Bleeding Requiring Blood Transfusion Research Articles

Non-descent vaginal hysterectomy surgery associated with less complications and good prognosis

Background: Removal of the uterus through vagina when performed in a case without uterine descent or prolapse is known as “non-descent vaginal hysterectomy” or NDVH. Vaginal route is preferred as compared to laparoscopic and abdominal methods. The advantages of vaginal hysterectomy being fewer complications, less post-operative stay, cost effective, and useful in bulky uterus. Aims and Objectives: The aims of the study were as follows: (1) To study the intraoperative and post-operative complications encountered during NDVH and their management. (2) To assess the intraoperative blood loss, the operative time, and post-operative hospital stay. (3) To study and check the feasibility of vaginal route as the primary route for all hysterectomies in the absence of uterine prolapse. Materials and Methods: A total of 50 patients were included in the study. Detailed history was taken including obstetric history and menstrual history and clinical examination was performed. After taking written, informed consent and doing proper pre-operative preparation, the patient was posted for NDVH. Post-operative complications were noted. Patients were asked to come for follow-up after 15 days. Results: In 92% of cases operated, no intraoperative complications were found suggesting low morbidity associated with the procedure. Hemorrhage requiring blood transfusion was found in 4% of cases. Average operative time was 61.2 ± 27.89 min, average blood loss was 170 ± 81.44 ml, and average hospital stay was 5.94 ± 4.95 days. On histopathological examination, 40% were having leiomyoma and dysfunctional uterine bleeding was seen in 22% of cases. Pain was the most common complication seen in 30% of cases while vaginal discharge was seen in just 4% of cases. About 80% of patients were discharged on post-operative day 5. Conclusion: In 92% of NDVH cases, no intraoperative complications were found suggesting low morbidity associated with the procedure. The post-operative hospital stay was restricted to 5 days in 80% of cases which indicates early discharge of the patient. Post-operative complications such as vaginal discharge and fever were seen only in 4% of cases. NDVH should, therefore, be considered as the primary route for all hysterectomies unless contraindicated in the absence of prolapse.

A descriptive study of concomitant vascular and bone injuries of the limbs in a tertiary care hospital in South India

Background: We studied patients with concomitant vascular and orthopedic trauma to limbs to assess their outcome and factors that affect the outcome of the limb. Methodology: We conducted a retrospective descriptive study and data from 68 patients was collected. Factors such as demography, mode of injury, and clinical parameters such as pulses, capillary refill time (CRT), sensory-motor function, compartment syndrome, type of bone and vessel injury, and ischemia time were compared and analyzed. Results: Out of 68 patients (n = 68) with concomitant vascular and orthopedic injury included in the study, 63 (92.65%) patients were males, and the mean age in the study was 30.16 ± 16.33 years; 56 (82.35%) patients sustained road traffic accident and 12 (17.65%) patients sustained fall from height, 7 (10.29%) patients were hypertensive, and 2 (2.94%) patients had diabetes mellitus; popliteal (30 patients – 22.06%) and brachial arteries (30 patients – 22.06%) are the most (total 44.12%) followed by femoral artery (seven patients, 10.29%) and radial artery (one patient, 1.47%); sensory function was absent in 20 (29.4%) patients; CRT was more than 3 s in 49 (72.06%) patients. No mortality occurred during the hospital stay in any of the 68 patients. The overall rate of amputation in the study was 20.59% (14 amputations). Significant association of amputation rate was found with increased CRT (P = 0.01), fracture (P = 0.05), open fracture (P = 0.05), transected vessel (P = 0.017), nonextremity injury (P = 0.01), and compartment syndrome (P = 0.002). Fasciotomy was done for 49 (72.06%) patients, and no significant association was found with the amputation rate. Mangled extremity severity score (MESS) was 7 or more than 7 in 23 (33.82%) patients. All the 14 (100%) patients who required amputation in the study had a MESS of 7 or more (P = 0.01), and limb salvage index (LSI) was 6 or more in 17 patients; among the 14 patients who underwent amputation, 13 patients had an LSI of 6 or more than 6 (P = 0.01). The vascular repair was redone in 3 (21.4%) patients, excessive bleeding requiring blood transfusion happened in 2 (14.3%) patients, and hypotension occurred in 4 (28.6%) patients. Intraoperative complications were associated with an increased rate of amputations (P = 0.001). The mean ischemia time was 15 ± 6.5 h with a median of 15 h; the shortest ischemia time was 10 h, and the longest was 19 h. The mean ischemia time was 14 h in the limb salvage group and 18.5 h in the amputation group. Long ischemia time was associated with increased amputation rates (P = 0.03). There was no significant difference in time between the time of injury and presentation to the hospital, the time between presentation and surgery, and the duration of surgery between the two groups (amputated vs. salvaged). Conclusion: The extent of soft-tissue injury and ischemia time are prime determinants of outcome in cases with concomitant vascular and skeletal injury. Early diagnosis, quick referral, addressing compartment syndrome, and proper vascular repair are the critical factors in salvaging a limb.

