were twice as much comparing to ones after laparoscopic surgery. Complications after open surgery were significantly higher than after laparoscopic procedures due to postoperative wound infections. After open surgery frequency of echinococcosis recurrence was higher than after laparoscopic one (8,5% vs 2,5%) (р<0,05). Nowadays it is possible to say that treatment of choice of noncomplicated liver echinococceal cysts is laparoscopic one. Correctly made laparoscopical procedure has a good long term results, few postoperative compications, less frequent recurrences and the excellent cosmetic effect. From the principles of radical surgical treatment's point of view laparoscopic approach is the same as an open surgery.

The Correlation Between CVP and SVV and Intraoperative Minimal Blood Loss in Living Donor Hepatectomy

BACKGROUND

Blood loss during liver surgery is found to be correlated with central venous pressure (CVP). The aim of the current retrospective study is to find out the cutoff value of CVP and stroke volume variation (SVV), which may increase the risk of having intraoperative blood loss of more than 100 mL during living liver donor hepatectomies.

METHOD AND PATIENTS

Twenty-seven adult living liver donors were divided into 2 groups according to whether they had intraoperative blood loss of less (G1) or more than 100 mL (G2). The mean values of the patients' CVP and SVV at the beginning of the transaction of the liver parenchyma was used as the cutoff point. Its correlation to intraoperative blood loss was evaluated using the χ² test; P < .001 was regarded as significant.

RESULTS

The cutoff points of CVP and SVV were 8 mm Hg and 13% respectively. The odds ratio of having blood loss exceeding 100 mL was 91.25 (P < .001) and 0.36 (P < .001) for CVP and SVV, respectively.

CONCLUSION

CVP less than 5 mm Hg, as suggested by most authors, is not always clinical achievable. Our results show that a value of less than 8 mm Hg or SVV 13% is able to achieve a minimal blood loss of 100 mL during parenchyma transaction during a living donor hepatectomy. Measurements used to lower the CVP or increased SVV in our serial were intravenous fluids restriction and the use of a diuretic.

Hidden blood loss and its influencing factors after percutaneous kyphoplasty surgery: A retrospective study

Percutaneous kyphoplasty (PKP) surgery is generally accepted as a minimally invasive treatment for osteoporotic vertebral compression fractures (OVCFs). However, hidden blood loss (HBL) caused by this procedure is usually disregarded. This study aimed to investigate the amount of HBL and its influencing factors after PKP surgery.A total of 160 patients were retrospectively examined from January 2014 to January 2016, and their clinical and radiological data were recorded and analyzed. Preoperative and postoperative hematocrit (Hct) and hemoglobin (Hb) levels were also documented. HBL was calculated using Gross formula. Different factors, including gender, age, bone mineral density (BMD), number of fracture levels, hypertension, diabetes mellitus, operative time, percentage of vertebral height loss, percentage of vertebral height restoration, and cement leakage, were examined. Multivariate linear regression analysis was performed to elucidate the related clinical or radiological factors of HBL.A total of 122 patients with 169 levels were eligible for inclusion in the study. The mean HBL was 279 ± 120 mL, and the postoperative Hb loss was 8.2 ± 3.9 g/L. Multivariate linear regression analysis revealed that HBL was positively associated with operative time (P = .000), percentage of vertebral height loss (P = .037), and percentage of vertebral height restoration (P = .000). By contrast, HBL was not associated with gender (P = .874), age (P = .148), BMD (P = .134), number of fracture levels (P = .079), hypertension (P = .259), diabetes mellitus (P = .495), and cement leakage (P = .975). The postoperative incidence of anemia significantly increased by 39.3% compared with that of the preoperative incidence (χ = 21.432, P = .000).For patients with OVCFs, the amount of HBL after PKP is much larger than that observed perioperatively. Operative time, percentage of vertebral height loss, and percentage of vertebral height restoration are influencing factors of HBL.

Comparison of long-term outcomes after laparoscopic-assisted and open colectomy for splenic flexure cancer

PURPOSE

This study aimed to use propensity score matching (PSM) to compare long-term outcomes after laparoscopicassisted and open colectomy for splenic flexure cancer (SFC).

METHODS

Clinical and follow-up data from 189 SFC patients undergoing colectomy at our hospital between January 2009 and January 2016 were retrospectively analyzed. According to the surgical approach employed, the patients were categorized into a laparoscopy group and an open group. The patients were matched at a ratio of 1:1 using PSM, with the match variables including gender, body mass index, clinical stage, and American Society of Anesthesiologists (ASA) score. Sixty-two patients in each group were ultimately included in this study and their short- and long-term outcomes were compared.

RESULTS

In contrast to the open group, the laparoscopy group had less intraoperative blood loss, faster postoperative recovery, and shorter hospitalization duration. On day 30 after surgery, there was no statistically significant difference in the incidence of minor or major complications between the two groups. The intraoperative mortality and mortality within 30 days after surgery were all 0% in the two groups. There was no statistically significant difference in pathological results between the two groups. There was no statistically significant difference in the tumor recurrence, 5-year overall survival (OS), and 5-year disease-free survival (DFS) rates between the two groups.

CONCLUSION

Laparoscopic-assisted colectomy for SFC had the same long-term outcome as open colectomy.

Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

INTRODUCTION

Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.

PURPOSE

To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.

MATERIALS & METHODS

Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).

RESULTS

A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).

CONCLUSIONS

According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.

Influence of obesity on short- and long-term outcomes after laparoscopic distal gastrectomy for gastric cancer

PURPOSE

Despite the increasing prevalence of obesity and gastric diseases, the impact of obesity on short- and long-term outcomes of laparoscopic distal gastrectomy for gastric cancer still remains unclear.

