Comparison of the Rex-recess approach with the standard approach in left lateral sectionectomy of the liver.

Blood Conservation

Application of computer-assisted virtual surgical procedures and three-dimensional printing of patient-specific pre-contoured plates in bicolumnar acetabular fracture fixation

Chirurgie virtuelle assistée par ordinateur et impression 3D de plaques individualisées pré-chantournées dans les fractures acétabulaires des deux colonnes

Introduction: Identifying risk factors of operative blood loss is imperative toward establishing an effective blood management implementation strategy and further minimize the requirement for perioperative blood loss and transfusion. Aim: To investigate whether the factors like obesity and hypertension affect blood loss and transfusion requirements in primary elective Total Knee Arthroplasty (TKA). Materials and Methods: A prospective clinical study was conducted at Shalby Hospitals in Ahmedabad, Gujarat, India, from November 2017 to November 2019, on 91 patients recruited for primary elective TKA. The subjects were divided into two groups, i.e, group A (normotensive and non obese; n=46) and group B (Hypertensive and obese; n=45). Charlson-Deyo comorbidity score were given to each patient as a measure of surgical risk. Data on intraoperative and postoperative blood loss, blood parameters (drop in haemoglobin, haematocrit value), and incidence of transfusion rates were recorded and assessed. All patients had standardized protocols of anesthesia, postsurgical and rehabilitation care protocols following surgery. Fisher’sexact test, Chi-square test, and student’s t-test were used for statistical analysis. Pearson’s correlation was performed to identify factors associated to blood loss. The p-value <0.05 was considered significant. Statistical Package for Social Sciences (SPSS) version 22.0 was used. Results: The intraoperative, postoperative and total blood loss (drop of haemoglobin and haematocrit) were significantly greater in the hypertensive and obese patients (p-value <0.001). The immediate postoperative day 1 haemoglobin and day 1 and 2 haematocrit were significantly better in the normotensive and non obese patients (p-value <0.001). Significantly greater number of hypertensive and obese patients required blood transfusion (p-value=0.045). There was a positive correlation between intraoperative blood loss and operative time in both groups (RA=0.04, p-value=0.74; RB=0.09, p-value=0.52) although statistically insignificant. Hypertensive and obese patients required longer hospitalization (p-value <0.0001). Three patients from group B were diagnosed to develop pulmonary embolism while admitted in hospital which was managed successfully by intensivists without any fatality. Conclusion: Hypertension and obesity were associated with greater blood loss and transfusion requirement compared to non obese and normotensive patients undergoing primary elective TKA.

Posterior spinal instrumentation and fusion for correction of adolescent idiopathic scoliosis (AIS) typically requires lengthy operating time and may be associated with significant blood loss and subsequent transfusion. This study aimed to identify factors predictive of duration of surgery, intraoperative blood loss and transfusion requirements in an Irish AIS cohort. A retrospective review of 77 consecutive patients with AIS who underwent single-stage posterior spinal instrumentation and fusion over a two-year period at two Dublin tertiary hospitals was performed. Data were collected prospectively and parameters under analysis included pre- and postoperative radiographic measurements, intraoperative blood loss, surgical duration, blood products required, laboratory blood values and perioperative complications. Mean preoperative primary curve Cobb angle was 62.3°; mean surgical duration was 5.6h. The perioperative allogeneic red blood cell transfusion rate was 42.8% with a median requirement of 1 unit. Larger curve magnitudes were positively correlated with longer fusion segments, increased operative time and greater estimated intraoperative blood loss. Preoperative Cobb angles greater than 70° [Relative Risk (RR) 4.42, p=0.003] and estimated intraoperative blood loss greater than 1400ml (RR 3.01, p=0.037) were independent predictors of red blood cell transfusion risk. Larger preoperative curve magnitudes in AIS increase operative time and intraoperative blood loss; preoperative Cobb angles greater than 70(o) and intraoperative blood loss greater than 1400ml are predictive of red blood cell transfusion requirement in this patient group.