Evaluation of the safety profile of endoscopic pyloromyotomy by G-POEM: a French multicenter study.

Background:Gastric per oral endoscopic esophageal myotomy (G-POEM) is a promising procedure to treat refractory gastroparesis. The safety profile of G-POEM is an important topic because gastroparesis is a functional pathology, with a procedure whose effectiveness is between 50 and 65% depending on the studies.Objectives:We present this retrospective multicenter study, with the aim of establishing a safety profile, focusing on serious adverse events (AEs).Design:This was a multicenter observational cohort study conducted in five French expert centers.Methods:All patients who underwent G-POEM for refractory gastroparesis between 2015 and 2021 were included for analysis. AEs were classified into per endoscopic, early postoperative, and late postoperative, up to 1 month. Their severity was assessed using Dindo–Clavien and American Society for Gastrointestinal Endoscopy classification. The primary objective was to evaluate the rate of G-POEM severe AEs. Secondary objectives were to document other postoperative AEs, and to identify predictive factors.Results:In all, 217 patients were included: 81 men and 136 women, mean age 52 ± 17 years. The average procedural time was 44 ± 14 min (12–78). The average hospital stay was 3.7 ± 2.3 days. The AEs rate classified as Clavien–Dindo ⩾3 was 0.4% (one delayed bleeding requiring blood transfusion and endoscopic management). There were no deaths or patients admitted to intensive care unit. The rates of mucosotomy and capnoperitoneum were 3.7 and 1.8%, respectively, without clinical consequences. Most patients (81.5%) did not experience any AE. Three cases of dumping syndrome occurred, quickly managed by dietary measures.Conclusion:Our study confirms the safety of G-POEM with less than 0.5% of serious AEs, medically managed. This outcome makes this a procedure to have a good benefit–risk ratio.

P-OGC68 Prophylactic Endoluminal Vacuum Therapy (EVT) following oesophagectomy

Abstract Background Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for the management of anastomotic leaks following oesophagectomy. However, patients are often critically unwell with mediastinitis and established sepsis by the time the leak is diagnosed. This results in a protracted recovery period regardless of the effectiveness of EVT in treating the leak. Prophylactic EVT to protect the anastomosis following oesophagectomy may reduce the incidence of anastomotic leak, and/or mediastinitis and sepsis if the anastomosis does fail. We report the outcomes of two patients considered high risk for anastomotic leak who were managed with prophylactic EVT following esophagectomy for cancer. Methods Two patients received prophylactic EVT following oesophagectomy between May and July 2021. The patients were considered high risk for anastomotic leak due to technical concerns with, or complications during, the operation. In both cases the oesophagogastric anastomosis (OGA) was fashioned with a circular stapler. The endoluminal vacuum device (EVD) was constructed using an 18F nasogastric tube and a piece of open cell foam, and placed intraluminally across the anastomosis under endoscopic guidance at the time of surgery. Continuous negative pressure (125mmHg) was applied. Information relating to treatment and outcome was recorded prospectively. Results Patient-1, a 72-year-old female, ASA 2, underwent minimally invasive oesophgectomy for an adenocarcinoma at the gastro-oesophageal junction. After creating the stapled OGA, inspection revealed the proximal (oesophageal) tissue doughnut was complete but attenuated. Patient 2, a 67-year-old male, ASA 3, underwent a hybrid Ivor Lewis oesophgectomy for a lower 1/3 oesophageal adenocarcinoma. Surgery was complicated by significant intra-abdominal bleeding requiring blood transfusion and pressor support. In both cases, endoscopic assessment of the anastomosis following removal of the prophylactic EVD was performed day seven post-operatively. The anastomoses were healthy with no evidence of a leak, dehiscence, or early stricture formation. Conclusions In this limited case series, prophylactic EVT of the OGA following oesophagectomy was delivered safely with no complications related to insertion of the EVD or delivery of EVT. This intervention should be considered in cases where the risk of anastomotic leak is high. An intraluminal EVD situated across the OGA may minimise the extent of extraluminal contamination, and the systemic consequences of sepsis associated with this, should an anastomotic breakdown occur. Further studies are required to determine the safety of prophylactic EVT following oesophagectomy, and whether this improves surgical outcomes by reducing the incidence and impact of anastomotic leaks.