METHODS

Sixty-one consecutive obese patients with body mass index (BMI)≥30 kg/m², who underwent laparoscopic distal gastrectomy, were compared with 76 non-obese patients with BMI<30 kg/m². Short- and long-term outcomes were analyzed in both groups.

RESULTS

Obesity was associated with a longer operative time and a greater estimated blood loss. The rate of conversion to open distal gastrectomy was similar between the two groups. There were no 30-day postoperative deaths in either group. There was no significant difference in the overall number or severity of 30-day postoperative complications between the two groups. Regarding long-term survival outcomes, there was no statistical difference in overall (OS) or disease-free survival (DFS) between the two groups. Multivariate analysis showed that BMI did not influence prognosis.

CONCLUSION

Laparoscopic distal gastrectomy appears to be a safe and reasonable option for selected obese patients with gastric cancer and results in short- and long-term outcomes similar to those in non-obese patients.

Thumb Tip Defect Reconstruction Using Neurovascular Island Pedicle Flap Obtained From Long Finger

INTRODUCTION

Thumb tip reconstruction has been a very challenging issue for hand surgeons. Varieties of reconstructive options have been described or modified to obtain satisfactory sensory recovery. However, none has yielded entirely satisfactory results. This study reports a retrospective review of clinical data records of patients treated with a neurovascular island pedicle flap obtained from the medial aspect of the long finger.

METHODS

We enrolled 15 patients (9 men and 6 women), who received neurovascular island pedicle flaps for thumb tip amputations between December 2011 and December 2015. The average size of the flap was 2.8 × 2.2 cm(2) (range 2.5 × 1.8 cm(2) to 3.5 × 2.5 cm(2)). At the final follow-up visits, static two-point discrimination, visual analogue scale, Michigan hand outcome questionnaire and return-to-work time were used to evaluate surgical outcomes.

RESULTS

All flaps survived well. The follow-up period was 18 months. The mean static 2PD values at the reconstructed thumb tip and donor finger pulp (medial side) were 5.3 mm (range 4-8 mm) and 3.2 mm (range 3-4 mm), respectively. The average VAS scores for the aesthetic appearance of the donor site and recipient site were 9.1 (range 8-10) and 9.0 (range 8-9.5), respectively. The average Michigan Hand Outcome Questionnaire (MHOQ) score for hand function (reconstructed hand) was 8.2 (range 6-16). The average RTW time was 8.4 weeks (range 7-12 weeks).

CONCLUSIONS

Neurovascular island pedicle flap obtained from the medial aspect of long finger is a very reliable alternative technique for thumb tip defect reconstruction.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Minimally Invasive Video-Assisted Thyroidectomy: Almost a Decade of Experience at an Academic Center

Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance as an alternative to conventional thyroidectomy. This technique results in less bleeding, postoperative pain, shorter recovery time, and better cosmetic results without increasing morbidity. We retrospectively assessed outcomes in 583 patients having MIVAT from May 2005 to September 2014. The study population was divided into groups according to periods: 2005 to 2009 and 2010 to 2014. Operative data, complications, and length of stay were collected and compared. Total thyroidectomy was undertaken in 185, completion thyroidectomy in 49, and hemithyroidectomy in 349. Malignancy was present in 127 (21.8%). Mean incision was 3.4 ± 0.7 cm and estimated blood loss was 23.7 ± 21.7 mL. Mean operative time was 86.5 ± 39.3 minutes for all operations, 78.5 ± 37.0 minutes for hemithyroidectomy, 70.9 ± 30.1 minutes for completion thyroidectomy, and 106.8 ± 41.3 minutes for total thyroidectomy. Postoperatively, 56 (9.6%) had unilateral vocal cord dysfunction, which resolved except for one case (0.17%). Fifty-nine patients (10.1%) developed hypocalcemia, but only three cases (0.51%) became permanent. Only one patient required readmission. In conclusion, MIVAT results in short operative times, minimal blood loss, and few complications and is safely performed in an academic institution.

A Comparison of the Haemodynamic Effects of 4% Succinylated Gelatin, 6% Hydroxyethyl Starch (200/0.5) and 4% Human Albumin after Cardiac Surgery

Background and Aims:

The goal for volume replacement therapy is to maintain stable haemodynamics after cardiac surgery. We hypothesized that a short term infusion of hydroxyethyl starch results in better haemodynamic response than an infusion of lower molecular weight gelatin.

Material and Methods:

45 patients received a predetermined fixed dose of 15 ml kg−1 of either 4% succinylated gelatin (GEL) or 6% hydroxyethyl starch (HES) or 4% human albumin (HA) after cardiac surgery.

Results and Conclusions:

Pulmonary capillary wedge pressure was more increased in GEL and HES groups [mean (SD) 153% (54) and 168% (57) of pre-infusion value] than in HA group [122% (23)] (P = 0.031) after completion of infusion, but no differences in cardiac index (CI) and stroke volume index (SVI) were observed. At 2 and 18 hours after end of study infusions SVI was more increased in HES [143% (38) and 148% (41) of pre-infusion values] and HA [143% (35) and 163% (42) of pre-infusion values] groups than in GEL [116% (23) and 125% (30)] group (P = 0.047 at 2 hours and P = 0.033 at 18 hours). In early postoperative phase after cardiac surgery, HES and HA infusions improve haemodynamics more and longer period than GEL infusion.