Preoperative embolization of spinal tumors is often used to reduce blood loss from surgery. Intraoperative blood loss, even in patients who undergo embolization, is potentially multifactorial; embolization techniques, surgical procedures or tumor characteristics may affect intraoperative blood loss. To retrospectively analyze factors affecting intraoperative blood loss in patients who had undergone spinal tumor embolization; and to assess the safety of the procedure. Sixty-two patients (median age, 60 years) with a tumor involving the thoracic (n = 42) or lumbar (n = 20) spine underwent preoperative tumor embolization with particles. Multiple variables, including patient characteristics, tumor characteristics, embolization techniques, and surgical procedures, were evaluated with respect to intraoperative blood loss and transfusion requirement. Complications related to the embolization procedures were also recorded. Univariate and multivariate analysis were performed to analyze the variables affecting the intraoperative blood loss and transfusion requirement. Complete or near-complete tumor embolization was achieved in 47 patients. The average estimated blood loss (EBL) and packed red blood cells units transfused during surgery were 2554 mL (range, 250-11,000 mL) and 7 units (range, 0-28 units), respectively. Univariate analysis indicated tumor volume, surgical approach, and invasiveness of the spinal surgery to be significant variables affecting EBL. Tumor histology and extent, tumor vascularity, degree of embolization, and size of embolic particle did not affect operative blood loss. On multivariate analysis, invasiveness of the surgery was the only variable that influenced EBL. Two patients developed irreversible neurologic deficits following embolization. Embolization technique or completeness has a limited effect on operative blood loss after preoperative spinal tumor embolization. Operative blood loss from spinal surgery is dependent primarily on the invasiveness of the surgery. Although preoperative embolization is a relatively safe procedure, there remains a risk of cord ischemia.

Classification of open liver resection based on operative time, blood loss, and comprehensive complication index

Pediatric craniosynostosis (CS) surgery is frequently associated with extensive blood loss and transfusion requirements. The aim of the study was to evaluate the authors' institutional procedure with 2-surgeon approach and early transfusion strategy on blood loss and blood product transfusions in children undergoing craniofacial surgery. A retrospective analysis of medical records was performed of pediatric CS corrections during a 15-year period. Primary endpoint was blood loss and transfusion requirement during and the following 24 hours postoperatively. Linear regression analyses were performed of associations between intra and- postoperative blood loss and blood loss and weight. A total of 276 children (median 9 months) were included. Intraoperative blood loss was 22 mL/kg (14-33 mL/kg) and postoperatively 27 mL/kg (18-37 mL/kg), with no change during the study period. Intraoperative transfusions of red blood cell and plasma were 16 mL/kg (10-24 mL/kg) and postoperative 14 mL/kg (9-21 mL/kg). Postoperative red blood cell and plasma transfusions were 2 mL/kg (0-6 mL/kg) and of 0 mL/kg, respectively. Craniosynostosis type was related to blood loss (P < 0.001). There was an association between intraoperative and postoperative blood loss (P = 0.012) and intra- and postoperative blood loss and weight (P = 0.002, P = < 0.001). Duration of surgery was 110 minutes (range 60-300 minutes).Pediatric CS surgery is associated with substantial intra- and postoperative blood loss and transfusion requirements, which did not change over a 15-year period. Blood loss was associated with type of CS. Intraoperative blood loss was correlated to postoperative blood loss and body weight.

Left lateral sectionectomy (LLS) is the most common type of anatomic laparoscopic liver resection performed, accounting for 20 % of all laparoscopic hepatectomies. Because there has been no standardized surgical technique for laparoscopic left lateral sectionectomy (LLLS), we offer an established operation: laparoscopically stapled left lateral sectionectomy (LSLLS). Our aim was to perform a case-controlled study of LSLLS with traditional (without vascular staplers) laparoscopic left lateral sectionectomy (TLLLS), validating the standardization and reproducibility of LSLLS. From February 2009 to December 2011, a total of 49 LSLLSs were performed. The results were compared with 33 cohort-matched TLLLSs from an earlier time period. Ordered sample cluster analysis was used to determine the learning curve of LSLLS based on the operating time and blood loss. All LSLLS were performed successfully. There were no conversions to laparotomy or hand-assisted laparoscopic resection. Two endoscopic linear staplers were used in each case. Despite a higher hospital cost ($10,892 ± $944 vs. $8,962 ± $943, p < 0.05), LSLLS compared favorably with TLLLS regarding operating time (103 ± 21 vs. 151 ± 32 min, p < 0.05) and blood loss (70.8 ± 41.6 vs. 173.3 ± 131.1 ml, p < 0.05). No specific complications related to laparoscopy were observed. Ordered sample cluster analysis demonstrated a learning curve of 18 cases for LSLLS. This study demonstrates the standardization and reproducibility of LSLLS. We therefore propose LSLLS as the standard technique for lesions located in the left lateral section of the liver.