Extracorporeal membrane oxygenation support for SARS-CoV-2: a multi-centered, prospective, observational study in critically ill 92 patients in Saudi Arabia

BackgroundExtracorporeal membrane oxygenation (ECMO) has been used as a rescue strategy in patients with severe with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2 infection, but there has been little evidence of its efficacy.ObjectivesTo describe the effect of ECMO rescue therapy on patient-important outcomes in patients with severe SARS-CoV-2.MethodsA case series study was conducted for the laboratory-confirmed SARS-CoV-2 patients who were admitted to the ICUs of 22 Saudi hospitals, between March 1, 2020, and October 30, 2020, by reviewing patient’s medical records prospectively.ResultsECMO use was associated with higher in-hospital mortality (40.2% vs. 48.9%; p = 0.000); lower COVID-19 virological cure (41.3% vs 14.1%, p = 0.000); and longer hospitalization (20.2 days vs 29.1 days; p = 0.000), ICU stay (12.6 vs 26 days; p = 0.000) and mechanical ventilation use (14.2 days vs 22.4 days; p = 0.000) compared to non-ECMO group. Also, there was a high number of patients with septic shock (19.6%) and multiple organ failure (10.9%); and more complications occurred at any time during hospitalization [pneumothorax (5% vs 29.3%, p = 0.000), bleeding requiring blood transfusion (7.1% vs 38%, p = 0.000), pulmonary embolism (6.4% vs 15.2%, p = 0.016), and gastrointestinal bleeding (3.3% vs 8.7%, p = 0.017)] in the ECMO group. However, PaO2 was significantly higher in the 72-h post-ECMO initiation group and PCO2 was significantly lower in the 72-h post-ECMO start group than those in the 12-h pre-ECMO group (62.9 vs. 70 mmHg, p = 0.002 and 61.8 vs. 51 mmHg, p = 0.042, respectively).ConclusionFollowing the use of ECMO, the mortality rate of patients and length of ICU and hospital stay were not improved. However, these findings need to be carefully interpreted, as most of our cohort patients were relatively old and had multiple severe comorbidities. Future randomized trials, although challenging to conduct, are highly needed to confirm or dispute reported observations.

Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis

BackgroundKetorolac is an opioid sparing agent commonly used in children. However, ketorolac may be avoided in children with peritonitis owing to a possible increased risk of bleeding. MethodsA retrospective cohort study of healthy children 2–18 years who underwent appendectomy for perforated appendicitis was performed using the Pediatric Health Information System (2009–2019). Multivariable logistic regression was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery, adjusting for patient and hospital level factors. An interaction between ketorolac and ibuprofen was evaluated to identify synergistic effects. ResultsOverall, 55,603 children with perforated appendicitis underwent appendectomy and 82.3% (N = 45,769) received ketorolac. Of those, 32% (N = 14,864) also received ibuprofen. Receipt of a blood transfusion was infrequent (N = 189, 0.3%). On multivariable logistic regression analysis, perioperative ketorolac administration was associated with decreased odds of a blood transfusion (OR 0.53, 95% CI: 0.35–0.79). However, children receiving ketorolac and ibuprofen were more likely to require a blood transfusion (OR 1.99, 95% CI: 1.42–2.79). In a subset of children receiving ketorolac, each additional day of ketorolac was associated with an increase odds of blood transfusion (OR 1.39, 95% CI: 1.30–1.49). ConclusionPerioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis. However, use of both ketorolac and ibuprofen during hospitalization was associated with increased risk of bleeding, although precise timing of administration of these medications was unable to be determined. Extended ketorolac use was also associated with increased risk of bleeding requiring blood transfusion. Level of evidenceLevel III.

Treatment Options After a Diagnosis of Early Miscarriage: Expectant, Medical, and Surgical.

Approximately 12% of pregnancies end in an early miscarriage (up to week 12 + 0 of pregnancy). Over the past 10 to 15 years, two alternatives to curettage have appeared in the pertinent international treatment guidelines: expectant treatment and medical (drug) treatment. In this review, we discuss the advantages and disadvantages of each of these therapeutic options. This review is based on pertinent publications (January 2000 to February 2021) retrieved by a selective search in PubMed, as well as on the guidelines of the American College of Obstetrics and Gynecologists, the Association of the Scientific Medical Societies in Germany, the National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists, and the International Federation of Gynaecology and Obstetrics. Three effective and safe treatment options are available after a diagnosis of early miscarriage. Expectant treatment yields success rates of 66-91%, depending on the type of miscarriage. Its complications include hemorrhage requiring blood transfusion in 1-2% of cases. If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated. Drug therapy with misoprostol yields a complete termination in 81-95% of cases and is thus a valid alternative to expectant therapy, with the advantage of better planning capability. The vaginal application of misoprostol is the most effective means of administration, with the fewest side effects. Curettage is needed in 5-20% of cases. Suctional curettage has a success rate of 97-98%, with an associated anesthesia-related risk of 0.2%, a 0.1% risk of perforation, and a 2-3% rate of repeat curettage. If there is no acute indication for the surgical treatment of an early miscarriage, the patient can choose among three treatment options. Expectant and medical treatment can be provided on an outpatient basis. Curettage is the treatment of choice in the presence of infection, marked and persistent bleeding, hemodynamic instability, or a pre-existing coagulopathy.