Local Excision Procedure for Warthin's Tumor of the Parotid Gland

The aim of this work is to establish a local excision procedure (LEP) and indications of this procedure for Warthin's tumor. Seventy-three patients (82 sides) with Warthin's tumor were studied. Point I was located 1 cm from the intertragal notch in the direction indicated by the notch. Point S was located 5 mm superior to the inferior end of the mandibular angle. The trunk of the facial nerve and the marginal mandibular branch run at the points I and S, respectively. In surgical maneuvers below the I-S line, the marginal mandibular and colli branches may exist within the surgical field, but the trunk and other peripheral branches of the facial nerve will not be encountered. For Warthin's tumor estimated to be below the I-S line (Group A), LEP was used, involving resection of the tumor after locating and dissecting the marginal mandibular and colli branches. For tumors not meeting these criteria (Group B), partial superficial parotidectomy was performed. Results indicated that mean volume of hemorrhage was significantly smaller, and that mean operation time was significantly shorter in Group A than in Group B. Conversely, no significant difference in tumor size or incidence of postoperative facial paresis was identified between the 2 groups. Recurrence has not yet been noted in either group. In conclusion, LEP is useful for Warthin's tumor below the I-S line. This procedure seems applicable not only to Warthin's tumors, but also to other benign parotid tumors in the surgical field below the I-S line, such as pleomorphic adenoma and lymphoepithelial cyst.

Hypocalcaemia After Total Knee Arthroplasty and its Clinical Significance

BACKGROUND

Transient hypocalcaemia is a frequent complication after total knee arthroplasty (TKA). In this study, we investigated the factors associated with the development of hypocalcaemia after TKA in order to explore its clinical significance and treatment.

PATIENTS AND METHODS

A retrospective analysis of the change of serum calcium levels for 40 patients after TKA was performed. We investigated the patients prospectively for age, gender, and amount of bleeding at operation. At 24 hours following the operation, serum calcium of the patients was evaluated and a t-test was performed to analyze the categorical variables. Pearson's correlation analysis was used to determine the risk of hypocalcaemia in univariate analysis.

RESULTS

After TKA, the serum calcium level was significantly lower than that before the operation (p<0.01); the incidence of postoperative hypocalcaemia was 77.5%, the decline was positively correlated with intraoperative blood loss (Pearson's r=0.405, p=0.01).

CONCLUSION

Hypocalcaemia occurs frequently after TKA, however, clinical symptoms associated with hypocalcaemia are rare. The calcium ion is an important electrolyte, neurotransmitter and blood coagulation factor. It is suggested that we should routinely monitor calcium ion levels during the perioperative period and deal with hypocalcaemia in a timely fashion.

Maintaining Optimal Surgical Conditions With Low Insufflation Pressures is Possible With Deep Neuromuscular Blockade During Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind, Parallel-Group Clinical Trial

Carbon dioxide (CO2) absorption and increased intra-abdominal pressure can adversely affect perioperative physiology and postoperative recovery. Deep muscle relaxation is known to improve the surgical conditions during laparoscopic surgery. We aimed to compare the effects of deep and moderate neuromuscular block in laparoscopic colorectal surgery, including intra-abdominal pressure. In this prospective, double-blind, parallel-group trial, 72 adult patients undergoing laparoscopic colorectal surgery were randomized using an online randomization generator to achieve either moderate (1-2 train-of-four response, n = 36) or deep (1-2 post-tetanic count, n = 36) neuromuscular block by receiving a continuous infusion of rocuronium. Adjusted intra-abdominal pressure, which was titrated by a surgeon with maintaining the operative field during pneumoperitoneum, was recorded at 5-minute intervals. Perioperative hemodynamic parameters and postoperative outcomes were assessed. Six patients from the deep and 5 from the moderate neuromuscular block group were excluded, leaving 61 for analysis. The average adjusted IAP was lower in the deep compared to the moderate neuromuscular block group (9.3 vs 12 mm Hg, P < 0.001). The postoperative pain scores (P < 0.001) and incidence of postoperative shoulder tip pain were lower, whereas gas passing time (P = 0.002) and sips of water time (P = 0.005) were shorter in the deep neuromuscular block than in the moderate neuromuscular block group. Deep neuromuscular blocking showed several benefits compared to conventional moderate neuromuscular block, including a greater intra-abdominal pressure lowering effect, whereas surgical conditions are maintained, less severe postoperative pain and faster bowel function recovery.

[INFUSION THERAPY IN RECONSTRUCTIVE MAXILLOFACIAL SURGERY]

Restricted infusion strategy in combination with antifibrinolytic agents such as aprotinin and tranexamic acid is effective for blood saving in maxillofacial surgery. But reduction of infusion volume can lead to intraoperative hypovolemia. The goal of this study was to assess compensative effect of different regimes of infusion therapy and antifibrinolytics on intraoperative volume status and electrolyte balance in reconstructive maxillofacial surgery.

MATERIALS AND METHODS

65 patients were included in the study. There were 4 groups: (1) Infusion rate 8-12 mg/kg/h and acute normo/hypervolemic hemodilution; (2) 4-6 mg/kg/h and aprotinin 500,000 - 100,000 IU/4 hours; 3.6-8 mg/kg/h and tranexamic acid 8-10 mg/kg every 4 hours; 4.6-8 mg/kg/h and tranexamic acid 8-10 mg/kg every 4 hours and regional analgesia offacial nerves. We assessed parameters of central hemodynamic, peripheral perfusion, water-electrolyte balance and acid-base status.

RESULTS

Different infusion strategies were effective in maintaining positive volume balance despite intraoperative blood loss and continuous diuresis. Hypovolemia or peripheral perfusion insufficiency weren't mentioned in the study. Water-electrolyte and acid-base balance was also secured in every case. Nevertheless, CVP and diuresis in the group with infusion rate 4-6 ml/kg/h were near the critical threshold and could be dangerous in poorly controlled intraoperative bleeding.

