Estimated Blood Loss Research Articles

Short- and long-term outcomes of laparoscopic right hemicolectomy with D3 resection for right colon cancer in elderly patients.

Laparoscopic right hemicolectomy (RHC) with D3 resection, similar to complete mesocolic excision, is an oncologically satisfying procedure; however, it remains controversial in elderly patients. There are no reports of the procedure for tumors fed by middle colic vessels because it is a difficult procedure. We evaluated the feasibility and oncological outcomes of the procedure in elderly patients. We retrospectively evaluated 336 consecutive patients undergoing laparoscopic right hemicolectomy with D3 resection for Stage I-III ascending and transverse colon cancer between 2010 and 2021. Patients were divided into the EP (age ≥ 75 years) and nEP (age < 75 years) groups, and short- and long-term outcomes were analyzed using propensity score matching. The median follow-up period was 60.7 months. After matching, we enrolled 129 patients. The surgery time, estimated blood loss, postoperative complication rate, number of harvested lymph nodes, and recurrence rate did not differ significantly between the groups; however, the adjuvant chemotherapy rate was significantly lower in the EP group. The EP group had significantly shorter overall survival (OS) (p < 0.01) than the nEP group; however, the cancer-specific (p = 0.15) and recurrence-free (p = 0.36) survivals did not differ significantly from those in the nEP group. In multivariate analyses, age ≥ 75 years, ASA ≥ 3, and pT4 were independent prognostic factors for OS (p = 0.02, < 0.01, < 0.01, respectively); however, only pT4 was an independent prognostic factor for CSS and RFS (p < 0.01 for both). This procedure offers safe, feasible, and satisfactory oncological outcomes for elderly patients.

Cutaneous ureterostomy following robot-assisted radical cystectomy: a multicenter comparative study of transperitoneal versus retroperitoneal techniques

BackgroundThe aim of this study was to evaluate the differences in perioperative outcomes between transperitoneal and retroperitoneal techniques in cutaneous ureterostomy (CUS).MethodsBetween 2018 and 2023, 55 patients underwent CUS following robot-assisted radical cystectomy. Among the 55 patients, we compared 33 patients who underwent transperitoneal CUS (t-CUS) and 22 who underwent retroperitoneal CUS (r-CUS).ResultsCompared with the r-CUS group, the t-CUS group had significantly shorter operative times (p < 0.001); significantly less estimated blood loss (p < 0.001); and significantly lower incidence of complications (Clavien–Dindo classification grade ≤ 2) within 30 days (p = 0.005). Unexpectedly, the incidence of ileus within 30 days was lower, though the difference was not statistically significant (p = 0.064). During the median follow-up period of 24.3 months, no ileus was observed in either group after 30 days postoperatively. There was no significant difference in the stent-free rate between the groups (p = 0.449). There were also no significant differences in the rates of change in estimated glomerular filtration rate from preoperatively at 3, 6, 12, and 24 months postoperatively between the groups (p = 0.590, p = 0.627, p = 0.741, and p = 0.778, respectively).ConclusionsCompared with r-CUS, t-CUS was associated with a shorter operative time and lower incidence of perioperative complications, including gastrointestinal complications. We believe that t-CUS can be performed safely and effectively.

Modified lateral enucleation technique-Surgery without ligation or clamping of the optic nerve: Technique description, complication rate and risk factors, and intraoperative blood loss estimation in companion animals.

The purpose of this study is to describe modification of the lateral enucleation technique without ligation or clamping of the optic nerve, document the incidence of complications, estimate intraoperative blood loss and identify possible risk factors for the developments of complications. Medical records of dogs, cats, and rabbits undergoing lateral enucleation without clamping of the optic nerve were identified and retrospectively reviewed for post-operative complications (2000-2022). The significance of possible risk factors for the development of complications, including species, sex, age, eye, surgeon, presumed ocular surface infection, cultures, follow-up, antibiotics, NSAIDs, complications and diabetes mellitus was examined in a subset of these patients (2019-2022). As a prospective study, intraoperative blood loss was estimated by gravimetric analysis in an additional subset. Records of 1296 enucleations were retrospectively reviewed and detailed evaluation regarding potential risk factors was performed in 446 enucleations. The overall complication rate and surgical site infection rate was 2.31% and 2.08% respectively. Only Pseudomonas spp. bacterial culture was associated with development of complications. Estimated relative intraoperative blood loss was 2.2% and 4.1% in 43 dogs and 29 cats respectively. The modified lateral enucleation technique is a safe and fast procedure with minimal risk of postoperative complications in dogs, cats, and rabbits. Based on the anatomy of the orbital vasculature ligation or clamping of the optic nerve and surrounding tissue is contraindicated.