Abstract 13609: Impact of Frailty on Hospital-Related Outcomes of Elective Left Atrial Appendage Closure

Introduction: Atrial fibrillation as the most common arrhythmia worldwide results in a significantly elevated risk of cardioembolic stroke. Left atrial appendage (LAA) closure has been advocated and supported by randomized clinical trials as an alternative treatment in patients with atrial fibrillation who have contraindications for anticoagulation. The safety of this procedure in patients who are considered frail remains unknown since they have been underrepresented in most clinical studies. Our study aims to investigate the impact of frailty on hospital-related outcomes in patients undergoing elective LAA closure. Methods: We reviewed the National Inpatient Sample database from January 2016 to December 2017 to identify patients that underwent elective percutaneous LAA closure using the ICD-10 code 02L73DK for the procedure. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. An individual is considered frail if they present >=1 diagnosis within the indicator. The outcomes include in-hospital mortality, hemorrhage requiring blood transfusion, respiratory failure, sepsis, length of stay, and total hospitalization cost. Multivariate logistic or linear regression was adopted to determine the impact of frailty on the outcomes while reducing the effect of possible confounding baseline characteristics. Results: From the period of January 2016 to December 2017, a total of 14795 patients underwent elective LAA closure. Of those patients, 830 were determined to meet the criteria for frailty, while 13965 were considered non-frail. The frail group is older than the non-frail group with a mean age of 78.77 years old than 75.53 years old. Frailty was associated with an increased risk of hemorrhage requiring transfusion (odds ratio 2.82, p=0.030) and a longer length of stay (2.10 vs 1.30 days, p=0.003). The frail group appears to have higher hospitalization costs, but the result was not statistically significant ($122668.2 vs $114295.3, p=0.091). Conclusions: The presence of frailty was associated with an increased risk of hemorrhage requiring transfusion and a longer length of hospital stay after elective left atrial appendage closure.

Abstract 12504: The Gender-Based Outcome in the Patients Undergoing Percutaneous Left Atrial Appendage Occlusion With the Watchman Device: A Longitudinal Nationwide Inpatient Sample Analysis

Introduction: Compared to men, women have an increased risk of having a stroke, cardiovascular disease, and death. It requires continuous anticoagulation use based on CHA 2 DS 2 -VASc scores for stroke prevention. The Watchman device is indicated for patients with non-valvular AF at high risk of stroke who have contraindications to long-term anticoagulation use. We sought to determine the periprocedural outcome difference based on gender in the patients undergoing watchman device implantation. Methods: National Inpatient Sample databases from 2016 to 2018 were utilized using Stata 16.0. NIS databases are the ICD-10-CM code-based largest publicly available all-payer inpatient database. Patients with atrial fibrillation who underwent the watchman procedure were identified; later divided and compared based on gender. Multivariate logistic regression, linear regression, and student t-t-tests were used for analysis. Data were further analyzed after greedy propensity matching for accuracy. Results: Out of 33,825 patients who had the procedure, 14,105 (41.8%) were female, and 19,690 (58.2%) were male. The mean age for women and men were 76.5±7.5 and 75.6±8.1 respectively. Co-morbidities such as DM, CAD, CKD, PVD, and history of CABG were more in men, whereas anemia and pulmonary hypertension were more in women. Mortalities in women were 30 whereas it was 26 in men. There was no difference in mortality on multivariate logistic regression analysis. Complications such as pericardial drain and major bleeding requiring blood transfusion were higher in women. There was no difference in pericardial complications, ischemic stroke, hemorrhagic stroke, and AKI. The overall mean LOS and cost per hospitalization were higher in women. Conclusions: Patients undergoing watchman procedure showed no difference in periprocedural mortality between men and women; however, women had high events of pericardial drainage and major bleeding requiring blood transfusion.

Impact of atrial fibrillation in patients with colorectal cancer: a national inpatient sample database analysis