Since the inception of laparoscopic liver surgery, the left-lateral sectionectomy has become the standard of care for resection of lesions located in segments II and III. However, few centers employee laparoscopic left hemihepatectomy on a routine basis. This study evaluated the safety and efficacy of the laparoscopic left hemihepatectomy as a standard of care. An international database of 1,620 laparoscopic liver resections was established and outcomes analyzed comparing the laparoscopic left lateral sectionectomy (L lat) to laparoscopic left hemihepatectomy (LH). All data are presented as mean ± standard deviation. A total of 222 laparoscopic L lat and 82 LH were identified. The L lat group compared with LH group had a higher incidence of cirrhosis (27 vs. 21 %; p = 0.003) and cancer (48 vs. 35 %; p = 0.043). Tumors were larger in the LH group (7.09 ± 4.2 vs. 4.89 ± 3.1 cm; p = 0.001). Operating time for LH was longer than L lat (3.9 ± 2.3 vs. 2.9 ± 1.4 h; p < 0.001). Operative blood loss was higher in LH (306 vs. 198 cc; p = 0.003). Patient morbidity (20 vs. 18 %; p = 0.765) was equivalent with a longer length of stay (7.1 ± 5.1 vs. 2.5 ± 2.3 days; p < 0.001) for LH. Patient mortality and tumor recurrence were equivalent. Laparoscopic left hemihepatectomy is a more technically challenging and often time-consuming procedure than a left-lateral sectionectomy. This international multi-institutional confirmed that intraoperative blood loss, complications, and conversions are more than acceptable for laparoscopic left hemihepatectomy in expert hands. Postoperative morbidity and mortality rates together with adequate surgical margins and long-term recurrence are not compromised by the laparoscopic approach.

This study aimed to investigate the clinical efficacy of the autologous vertebral-filled polyetheretherketone (PEEK) cage in anterior cervical discectomy and fusion with instrumentation (ACDFI). The clinical data of 368 patients who received ACDFI from September 2012 to September 2017 were retrospectively analyzed. Based on the material that filled PEEK cage during the surgery, the patients were divided into two groups, the autologous vertebrate group (n equal to 185) and the autologous iliac group (n equal to 183). The operative time, operative blood loss, postoperative complications in the two groups were recorded and analyzed. The bone graft fusion and postoperative functional outcomes, including scores of modified Japanese Orthopedic Association score (mJOA), Neck Disability Index (NDI), and Visual Analog Scale (VAS) were compared. Patients were followed-up for 14.04 ± 0.98 months. At 6-months follow-up, the rate of spinal fusion was 96.29% (178/185) in the vertebral group and 95.94% (176/183) in the iliac group, with no significant difference between the two groups (p &gt; 0.05). The postoperative VAS, mJOA, and NDI scores were also not significantly different between two groups during the follow-up (p &gt; 0.05). The operative time and blood loss in the vertebral group were significantly less than that of the iliac group (p &lt; 0.01). All patients in the iliac group suffered pain at the iliac donor site, 65 patients suffered numbness, 12 patients had fat liquefaction at donor incision. Meanwhile, all the patients in the vertebral group had no postoperative complications. This study concluded that the autologous vertebrae-filled PEEK cage could achieve the same clinical outcome as the autologous iliac, but have the advantages of shorter operative time, less intraoperative blood loss, and postoperative complications.

Pur p ose: C omplications are quite common in surgery to correct spinal deformities due to the long duration under anesthesia and massive blood loss. T he aim of this study was to evaluate and compare the effectiveness of Aprotinin in spinal deformity surgery. Mat e r ia ls and Met h ods: Fifty-nine patients who underwent spinal deformity surgery were ana- lyzed. Thirty-two patients were administered Aprotinin, and 27 control patients were not. T he P re- and P ost- operative hemoglobin and hematocrit, blood loss, transfusion requirements, operative time, postoperative blood loss through suction drains and duration of suction drains were measured in both groups. Resul ts : There were no differences in age, gender, height, weight, hemodynamic indices, post- operative blood loss through the suction drains and the duration of the suction drains between the two groups. Intraoperative blood loss, transfusion and operative time were 1,345±425 cc, 1,008±721 cc, and 247 minutes in the Aprotinin (+) group and 2,070±1,276 cc, 2,552±2,791 cc, and 279 minutes in the Aprotinin ( -) group, respectively. The postoperative hemoglobin and hematocrit levels were also significantly different (12.9±1 cc and 38.3±3.1% in the Aprotinin (+) group, and 11.9±1.8 cc and 35±5.5% in the Aprotinin ( -) group, respectively). Concl u si o n: T here was significantly less intraoperative blood loss, transfusion and surgery time in the group administered Aprotinin. T herefore, Aprotinin can be used in spinal deformity surgery that has a high risk of massive blood loss.

Background: Prolonged operative time and blood loss may affect the success rate in total hip arthroplasty (THA). The aim of the current study was to evaluate the effects of the press-fit (PF) technique without screws combined with tranexamic acid (TXA) on operative time and intraoperative blood loss in THA.Methods: We retrospectively evaluated 114 hips treated with THA between March 2017 and January 2021 in this study. The patients were divided into three groups, including PF-TXA group, only PF group, and screw group. PF-TXA group received intravenous (IV) 1 g TXA 15 minutes before surgical incision, followed by a peri-articular 1 g/50 ml TXA. Only the PF group and screw group did not receive TXA. The primary outcome measures were operative time and intraoperative blood loss. Secondary outcomes included postoperative blood loss, hemoglobin and hematocrit levels, allogeneic blood transfusions, length of hospital stay, the Harris Hip Score (HHS), and thromboembolic complications.Results: Operative time was lower in the PF-TXA group than that in the only PF and the screw group (p=0.0001). Intraoperative blood loss was significantly different in the PF-TXA group compared with the only PF and the screw group (423 ml, 516 ml, and 534 ml; respectively). The patients who received the PF technique combined with TXA had significantly less hospital stay length than the only PF group and the screw group (p=0.021).Conclusion: The findings obtained in this study suggest that although only the PF technique can provide a shorter operative time compared to using screws, less blood loss may not be obtained using this technique in THA. PF technique combined with TXA significantly decreased operation time and intraoperative blood loss as well as the length of hospital stay following primary THA.