Perioperative complications in patients aged ≥85 years undergoing spinal surgery: a retrospective comparative study of pre-old and old patients in Japan.

A retrospective comparative study. To compare the characteristics of perioperative complications in patients aged ≥85 years with those of younger patients undergoing similar spine surgery and examine factors associated with perioperative complications and clinical outcomes among patients aged ≥85 years. The risk factors for perioperative complications and their effect on outcomes in patients aged ≥85 years remain unclear. Furthermore, no study has compared younger patients with similar surgeries and condition with those aged ≥85 years. The study included patients aged ≥65 years who underwent spinal surgeries. The patients aged ≥85, 75-84, and 65-74 years were categorized into the super-old, old, and pre-old groups, respectively. The differences in perioperative age-related complications were compared among the three groups while matching for surgical procedures and general conditions (study 1). Furthermore, preoperative and intraoperative factors were examined for perioperative complications in the super-old group (study 2). Complications were categorized into surgical site and systemic complications. The analysis included 44 patients from each group. In study 1, the total complication rates were 40.9%, 25%, and 18.2% of the super-old, old, and pre-old groups, respectively. Differences in complication rates were observed between the super-old and pre-old groups (p=0.011). In study 2, 58 patients from the super-old group were analyzed. Surgical site complications were significantly associated with longer surgical duration (p=0.02) and more estimated blood loss (p=0.003). Systemic complications were significantly associated with previous cerebrovascular disease (p=0.014), preoperative motor deficit (p=0.023), and emergency case (p=0.006) and negatively associated with diabetes mellitus (p=0.048). Perioperative complications increased with advancing age in the super-old, old, and pre-old groups. The complication type is associated with specific background factors; therefore, determining them may help prevent perioperative complications.

The safety and feasibility of laparoscopic partial splenectomy: analysis of perioperative indications from different vascular subtypes and improvement of surgical approach.

While laparoscopic splenectomy (LS) has been widely used in benign splenic tumor, more concerns have been raised for postoperatively short-term and long-term complications. Laparoscopic partial splenectomy (LPS) is a surgical option, to preserve splenic function, and reduce postoperative complications. The aim of our study was to retrospectively identify the safety and feasibility of LPS compared with LS in patients with splenic benign tumor. From 2014 to 2024, a total of 165 patients diagnosed with occupational splenic lesions underwent splenectomy, of whom 87 underwent LPS and 78 underwent LS. We compare the perioperative parameters and long term follow up between these two groups. The etiology of splenic space-occupying lesions was nonparasitic splenic cysts, followed by splenic lymphangioma and splenic hemangioma. Of the patients with LPS, 55 underwent conventional surgery with blockage of the splenic arterial branch and resection along the ischemic line (RAIL), and 32 underwent with our modified total splenic blood supply blockade followed by resection alone the tumor edge (RATE). The tumor size, the operative time and estimated blood loss were comparable between the LPS and LS groups. One patient developed abnormal signs during the LPS procedure and was promptly referred for LS. The LPS group had fewer pancreatic leakage, incision infection, and pulmonary infection. As for different vascular types, patients with LS under all branches of the splenic artery had a longer time to resume postoperative feeding. As for the comparison of RAIL and RATE, estimated blood and operative time were significantly reduced in patients receiving RATE. Postoperative complications were the same in patients underwent each surgical procedures. LPS is a viable approach for patients with splenic benign tumor. We introduce the tumor artery supply types to indicate the resection region. Our RATE technique has proven to be clinically effective and safety.

Comparative Efficacy of Interlocking Intramedullary Nails and Percutaneous Plate Implantation in the Treatment of Femoral Shaft Fractures: A Meta-Analysis.