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting approximately 1–2% overall population (1). Its causal relationship with colorectal cancer (CRC) is much for debate. According to one hypothesis, the presence of autoantibodies directed against ionic channels or acetylcholine receptors can predispose to the development of atrial fibrillation (2–3). Thus, AF may be regarded as an inflammatory complication in patients with colon cancer. Our study objective was to determine if AF impacts the outcome of patients with CRC. Method We analyzed the National Inpatient Sample (NIS) database from Oct-2015 to Dec 2018 using Stata 16.0. The NIS databases are released under the Healthcare Cost and Utilization Project, which includes inpatient admissions from the United States' participating hospitals. Total population with CRC were identified using their respective ICD-10 diagnostic codes then divided based on AF. To determine atrial fibrillation association with mortality and complications, we used multivariate logistic regression analysis using weights to generate nationally representative results. Later, a propensity-matched population analysis was done for the accuracy of the results. Result We found 245,305 patients admitted with CRC between Oct 2015 to Dec-2018 in the USA, out of which 28,170 (11.5%) were having AF. The mean age for the patients with AF was 77±10 compare to 65±14 years in those without AF. Patients with AF were associated with higher comorbidities and had a high population percentage with Carlson category three or above. There were 1,456 (5.2%) mortalities in the AF group compared to 5,689 (2.6%) in the other. The higher odds of mortality in patients with AF was present in multivariate logistic regression analysis in both non-propensity matched [1.71 (1.45–2.02), P-value: <0.000] and propensity-matched [1.44 (1.18–1.75), P-value: <0.001] cohorts. Patients with AF were hospitalized longer (9.20±7.8 vs. 6.85±7.0 days), leading to a high admission costs (US$ 25,875±22,875 vs. 20,087±19,314). Odds of complications such as need for blood transfusions [1.61 (1.05–1.29), P-value: 0.005], hemorrhage requiring blood transfusion [1.17 (1.05–1.29), P-value: 0.003], lower-GI bleed [1.31 (1.21–1.43), P-value: <0.001], sepsis [1.45 (1.30–1.62), P-value: <0.001], respiratory failure [1.39 (1.15–1.67), P-value: 0.001] etc. were also higher in group of patients with CRC and AF. Conclusion In our retrospective, propensity-matched national inpatient sample analyses of patients admitted with colorectal cancer, atrial fibrillation is associated with higher morbidity and mortality. AF was associated with a high burden of complications with prolonged hospital stay leading to increased health care expenditures. Funding Acknowledgement Type of funding sources: None.

Sex-differences in outcomes after percutaneous coronary intervention of chronic total occlusions: insights from a large single-center registry

Abstract Introduction Patients undergoing PCI of chronic total occlusions (CTO) are at high risk of both periprocedural and post-procedural adverse events. Whether sex-differences in outcomes exist after PCI of CTO remains unclear. Purpose We sought to investigate sex-differences in outcomes after CTO-PCI among an unselected real-world cohort of patients. Methods In our single-center retrospective study, patients who underwent elective CTO intervention from January 2000 to December 2019 were included. The primary endpoint of interest was major adverse cardiac events (MACE) defined as the composite of death, myocardial infarction (MI), and target vessel revascularization (TVR) at 1 year of follow-up. Results A total 1897 patients were included of which 368 were women (19.4%). Women were older (67±11.3 years vs. 62.6±10.9 years) and had a higher prevalence of comorbidities including diabetes and chronic kidney disease. Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding requiring blood transfusion (3.0% vs 1.1%; p=0.007), and acute vessel closure (1.36% vs 0.2%; p=0.009). In multivariable-adjusted models for baseline confounders, female sex was associated with higher risk of MACE and TVR (Table 1). Conclusion Gender differences in CTO management are observed, with fewer females going for CTO revascularization in contemporary practice. Female sex is associated with procedural-related complications, higher MACE, and TVR even after successful CTO intervention. Funding Acknowledgement Type of funding sources: None.

Effect of thrombocytopenia in patients with infective endocarditis: an insight from the National Inpatient Sample database

Abstract Introduction Infective endocarditis (IE) is one of the feared diseases in septic patients, and incidences are rising due to the intravenous drug abuse epidemic. Sepsis causes an escalation of the platelet destructions leading to thrombocytopenia (1). Few independent hospital-based studies have proposed increase mortality with thrombocytopenia in patients with IE (2–5). We aim to evaluate the significance of thrombocytopenia in IE subjects from the national inpatient sample (NIS) database. Method We analyzed the NIS database from Jan-2016 to Dec-2018 using Stata 16.0. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays per year. We identified patients with IE with or without thrombocytopenia using ICD-10 codes. The primary outcome of interest was in-hospital mortality comparison. We adjusted potential confounders (age, sex, diabetes, hypertension, etc.) with multivariate logistic regression analysis. Further analysis was done after balancing the population co-morbidity using a Greedy propensity match for accuracy. Results A total of 174,495 subjects were included in this study with a diagnosis of IE. Among these individuals, 33,285 patients had a concurrent diagnosis of thrombocytopenia. The mean ages were 53±19.5 years for the thrombocytopenia group and 55±19.8 years for others. Females were equally represented in both cohorts. There were 4,945 (14.86%) vs 2,835 (2.01%) mortalities reported in with and without thrombocytopenia group respectively. After propensity matching, there was a pronounced increase in mortality [Odds ratio (OR): 1.93 (1.72 – 2.15), p-value: <0.001] in the group with thrombocytopenia comparing to others. Complications such as Major bleeding requiring blood transfusion [OR: 1.45 (1.35–1.57)], acute myocardial infarction [OR: 1.56 (1.35–1.70)], complete heart block [OR: 1.44 (1.16–1.53)], cardiac arrest [OR: 1.44 (1.25–1.72)], acute respiratory failure [OR: 1.51 (1.39–1.73)] and pressor support requirement [(OR: 1.73 (1.57–2.01)] were notably higher in the cohort of thrombocytopenia with statistically significant p-value (<0.001). The difference in length of stay between both cohorts after propensity match wasn't statistically significant. Conclusion In conclusion, IE patients with thrombocytopenia have higher incidences of in-patient mortality and poor outcomes than cohort without thrombocytopenia. Some of the adverse consequences could be temporally explained by complications related to underlying thrombocytopenia. Further investigations are needed to delineate the outcome in this group of subjects. Funding Acknowledgement Type of funding sources: None.