CONCLUSION

The optimal infusion rate for surgical interventions in reconstructive maxillofacial surgery is 6-8 ml/kg/h. Infusion rate 8-12 ml/kg/h can potentially lead to dilutional coagulopathy and thus to increase the volume of blood loss. Infusion rate 4-6 ml/kg/h is associated with relative risk of hypovolemia and can't be recommended.

[PREDICTING, POSSIBLE WAYS TO REDUCE AND CORRECTION OF MASSIVE INTRAOPERATIVE BLOOD LOSS IN SPINAL TUMOR SURGERY]

The paper discusses the problem ofpredicting, prevention and therapy of massive intraoperative blood loss in patients with metastasis in spine and spinal cord. We analyze 60 surgical cases in last 14 years in our clinic. Amount of blood loss was more that 80% of total blood volume in each case (from 2.5 to 17 liters). Preoperative selective angiography data on intensity of tumor blood supply were essential for blood loss prediction. Simultaneous embolization oftumor during angiography dramatically reduced intraoperative blood loss. Combination of blood saving techniques (preoperative autodonation, acute normovolemic hemodilution and intraoperative cell salvage) led to effective compensation of blood volume deficit and minimizing of allogenic blood transfusion. Plasma-derived and recombinant factors were effective in management of hemostatic disorders associated with massive blood loss.

Identification of frequency, severity and risk factors of complications after open gastrectomy: Retrospective analysis of prospectively collected database using the Clavien-Dindo classification

Introduction The purpose of this study was to identify the frequency, severity, and risk factors of complications after open gastrectomy using the Clavien- Dindo classification because institution-specific criteria were mostly used in the previous articles. Materials and Methods All complication data were obtained from our prospectively collected database of open gastrectomy from January 1999 to December 2012 (n=539). Complications were classified into either major surgical complications such as pancreatic fistula, abdominal abscess, and anastomotic leakage, or others. Frequency and severity were graded retrospectively according to the Clavien- Dindo classification for subsequent analysis of risk factors. Results There were 222 events occurred in 156 patients (28.9%). Complications of grade IIIa or greater were 8.3% for major surgical complications and 10.6% for all complications. The mortality rate was 1.1%. Blood loss was the only independent risk factor for major surgical complications of grade IIIa or greater (odds ratio 1.923, 95% Confidence Interval 0.320-0.786, p=0.003). Total gastrectomy was the only independent risk factor for all complications of grade IIIa or greater (Odds ratio 2.075, 95% Confidence Interval 0.260-0.896, p=0.021). Disscussion The present study provided the objective overview regarding complications after open gastrectomy. Blood loss and total gastrectomy were revealed as the significant risk factors for complications.

CESARIAN SECTION - HIGHER RATE AND HIGHER CHALLENGES

There is evidence that perinatal morbidity and mortality has not changed - caesarean section rate increased and data remained stable and rate of intro and post operative complications was increased. There is another view of the picture: the right of patient to choose mode of delivery and the reality, that the number of patients with prior caesarian section and number patient and physician prefer caesarean section. The following topics are discussed as well: age of pregnant woman, macrosomia and intrauterine growth restriction, malpresentation, multiple gestation, preeclampsia, BMI, role of assisted reproductive technologies, electronic monitoring of fetal heart rate in labor, induction of labor. Private sector role and physicians fear of legal issues are also addressed. Postoperative complications are discussed and authors conclude that it is associated with non rational rate of caesarian section. The health sector authorities and physicians must carefully choose the mode of delivery especially in primagravidas.

Minimally Invasive Versus Open Lumbar Fusion: A Comparison of Blood Loss, Surgical Complications, and Hospital Course

BACKGROUND

Perioperative blood loss is a frequent concern in spine surgery and often necessitates the use of allogeneic transfusion. Minimally invasive technique (MIS) is an option that minimizes surgical trauma and therefore intra-operative bleeding. The purpose of this study is to evaluate the blood loss, surgical complications, and duration of inpatient hospitalization in patients undergoing open posterolateral lumbar fusion (PLF), open posterior lumbar interbody fusion (PLIF) with PLF, or MIS transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

Operative reports and perioperative data of patients undergoing single-level, primary open PLF (n=41), open PLIF/PLF (n=42), and MIS TLIF (n=71) were retrospectively evaluated. Patient demographics, operative blood loss, use of transfusion products, complications, and length of stay were tabulated. Patient data was controlled for age, BMI, and gender for statistical analysis.

RESULTS

Patients undergoing open PLF and open PLIF/PLF respectively experienced a significantly higher blood loss (p<0.001), higher volume of blood transfusion (p<0.001), higher volume of cell saver transfusion (p<0.001), and more surgical complications (dural injury, wound infections, screw malposition) (p=0.02) than those undergoing MIS TLIF. There was no statistically significant difference in duration of hospital stay (p=0.11).

CONCLUSIONS

MIS TLIF provides interbody fusion with less intraoperative blood loss and subsequently a lower transfusion rate compared to open techniques, but this did not influence length of hospital stay. MIS TLIF is at least as safe as open techniques with respect to dural tear, wound infection, and screw placement.

LEVEL OF EVIDENCE

Level III, Therapeutic.

Intraoperative blood loss in female patients with adolescent idiopathic scoliosis during different phases of the menstrual cycle

BACKGROUND

The vast majority of AIS patients who require surgical intervention are women. Blood loss is a major concern during the operation.