Interlocking intramedullary nailing and percutaneous plate implantation are commonly used techniques in the treatment of femoral shaft fractures. This study aimed to determine the most appropriate and effective treatment strategy between interlocking intramedullary nails and percutaneous plate implantation by analyzing and summarizing the available evidence. Relevant articles published from the date of database construction in PubMed, Embase, Web of Science, and Cochrane to 2024 were searched and downloaded according to PRISMA 2020. These studies were screened following pre-established inclusion criteria, and the data were extracted. Methodological quality assessment for retrospective studies was performed using the Newcastle-Ottawa Scale, whereas Review Manager Software was used for methodological quality assessment of randomized controlled trials (RCTs) and statistical analysis. Only 13 studies containing 1061 patients were included in the meta-analysis. Femoral shaft fractures treated with interlocking intramedullary nailing had shorter operative and fluoroscopic time and less estimated blood loss. Pediatric patients treated with interlocking intramedullary nails had less estimated blood loss and shorter healing time. Interlocking intramedullary nailing group in the retrospective study was associated with shorter operative time and less blood loss, whereas, in the randomized controlled trial (RCT) study, it was associated with less blood loss and shorter healing time. Interlocking intramedullary nailing is more advantageous in treating femoral shaft fractures and is a more appropriate option for treating femoral shaft fractures in pediatric patients. PROSPERO: CRD42024564563.

Short-term surgical outcomes of open, laparoscopic, and robot-assisted pancreatoduodenectomy: A comparative, single-center, retrospective study.

Although laparoscopic pancreaticoduodenectomy (LPD) and robot-assisted pancreaticoduodenectomy (RPD) are gradually gaining popularity, their advantages over open pancreaticoduodenectomy (OPD) remain controversial. This study aimed to compare the short-term outcomes of OPD, LPD, and RPD to elucidate the advantages and disadvantages of each procedure. We retrospectively analyzed 16 LPD, 43 RPD, and 36 OPD procedures performed at a single center between April 2020 and May 2024. Clinical data, including operative time, estimated blood loss, postoperative complications, length of hospital stay, and hospitalization costs, were retrospectively collected and analyzed. RPD demonstrated a significantly longer operative time (553 min) than OPD (446 min) and LPD (453 min) but a significantly lower estimated blood loss than OPD (150 mL vs. 400 mL, p < .001). Postoperative complication rates (Clavien-Dindo grade ≥3) were lower for RPD (24.4%) than those for OPD (50.0%) and LPD (68.8%). RPD also showed a significantly lower rate of clinically relevant postoperative pancreatic fistula (14.6% vs. 38.9% for OPD and 43.8% for LPD) and a shorter duration of hospitalization (11 vs. 28 days for OPD and 21 days for LPD, p < .001). Hospitalization costs were higher for RPD (20 109 USD) than for OPD (18 487 USD, p < .001), with LPD (20 496 USD) and RPD costs being similar. RPD appears to offer advantages in terms of reduced blood loss and postoperative complications and shortened hospital stay despite longer operative times and higher hospitalization costs. Therefore, RPD may be a more beneficial approach than OPD or LPD in pancreatic surgery.

Oncologic Outcomes and Safety Assessment of Retroperitoneal Laparoscopic Partial Nephrectomy versus Open Partial Nephrectomy in Treating Patients with Localized Renal Cell Carcinoma: A Propensity Score Matching Study.

Surgical intervention is crucial in radical resection of renal cell carcinoma (RCC). Different surgical procedures have different oncologic outcomes and safety in patients with RCC. Therefore, we aimed to investigate the oncologic outcomes and safety of retroperitoneal laparoscopic partial nephrectomy (RLPN) versus open partial nephrectomy (OPN) in treating patients with localized RCC. This retrospective cohort study included 160 patients with localized RCC who underwent either OPN or RLPN from January 2016 to June 2020. Out of these patients, 75 patients were treated with OPN and 85 patients were treated with RLPN. After propensity score matching, 130 patients (65 cases in each group) were finally included in the analysis. Additionally, surgical outcomes, three-year survival rates, and renal function parameters were assessed between the two groups, and the data were statistically analyzed using SPSS. Compared to the OPN group, RLPN demonstrated significantly shorter surgical time, lower estimated blood loss (p < 0.05), and lower incidence of complications (p = 0.024). In contrast, the RLPN group had significantly longer warm ischemia time (p = 0.011) than the OPN group. Furthermore, there were no significant differences in three-year overall survival, disease-free survival, cancer specific survival rates, positive surgical margins, hospitalization time between the RLPN and OPN groups (p > 0.05). The incidence of complications in the RLPN group was significantly lower than that in the OPN group (p = 0.024). Postoperatively, creatinine level was significantly lower following RLPN at one year compared to OPN (p = 0.029). RLPN offers advantages in surgical time, estimated blood loss, and postoperative complications, and it positively affects postoperative renal function, while OPN shows a shorter warm ischemia time. These two approaches result in comparable three-year survival rates. This study provides valuable insights into the oncologic outcomes and safety of RLPN compared to OPN in treating localized RCC.