58 Should Single Group and Save (G&S) Sampling be Implemented in Spinal Cord Stimulation Surgery (SCSS)?

Abstract Aim SCSS is offered to patients who have persistent chronic neuropathic pain after trials of conservative management. Although severe bleeding complications are rare, it is common practice to take two G&S samples from patients pre-operatively. Unnecessary testing can induce patient anxiety and is a financial burden to the NHS. We aim to determine if a single G&S sample before SCSS would be beneficial, and to assess the association between number of risk factors for bleeding and blood loss in SCSS. Method Retrospective analysis of 100 patients in one centre who had SCSS over a 3-year period. Bleeding risk factors, haemoglobin levels and complications were recorded for each patient. A review of current literature along with a cost analysis was subsequently performed. Results An average drop in haemoglobin levels of 9g/L post-operatively was seen. No patients required blood transfusions. There was no statistically significant difference (P = 0.364) between number of risk factors and blood loss. Conclusions The results obtained suggest that SCSS carries a low risk of adverse bleeding requiring blood transfusions. With the lack of guidelines for preoperative G&S samples it is difficult to make decisions on the amount of samples needed before SCSS. Single G&S sampling in patients without bleeding risk factors can reduce patient burden, save costs, and reduce environmental footprints left by laboratory tests. Those with risk factors may still benefit from two pre-operative G&S samples to ensure patient safety.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Abstract Aim To determine the necessity and cost effectiveness of routine blood group and save tests (G&S) before thyroidectomy Background Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion. Method Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&S tests, pre-operatively reserved blood products and peri-operative transfusions. Results 261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion. Conclusions The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&S tests are unnecessary for elective thyroidectomies.

Comparison between OPEN STONE SURGERY vs PERCUTENOUS NEPHROLITHOTOMY in Management of Renal Stones By Using S.T.O.N.E Nephrolithometry Scoring System

Abstract Background In spite of Percutaneous nephrolithotomy (PCNL) became the first-line treatment option for patients with large and complex renal stones, there still remains a need of using open stone surgery (OSS) for removal of stones as a second or third line of treatment option. To date, 3 scoring systems have been proposed utilizing different metrics including the Guy’s Stone Score, S.T.O.N.E. nephrolithometry and the Clinical Research Office of the Endourological Society (CROES) nomogram, and that used to assess and estimate the treatment success rate. Aim of the Work To evaluate and compare between OSS and PCNL in the management of renal stones by using the S.T.O.N.E. nephrolithometry scoring system to predict and assess the stone free rate and the correlation with peri-operative complications in that two procedures. Patients and Methods A total 100 patients who need surgical intervention for renal stones were treated with OSS (35 pa ents) and PCNL (65 pa ents) from January 2019 ll the end of October 2019, were invited to participate in the present study. This was a multicenter, comparative, prospective cohort controlled study. This study was controlled by the standard results recorded in the previous literatures. Only adult(>18 ys. Old) patients with renal stone size ≥ 20mm were involved in the study. Peri-operative and follow-up data included stone free rate and complications were collected for all patients and were compared between both procedures. S.T.O.N.E nephrolithometry scoring systems was applied to preoperative non-contrast computed tomography(CTUT) for all cases and compared the results of both procedures. Stone-free rate was diagnosed using early postoperative kidney, ureter, bladder X-rays(KUB) and another CTUT on the postoperative day30. Results There was a significant difference between the PCNL group and the OSS group in the primary stone free rate (90% and 97.5% respec vely, p-value=0.021), peri-operative major complications (3% and 14.3% respectively, p-value=0.033), opera ve me (123.46 ± 34.61 and 175.71 ± 55.10 respec vely, p-value=0.000) and postopera ve hospital stay (3.52 ± 0.84 and 5.23 ± 1.00 respec vely, p-value=0.000), while there was no significant difference in the intra-opera ve bleeding requiring blood transfusion (10.8% and 14.3% respec vely, pvalue=0.124). S.T.O.N.E score showed a significant difference between PCNL and OSS groups ( 7 (6-11) and 10 (7-12) respectively, p-value=0.000) and it also had a significant rela on with the outcome SFR (p-value=0.000) a er both PCNL and OSS(r= -0.581 and r= -0.567 respec vely), the higher the score, the lower the SFR and the higher the possibility of OSS choice. While this score had on relation with the peri-operative complications. Conclusion The S.T.O.N.E. nephrolithometry score was predictive of the stone-free status in both surgical procedures (PCNL and OSS) and can be used as an formal guidance for surgical planning and patient counseling. This score would be classified into two categories “low” score range from 5 to 8 recommend PCNL procedure with expec ng SFR of 88% to 97% and “high” score range from 9 to 12 recommend Open Stone Surgery with expec ng SFR of 90% to 96%, to reach the most acceptable results for each procedures to sa sfy the patient and the doctor. The S.T.O.N.E score was not associated with the peri-operative complications in both procedures.