METHODS

The medical records of all female AIS patients who underwent posterior correction and fusion operations using the all-pedicle screw system from January 2012 to January 2014 were reviewed. Patients with irregular menstruation; underwent osteotomy; use coagulants were excluded from the study. The remaining patients were divided into 4 groups according to the operation date in the menstrual cycle (A: premenstrual group, 24-30 d; B: follicle group, 6-11 d; C: ovulatory group, 12-17 d; D: luteal group, 18-23 d). The information of patients from the 4 groups was reviewed. The data was analyzed using analysis of variance, the Student-Newman-Keels test and Kruskal-Wallis Test.

RESULTS

A total of 161 patients were included in this study. There were 40 patients included in group A, 38 patients in group B, 41 patients in group C and 42 patients in group D. The 4 groups were matched in age (P = 0.238), body height (P = 0.291), body weight (P = 0.756), Risser sign (P = 0.576), mean curve Cobb angle (P = 0.520), and bending flexibility index (P = 0.547), the number of levels fused (P = 0.397). The activated partial thromboplastin time (P = 0.235) and prothrombin time (P = 0.074) tended to be higher in group A, but the difference was not statistically significant. The fibrinogen level was lower in group B than the other 3 groups (P = 0.039). Blood loss and normalized intraoperative blood loss (NBL) was significantly higher in group A than the other 3 groups (P<0.01).

CONCLUSIONS

The hemostatic function tended to be lower in the premenstrual phase. The fibrinogen level was lowest in the mid-follicle phase. Female AIS patients tended to endure more intraoperative blood loss when the operation was performed in the premenstrual phase during the menstrual cycle.

Preoperative hypofibrinogenemia is associated with increased intraoperative bleeding in ruptured abdominal aortic aneurysms

INTRODUCTION

Ruptured abdominal aortic aneurysm (rAAA) is associated with coagulopathy and intraabdominal hemorrhage. Fibrinogen acts as a key coagulation factor and has previously been suggested as a biomarker for increased perioperative bleeding in other surgical areas. The aim of the present study was to investigate fibrinogen and standard laboratory parameters and their association to preoperative hemodynamic status, intraoperative bleeding (IOB), and outcome in treatment of rAAA.

METHODS

This is a single university center retrospective cohort study of 91 consecutive patients with rAAA undergoing open surgery or endovascular aneurysm repair (EVAR) between 2008 and 2013. Patients were analyzed using the Swedish Vascular Registry (Swedvasc), and local hospital medical and laboratory records. Laboratory data analyzed included fibrinogen, hemoglobin, platelet count, prothrombin time ratio, activated partial thrombin time, and creatinine. Odds ratios (OR) with 95% confidence intervals (CI) were calculated in a logistical regression model.

RESULTS

In the study cohort (n = 91), median age was 74 (57-91) years; 80 % men; open surgical repair (n = 72; 77%); EVAR (n = 19; 23%). Median preoperative fibrinogen concentration was 1.8 g/L (IQR = 1.4) and varied significantly across bleeding groups: ≤1999 ml 2.3g/L, IQR = 1.4 (n = 35); 2000-4999 ml 1.6 g/L, IQR = 1.5 (n = 33); ≥5000 ml 1.4 g/L, IQR = 1.0 (n = 23) (P < 0.001). Preoperative fibrinogen concentration showed a linear relationship with preoperative blood pressure (r = .447, P = 0.01). When analyzing other preoperative laboratory values, only platelets showed a similar linear relationship with preoperative blood pressure (r = .247, P = 0.05). Patients with blood pressure <70 mmHg had an associated median fibrinogen concentration of less than 1.5 g/L (P = 0.001). In the multivariable logistic regression analysis, preoperative fibrinogen < 1.5 g/L [OR 10.0, CI (1.8-57.1), P = 0.009] was associated with IOB >2000 ml and preoperative blood pressure < 70 mmHg was associated with IOB >2 000 ml [OR 3.7, CI (1.1-12.6), P = 0.03] and >5000 ml [OR 5.2, CI (1.3-21.1), P = 0.02]. Low fibrinogen concentration (< 1.5 g/L) was associated with 30-day mortality in the univariate analysis but not in the multivariable logistic regression analysis.

CONCLUSION

Low preoperative fibrinogen concentration was significantly associated with preoperative hypotension and increased intraoperative bleeding in patients with rAAA. Patients in hemodynamic shock with blood pressure <70 mmHg had an associated fibrinogen concentration of less than 1.5 g/L. A fibrinogen concentration less than 1.5 g/L was associated with a ten-fold increased risk of intraoperative hemorrhage of more than 2000 ml.

Nephron sparing surgery in a tertiary care center in Nepal--an initial experience

BACKGROUND

Malignant renal mass accounts for 2 to 3% of all malignant diseases in adults. Radical surgery used to be the treatment of choice with high propensity to develop chronic kidney disease in the compromised contralateral kidney. Currently, nephron sparing surgery is considered to be the standard of care with equivalent oncological outcome.

METHODS

This was a retrospective chart review of patients with renal mass less than seven cm in size who had open nephron sparing surgery from July 2012 to Sep 2013 at Tribhuvan university teaching hospital, Nepal. Latest follow up either from record or over telephone was documented.

RESULTS

Eight patients (mean age 45 years, male: female ratio1:1.6) underwent nephron sparing surgery over the specified period. Mean size of tumor was 4.75 cm. Mean ischemia time was 16.37 min. Histopathological diagnosis was benign in two and renal cell carcinoma in six patients.

CONCLUSIONS

Nephron sparing surgery is safe in low stage renal tumors. It also prevents unnecessary nephrectomy in benign lesions and prevents negative sequelae of long term chronic renal impairment in remaining contralateral kidney.