To highlight the success rates of two approaches of transvaginal vs. transabdominal closures for the vesicovaginal fistula (VVF) repair and to investigate the patient, fistula, and surgical factors relevant to surgical characteristics and successful outcomes. Retrospective analysis of 66 consecutive patients who underwent VVF repair between 2005 and 2020. Fistula profile, operative data, and postoperative outcomes were analyzed. Primary outcome was success rate with regard to surgical approach. Secondary outcomes were to compare patients' and surgical characteristics with regard to surgical approach and correlate these characteristics relevant to surgical outcomes. A total of 66 women with a median age of 47 (27-82) years were included. Most (93.9%) of the VVFs were secondary to gynecological procedures. Thirteen (19.7%) patients had previous VVF repair. The median time from onset of leakage to surgical repair was 120days. Forty-nine patients underwent transvaginal repair, whereas 17 (25.7%) women had abdominal repair. The success rates of transvaginal and abdominal techniques were 98% and 82%, respectively. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced hospital stay, and lower complication rates (p< 0.005). Age and time to surgery were positively and significantly correlated with surgical time [r (p value): 0.392 (0.003), (0.0386 (0.01)] and estimated blood loss [0.388 (0.002 and 0.410 (0.001)], respectively. Transvaginal repair of VVF is a technically feasible and successful approach with significantly better operative parameters and lower complications. Despite varied etiology and different surgical approach, age and time to surgery are the main factors that correlate with operative time and blood loss.

BackgroundMetastatic spinal tumors pose a significant challenge regarding intraoperative blood loss. Identifying risk factors for intraoperative blood loss is crucial for appropriate surgical planning and early intervention. However, current studies have not comprehensively evaluated risk factors for predicting intraoperative blood loss. This study aims to determine whether smoking significantly contributes to intraoperative blood loss among metastatic spinal tumors and to investigate other potential risk factors.MethodsThis study analyzed 252 patients with metastatic spinal disease who underwent posterior decompressive surgery, and the primary outcome measured was intraoperative blood loss, with massive intraoperative blood loss defined as exceeding 2500 mL. Propensity score matching analysis was employed to analyze the influence of smoking on intraoperative blood loss. In addition, subgroup analysis was performed based on smoking status before and after propensity score analysis. Multivariate analysis was used to analyze the relationship between smoking and intraoperative blood loss. To assess the predictive value of smoking status for intraoperative massive blood loss, we conducted an analysis using the Area Under the Receiver Operating Characteristic Curve (AUROC), and the corresponding Area Under the Curve (AUC) values were subsequently calculated.ResultsBefore conducting the propensity score analysis, the study found that smoking patients had a significantly higher volume of intraoperative blood loss (1938.30 mL vs. 1722.32 mL, P = 0.014) and a greater incidence of massive intraoperative blood loss (36.4% vs. 20.1%, P = 0.008) compared to non-smokers. After adjusting for propensity scores, the results showed that smokers still had a higher volume of intraoperative blood loss (1938.30 mL vs. 1703.41 mL, P = 0.019) and a higher proportion of massive intraoperative blood loss (39.7% vs. 14.9%, P = 0.002) than non-smokers. Multiple linear regression analysis confirmed that smoking status was significantly associated with intraoperative blood loss before (Estimate = 1.410, P = 0.001) and after (Estimate = 1.443, P = 0.010) propensity score matching analysis. Additionally, the logistic regression demonstrated that smokers were 2.268 times (95% CI: 1.272–4.044) more likely to experience intraoperative massive blood loss compared to nonsmokers before propensity score analysis (P = 0.005). After propensity score analysis, the fold increase in risk further rose to 3.764 (95% CI: 1.643–8.621), indicating an even stronger association between smoking and intraoperative blood loss (P = 0.002). Furthermore, the AUC value increased from 0.596 (95% CI: 0.527–0.666) for smoking status before propensity score matching analysis to 0.660 (95% CI: 0.567–0.753) after propensity score matching analysis.ConclusionsSmoking is a significant risk factor for increased intraoperative blood loss and should be taken into consideration when planning surgical interventions for patients with metastatic spinal tumors.