Survey on spontaneous miscarriage and induced abortion surgery safety at less than 12 weeks of gestation in Japan.

In Japan, dilatation and curettage (D&C) is a common procedure for spontaneous miscarriage and induced abortion, and its safety has long been an issue. Electric vacuum aspiration (EVA) is also common, but manual vacuum aspiration (MVA) was introduced recently, with medical abortions using mifepristone or misoprostol which are not yet legally accepted. This nationwide retrospective study surveyed the surgical methods and complications associated with spontaneous miscarriage and induced abortion at less than 12 weeks of gestation in Japan to assess their safety, in comparison with a similar survey for induced abortions in 2012. Questionnaires were sent to 4176 facilities with a license for induced abortion surgeries in 2019. The questions included were the methods used, number of spontaneous miscarriages and induced abortions, and number of complications (uterine perforation, incomplete abortion, and gross bleeding requiring blood transfusion). Responses were received from 1706 facilities (40.9%). Although EVA with sharp curettage was the most common surgical method, which was used for 11 953 spontaneous miscarriages (28.9%) and 24 045 induced abortions (37.3%), the most common surgical method per facility was D&C, and the rates of D&C for spontaneous miscarriages (38.4%) and induced abortions (44.7%) performed in general hospitals were significantly higher than those in clinics (24.1% and 22.0%, respectively). There was no significant difference in the complication incidence rate among surgical methods for spontaneous miscarriages. However, in induced abortion surgery, the total complication and incomplete abortion incidence rates for D&C were significantly higher than those for EVA without sharp curettage (47/15 162 [0.31%] vs. 29/18 693 [0.16%], p=0.00362, 45/15 162 [0.30%] vs. 27/18 693 [0.14%], p= 0.00285, respectively). There was no significant difference in the complication incidence rate between MVA and other surgical methods for each abortion surgery. In Japan, especially in general hospitals, D&C is still widely used for miscarriage and induced abortion surgery. Its complication-incidence rates significantly decreased compared with that of the nationwide survey in 2012, but were still significantly higher than EVA without sharp curettage. Few facilities used MVA, but its complication rate was comparable with those of other surgical methods.

Is It Safe to Mobilize Patients Very Early After Transfemoral Coronary Procedures? (SAMOVAR)

Coronary angiography (CAG) and percutaneous coronary intervention (PCI) are performed via the femoral or radial arteries. In patients examined via transfemoral access, closure devices facilitate hemostasis, but it is unknown whether it is safe to mobilize these patients immediately and how acceptable this may be in terms of patient comfort. The aims of this study were to investigate bleeding complications in patients mobilized immediately after transfemoral CAG or PCI compared with patients on bed rest (BR) for 2 hours after the procedure and, furthermore, to investigate patient comfort in relation to mobilization and BR. SAMOVAR was a noninferiority trial with patients randomized to immediate mobilization (IM) or 2 hours of BR after transfemoral CAG or PCI and use of the AngioSeal as a closure device and reversal of heparin effect. The primary end point was development of hematoma greater than 5 cm, pseudoaneurysm, or bleeding requiring blood transfusion. Secondary end points were oozing from the puncture site, small hematoma, and patient comfort. Of 2027 patients (IM, 1010; BR, 1017), 40% underwent PCI. The primary outcome was recorded in 0.7% patients randomized to IM versus 0.5% in BR ( P = .58). There was no difference in the incidence of small hematoma, whereas persistent oozing was seen slightly more often after IM compared with BR (12% vs 9%, P = .04). Patients mobilized immediately reported less back pain and micturition problems ( P < .001). In patients who had CAG and PCI performed through transfemoral access, reversal of anticoagulation and use of closure devices allowed IM with low rates of complications and improved patient comfort.