Bipolar cautery tonsillectomy using different energy doses: pain and bleeding

OBJECTIVE

Tonsillectomies are the most frequently applied operations in the ENT practice. Even though different surgical tonsillectomy techniques have been used, bipolar cautery is the most frequently used one. Our aim was to compare postoperative bleeding rates, pain scores and recovery times in tonsillectomies performed by using bipolar cautery in Joules (1Watt·sec or Ws) calculated by multiplying Watts by the duration of cauterization.

METHODS

Adenotonsillectomy and tonsillectomy patients, admitted to the Department of otorhinolaryngology of Izmir Ataturk Training and Research Hospital and Mardin State Hospital, between January 2007 and December 2012 constituted the study group prospectively. The patients divided into 4 groups due to the energy they exposed.

RESULTS

Patients in Group 1 recovered most rapidly (mean recovery time, 13.9 ± 1.8 days). Statistically significant results were obtained between Groups 1 and 4 and also Groups 2 and 4 when recovery times of the patient groups were evaluated with Bonferroni correction test.

CONCLUSION

As a result, for hemostatic control, electrocauterization should be used at lower doses and short-term as possible so as to decrease frequency of bleeding episodes, alleviate postoperative pain and accelerate wound healing.

Intraoperative bleeding during endoscopic sinus surgery and microvascular density of the nasal mucosa

PURPOSE

To evaluate the correlation between quality of the surgical field, intraoperative bleeding during endoscopic sinus surgery (ESS) and the density of microvasculature of the nasal mucosa.

MATERIAL/METHODS

Nasal mucosa of 30 patients, operated for chronic rhinosinusitis, was biopsied to assess expression of CD34 antigen on vascular endothelium. Quality of surgical field was evaluated with Fromm-Boezaart scale at mean arterial pressure (MAP) of 70-80 mmHg. If at this MAP surgical field quality was not satisfactory further reduction of hemodynamic parameters was performed until 'bloodless surgical field' (grade 2 or lower) was achieved. The rate of intraoperative bleeding was calculated from the ratio of total blood loss and the operative time. The extent of the disease was assessed according to computed tomography findings using Lund-Mackay staging system.

RESULTS

Significant positive correlation (Spearman correlation test; p<0.05) was found between CD34 antigen expression and quality of surgical field at MAP between 70 and 80 mmHg as well as the rate of intraoperative bleeding. More intense reduction of MAP was necessary to achieve 'bloodless surgical field' in patients with high CD34 expression than in those with moderate and low expression. Lund-Mackay score correlated with quality of surgical field but not with the rate of intraoperative bleeding.

CONCLUSION

During ESS, it is microvascular density of the nasal mucosa rather than the extent of the disease that contributes to the intensity of intraoperative bleeding, although both factors negatively influence the quality of surgical field.

Totally laparoscopic hepatectomy exposing the major vessels

BACKGROUND

Even during laparoscopic hepatectomy, a technique is often required to expose the major vessels, for example, in anatomical hepatectomy. We have standardized and performed such laparoscopic hepatectomy as successfully as open hepatectomy.

METHODS

We divide the liver parenchyma without pre-coagulation, exposing the major vessels using CUSA. To control the bleeding, we keep the central venous pressure low and often perform Pringle's maneuver. Over 49 months, we performed totally laparoscopic hepatectomies in 41 patients with the technique of exposing the major vessels. These included major hepatectomy in 7, sectorectomy in 17, segmentectomy in 14, and others in 3.

RESULTS

The median operative time was 361 (range 176-605) minutes, with median blood loss of 216 (range 0-1600) g. The conversion rate was 4.9 %. Postoperative morbidity rate was 9.8 % (prolonged ascites in 1, port site infection in 1, peroneal palsy in 2). Mortality was zero. The median length of hospital stay after surgery was 8 (range 5-28) days. No local recurrence was found at the time of writing.

CONCLUSIONS

By using our standardized procedure exposing the major vessels, we could raise the quality of laparoscopic hepatectomy toward the level of open hepatectomy significantly.

Safety advantage of modified minimally invasive cardiac surgery for pediatric patients

Minimally invasive cardiac surgery (MICS) using a small surgical incision in children provides less physical stress. However, concern about safety due to the small surgical field has been noted. Recently, the authors developed a modified MICS procedure to extend the surgical field. This report assesses the safety and benefit of this modified procedure by comparing three procedures: the modified MICS (group A), conventional MICS (group B), and traditional open heart surgery (group C). A retrospective analysis was performed with 111 pediatric patients (age, 0-9 years; weight, 5-30 kg) who underwent cardiac surgery for simple cardiac anomaly during the period 1996-2010 at Juntendo University Hospital. The modified MICS method to extend the surgical view has been performed since 2004. A skin incision within 5 cm was made below the nipple line, and the surgical field was easily moved by pulling up or down using a suture or a hemostat. The results showed no differences in terms of gender, age, weight, or aortic cross-clamp time among the groups. Analysis of variance (ANOVA) indicated significant differences in mean time before cardiopulmonary bypass (CPB), CPB time, operation time, and bleeding. According to the indices, modified MICS was similar to traditional open surgery and shorter time or lower bleeding volume than conventional MICS. No major mortality or morbidity occurred. In conclusion, the modified MICS procedure, which requires no special techniques, was as safe as conventional open heart surgery and even reduced perioperative morbidity.

Factors influencing blood loss and postoperative morbidity in children undergoing craniosynostosis surgery: a retrospective study

BACKGROUND

Craniosynostosis is a condition resulting from the premature fusion of cranial sutures. Corrective surgery is often associated with a large amount of blood loss, with transfusion of red blood cells (RBC) and fresh frozen plasma (FFP). The aims of this study were to determine the variables associated with increased blood loss and postoperative complications.

METHODS

A retrospective analysis was performed of 42 pediatric patients who underwent craniosynostosis surgery. We analyzed the following: demographic parameters, duration of surgery, intraoperative blood loss, RBC, FFP and fluid transfusion, urine output, and hemodynamic parameters. In addition, we recorded the postoperative length of stay in the intensive care unit and hospital, postoperative blood loss and early complications.

RESULTS

The mean age, weight and surgical duration were 9.2 ± 3.2 months, 9.3 ± 2.0 kg and 255.8 ± 46.7 min, respectively. Intraoperative blood loss was 61.2 ± 15.3 ml/kg and RBC, FFP and fluid transfusion were 27.3 ± 7.1 ml/kg, 16.5 ± 4.7 ml/kg and 21.7 ± 4.6 ml/kg/h, respectively. Greater intraoperative blood loss was associated with longer surgical duration (p = 0.001, correlation coefficient = 0.495, R2 = 0.245) and lower patient weight (p < 0.001, correlation coefficient = -0.557, R2 = 0.311). Longer hospital stay was associated with greater intraoperative blood loss (p < 0.001, correlation coefficient = 0.754, R2 = 0.568) and greater intraoperative RBC transfusion (p < 0.001, correlation coefficient = 0.795, R2 = 0.632).

CONCLUSION

Severe blood loss occurred in all children who underwent craniosynostotic corrections. Furthermore, the duration of surgery, patient weight and certain surgical procedures correlated with greater blood loss. Careful hemodynamic monitoring and evaluation of a patient's hematocrit value and volume status together may be helpful in maintaining the balance between insufficient and excessive blood product transfusion.

Can the Surgical Apgar Score predict morbidity and mortality in general orthopaedic surgery?

PURPOSE

The Surgical Apgar Score (SAS) is a simple tally based on intra-operative heart rate, blood pressure and blood loss; it predicts 30-day major postoperative complications and mortality in different surgical fields, but no validation has been performed in general orthopaedic surgery.

METHODS

A prospective assessment of the SAS in 723 consecutive patients undergoing major and intermediate orthopaedic procedures was performed in an 18-month period. The SAS was calculated immediately after surgery, and the occurrence of major complications or death was registered within a 30-day follow-up.

RESULTS

Thirty-seven patients had ≥1 complication (5.12 %). The complication rate did not augment as the score decreased (SAS 9-10 = 6.56 %; SAS 7-8 = 2.62 %; SAS 5-6 = 7.21 %; SAS ≤4 = 10.2 %), the relative risk did not augment as the score decreased and the likelihood ratio did not increase with decreasing SAS values, except in the subgroup of patients undergoing spine surgery. The C-statistic was 0.59 (95 % confidence interval 0.48-0.69), a weak discriminatory value. Using a threshold of 7 to define high-risk and low-risk patients, the SAS allowed risk stratification only for spine surgery.

CONCLUSIONS

The SAS does not predict 30-day major complications and death in patients undergoing general orthopaedic surgery, but it is useful in the subgroup of patients undergoing spine surgery.

Efficacy and safety of high-concentration adrenaline wicks during functional endoscopic sinus surgery

BACKGROUND

Epinephrine is a commonly used vasoconstrictor for instillation or infiltration to limit bleeding and improve the quality of the surgical field in functional endoscopic sinus surgery (FESS). No study to date has shown the efficacy of varying concentrations of adrenaline wicks into the nasal mucosa during FESS.

METHODS

A prospective, randomized, double-blind pilot study was conducted in which 30 American Society of Anesthesiologists (ASA) class I and II patients aged 20 to 60 years were divided into two groups. Patients in group 1 and 2 received 1 and 4 mg of epinephrine, respectively, with a nasal pack soaked in 20 mL of saline for 10 minutes before surgery after induction of anesthesia. A standard anesthesia protocol was followed using morphine, propofol, vecuronium with oxygen, and nitrous oxide. Patients were monitored for assessment of the surgical field and the amount of blood loss during FESS. Patients were also monitored for heart rate, invasive blood pressure, and cardiac output to assess the safety of varying concentrations of adrenaline wicks. Blood loss was measured meticulously. The surgical field was assessed by a surgeon blinded to the patient group using the Boezaart scale. Hemodynamic instability (± 20% of baseline values) was treated by rescue drugs (nitroglycerin infusion, metoprolol).

RESULT

Blood loss was found to be significantly decreased in group 2 compared to group 1 (p < .05). The rescue medication requirement to treat hypertension was more in group 2 than in group 1 (p < .05) but within the recommended limits. There was no significant difference in cardiac output between the two groups.

CONCLUSION

High-concentration (4 mg in 20 mL of saline) adrenaline wicks used during FESS significantly improve the quality of the surgical field and decrease blood loss compared to low-concentration (1 mg in 20 mL saline) wicks. Associated hemodynamic changes can be controlled in both groups without significant clinical consequences.

[The arrest of bleeding from the sigmoid sinus and the upper segments of internal jugular vein]

The objective of the present work was to develop an efficacious non-injurious technique for the arrest of hemorrhage from the sigmoid sinus and the upper segments of the internal jugular vein. The authors proposed a relatively simple and highly effective method to be used to the blockade of the sigmoid sinus. It was employed to treat 8 patients none of whom suffered complications in the late postoperative period (the follow-up study lasting from 6 months to 2 years after the intervention).

[No evidence for routine use of tourniquet during orthopaedic surgery]

The tourniquet is often used during orthopaedic surgery in order to optimize the view of the surgical field. The recommended guidelines for the use of tourniquet are not well known even though complications following tourniquet use are well documented. We have made a short review of the literature and found that the evidence for using tourniquet is very limited and that the use even might prolong the length of stay.