Complications of robot-assisted and laparoscopic partial nephrectomy

Objective: to analyze complications after laparoscopic and robotic-assisted partial nephrectomy.Materials and methods. In our study was included 246 cases. Intra- and postoperative complications were studied after nephron-sparring surgery. The laparoscopic approach was used in 68 (27.3 %) cases, the robot-assisted - in 178 (71.5 %) cases. Intraoperative complications were assessed according to the Rosenthal classification, postoperative complications - according to the Clavien-Dindo classification.Results. The overall incidence of intraoperative complications was 12.6 %. The most frequent intraoperative complication was bleeding that did not require blood transfusion (grade I) - 5.69 % (laparoscopic approach - in 3 (4.41 %) cases, robot-assisted approach - in 11 (6,18 %) cases). Bleeding requiring blood transfusion and injuries of internal organs, which were restored intraoperatively (grade II), were recorded in laparoscopic and robot-assisted approaches in 4.41 % and 2.25 % of cases, respectively. Complications leading to the loss of organ (nephrectomy, splenectomy) were observed in 2.94 % and 4.49 % of cases, respectively. Intraoperative deaths (grade IV) were not registered.The incidence of postoperative complications was 18.29 %. Minor complications (Clavien-Dindo ≤II) were detected in 16 (6.5 %) patients (laparoscopic approach - 7.35 %, robot-assisted approach - 6.18 %). Serious complications (Clavien-Dindo ≥III) were detected in 29 (11.79 %) cases (with laparoscopic approach - 14.71 %, robot-assisted - 10.67 %). In the group of tumors with the RENAL index 4-6, the incidence of postoperative complications was 14.7 % with the laparoscopic approach, and 7.1 % with the robot-assisted approach; in the RENAL 7-9 group - 21.9 % and 13.0 %, respectively. In the group of tumors of high complexity (RENAL 10-12), only the robot-assisted approach was used, the incidence of postoperative complications was 22.0 %.Conclusion. Partial nephrectomy for kidney tumors is an effective and safe surgical technique. The incidence of complications when using the laparoscopic approach is higher than when using the robot-assisted technique in groups of tumors of simple and medium complexity. For tumors of high complexity, robot-assisted approach is a priority. The largest number of serious complications is observed with partial nephrectomy with complex tumors.

OUTCOME ANALYSIS OF PERCUTANEOUS NEPHROLITHOTOMY IN SUPINE POSITION

Supine PCNL (Percutaneous Nephrolithotomy) is an Alternative to traditional prone positioning. Benets of the supine position include easy access to the airway and Optimization of cardiopulmonary function in patients. This is a prospective study which analyzes the outcome of percutaneous nephrolithotomy in supine position. There were totally 50 patients included in the study. 27 were male and 23 female patients. Mean age was 43 years, ranging from 18 to 70 years. Right side stones seen in 60% of cases ( 30/50). Average stone size was 2.6cm ranging from 1.8 to 6cm. Average operating time were 63.5 minutes and uroscopy 18.9 minutes (5 to 35 minutes). Clearance rate in our study were pretty good with 90% (45 out of 50 cases). Five patients required secondary procedures and ve had complications in form of sepsis and bleeding requiring blood transfusion. There were no visceral injury or srtula. Thus Supine PCNL has several potential advantages with successful technical feasibility and can be used to treat all stone sizes especially very effective in high risk patients for anesthesia. There is no added risk in this technique, and the stone clearance and complication rates are comparable to standard prone PCNL

Preoperative anemia and complications after surgery for pelvic organ prolapse: an analysis of the national surgical quality improvement program database.

Preoperative anemia is a well-established risk factor for adverse perioperative outcomes in major surgery, but studies exploring complications after pelvic reconstructive surgery are limited. The objective of this study is to examine the impact of preoperative anemia on 30-day adverse outcomes in patients undergoing pelvic organ prolapse surgery. A retrospective cohort of women undergoing pelvic organ prolapse surgery was captured from the National Surgery Quality Improvement Program database (2014-2019). The primary outcome was a composite of postoperative medical complications such as pulmonary embolism, acute renal failure, stroke, myocardial infarction, cardiac arrest, deep vein thrombosis, and sepsis. Secondary outcomes included surgical site infection, bleeding requiring blood transfusion, readmission within 7days of surgery, and return to the operating room within 30days. Multivariate logistic regression was used to adjust for important pre-specified potential confounders. A total of 50,848 women were included in the analysis and 9.9% (4,579) met the criteria for anemia (hematocrit <36%). Potentially serious medical complications were rare, occurring in only 348 women (0.7%), and were more common among anemic patients (1.1% vs 0.6%, p < 0.001). On multivariate analysis, preoperative anemia was associated with higher odds of both potentially serious medical complications (OR 1.38, 95% CI 1.01-1.88) and returning to the operating room (OR 1.55, 95% CI 1.23-1.94). Anemic patients had a four-fold increase in the odds of requiring a blood transfusion (OR 4.47, 95% CI 3.60-5.56). Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in women having surgery for pelvic organ prolapse.