Argon plasma coagulation versus cold dissection in pediatric tonsillectomy

PURPOSE

Argon plasma coagulation (APC) is a new surgical procedure based on a conductive plasma of ionized argon between an activating electrode and a tissue surface. It is a good alternative for tonsillectomy because of its effective hemostasis and limited penetration depth of the coagulation beam. The aim of this prospective, randomized trial was to evaluate the operative time, intraoperative bleeding, and postoperative morbidity of the "hot" APC tonsillectomy compared with a traditional "cold" dissection tonsillectomy in children.

MATERIALS AND METHODS

Two hundred eighteen pediatric patients (aged 4-15 years; mean, 7,2 years) were randomized into 2 groups: treatment A (tonsillectomy with APC, n = 109) and treatment B (conventional tonsillectomy, n = 109). The outcome measures were as follows: (1) operative time, (2) intraoperative blood loss, (3) postoperative pain (evaluated using a visual analogue scale with a range score 0-10 on postoperative days 1, 3, 5, 8, and 15), and (4) postoperative primary and secondary hemorrhage. Statistical analysis was carried out using the Student t test.

RESULTS

In treatment A group, the mean duration of operative time and the intraoperative blood loss were significantly reduced (P < .001). There was no statistical significant difference between 2 groups in the intensity of postoperative pain and the incidence of postoperative hemorrhage (P > .05).

CONCLUSIONS

Argon plasma coagulation tonsillectomy in children is a new, easy, and safe technique that offers a complete eradication of the tonsillar disease, short operating time, minimal intraoperative blood loss, and a suitable cost with no additional increase in postoperative pain and hemorrhage when compared with the conventional "cold dissection."

Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes

PURPOSE

During pancreatoduodenectomy (PD), two techniques have been described to dissect the head of pancreas, viz. the superior mesenteric artery (SMA) approach by dissecting the uncinate process and the uncinate process first approach.

METHODS

Forty-four consecutive patients, who underwent PD between June 2009 and April 2010, were analyzed. Thirty patients underwent the SMA first approach along with uncinate dissection (group 1), while 14 patients underwent the uncinate process first approach (group 2).

RESULTS

There were 30 male and 14 female patients. The median age was 51 years (range 19-76 years). Median intraoperative blood loss in group 1 was 800 ml, while that in group 2 was 600 ml. A mean of 0.52 units of blood were transfused in group 1 (range 0-3) compared to 0.2 units in group 2 (range 0-1). The median operative time in group 1 was 457.5 min and the median operative time was 450 min in group 2. Complication rate was 40% and 14.3% in groups 1 and 2, respectively. Median duration of hospital stay was 14 days in group 1 and 12.5 days in group 2. Median nodes resected in group 1 were 8 (range 0-26), while in group 2 they were 9 (range 2-14). Resection margins were positive in two cases (one in each group). There were two mortalities in group 1 and no mortalities in group 2. None of the above differences were significant.

CONCLUSIONS

SMA first is a safe technique. It compares well with the uncinate first approach in terms of operative time, blood loss, number of lymph nodes retrieved, margin positivity and operative morbidity. Both techniques may be useful in situations such as a large uncinate process tumor or when superior mesenteric vein/portal vein/superior mesenteric artery involvement is suspected or present. Further studies, evaluating data related to specific predefined uncinate tumors, would be the next logical step in further defining the precise role of these techniques.

Hemostatic response in paediatric patients undergoing cardiopulmonary bypass surgery

This prospective, single-center cohort study aimed to evaluate the hemostatic response during and after Cardiopulmonary Bypass (CPB) surgery in a large cohort of children up to 6 years of age. Blood samples were drawn at eight time points: post-induction of anesthesia, pre-unfractionated heparin (UFH), post-UFH, post-initiation of bypass, pre-protamine, post-protamine, post-chest-closure, and 6 h post-chest-closure. As expected, all measures of the UFH effect increased significantly post-UFH bolus and decreased post-protamine administration. However, thrombin generation remained inhibited compared to baseline values despite the post-UFH reversal by protamine. We also demonstrate that residual UFH effect is not responsible for the ongoing inhibition of thrombin observed post-protamine administration. The significant increase in both free and total tissue factor pathway inhibitor levels during the CPB surgery might contribute to the persistent thrombin generation/endogenous thrombin potential inhibition post-protamine administration. This study makes a significant and novel contribution by investigating the physiological mechanisms behind the degree of thrombin inhibition by UFH and the residual levels of thrombin inhibition that continue despite protamine reversal and provides a new foundation for future interventional studies in the setting of paediatric CPB surgery.

[Clinical application of the plasma substitutes in patients with postoperative complications after surgeries for brain meningioma]

The issues on optimization of the restoration treatment of patients, suffering the brain meningioma, were discussed, basing on analysis of 498 observations. Tactics of the patients management in noncomplicated, complicated and severe course of postoperative period is adduced. The indices of survival and lethality, peculiarities of the infusion therapy were analyzed. The role of plasm-restituting preparations was demonstrated in complicated course of postoperative period. Rational complex approach to the restoration measures and intensive therapy conduction promotes the treatment efficacy raising, the patients fair quality of life securing in the brain meningioma in postoperative period.

[Surgical treatment of the aortic dissection type B: analysis of 15 years' experience]

65 patients with the aortic dissection type B were operated on in the period 1995-2010. The proximal local aortic prosthetics proved to be the method of choice in treatment of such patients. The method allowed the reduction of the hospital lethality on 5,7 ± 3,9% and considerably decrease the overall hospital stay.