Impact of intraoperative intravenous tranexamic acid on hematomas and bleeding events in gender-affirming vaginoplasty patients

One of the more common and disruptive complications of gender-affirming vaginoplasty is postoperative bleeding. The present study aimed to evaluate the impact of intraoperative intravenous tranexamic acid (IV TXA) administration on postoperative bleeding events in a large sample of gender-affirming vaginoplasty patients. Patients receiving gender-affirming vaginoplasty at the between June 2019 and July 2023 were evaluated retrospectively. IV TXA use, estimated blood loss, and bleeding complications were evaluated. Postoperative complications included minor hematomas, defined as hematomas requiring conservative treatment; major hematomas, defined as hematomas requiring intervention such as return to the operating room and readmission; major bleeding, defined as continuous bleeding from the surgical site requiring intervention; and readmission and reoperation related to bleeding. Statistical significance was set at p<0.05. In total, 628 patients were included in the study, 271 did not receive IV TXA and 357 received IV TXA. Surgeon preference dictated IV TXA use. Significantly fewer patients in the IV TXA group had a hematoma event (18% vs. 2%, p<0.001), a minor hematoma (16% vs. 3%, p<0.001), postoperative major bleeding (4% vs. 2%, p=0.008), and readmission for bleeding (6% vs. 1%, p=0.018). On logistic regression analysis, IV TXA use was associated with a decreased odds of developing any type of hematoma (OR 0.140, 95% CI 0.071-0.277, p<0.001), a minor hematoma (OR 0.126, 95% CI 0.059-0.270, p<0.001), and postoperative bleeding (OR 0.348, 0.153-0.794, p=0.012). The use of IV TXA reduces certain bleeding events in gender-affirming vaginoplasty patients, complications that can cause distress in the postoperative period.

Surgical management of thoracolumbar burst fractures by three different posterior techniques: A prospective comparative study

Study designProspective Comparative Study. ObjectivesThis study aims to study the outcome of thoracolumbar burst fractures by comparison of 3 different posterior constructs groups of patients treated by the posterior approach. SettingUniversity level Tertiary care Centre of Northern India. MethodsSingle centre study conducted from September 2020 to April 2022, the study included patients aged 18–50 years with burst fractures in the thoracolumbar region, TLICS score ≥4, and injury surgery duration <3 weeks. Sixty patients were divided into three groups: Group I (short segment with index screw(s) in the fractured vertebrae), Group II (short segment with interbody cage fusion), and Group III (long segment without index screw or interbody cage). Clinical and radiological assessments were performed over a 6-month follow-up period. Outcome measures included the Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), American Spinal Injury Association (ASIA) impairment scale, and radiological parameters. ResultsAmong 60 patients, 38 were male, and 22 were female, with a mean age of 33.37 ± 12.26 years. The most common injury mechanisms were falls from heights (85 %). Group I had the lowest estimated blood loss (395 ± 36.20 ml) and shortest surgery duration (140 ± 26.56 min), while Group III had the highest blood loss (744.25 ± 113.69 ml) and longest surgery duration (203.50 ± 23.40 min). No statistically significant differences were observed in kyphosis correction, canal clearance, or fusion status among the groups. Neurological and functional outcomes improved across all groups, with no significant intergroup differences. ConclusionAll three posterior instrumentation constructs provided effective management of thoracolumbar burst fractures, demonstrating high rates of fusion, significant kyphosis correction, and minimal loss of alignment. Despite variations in surgical parameters such as estimated blood loss and surgery duration, the clinical and radiological outcomes were comparable. Level of evidenceIII.

Laparoscopic central hepatectomy: Feasibility and safety.

Anatomical liver resection is the gold standard for hepatocellular carcinoma (HCC), enhancing survival and disease-free outcomes. For centrally located tumors, major resections are necessary but risky, especially for patients with liver disease. Central hepatectomy (CH) offers a parenchymal-sparing alternative to extended or hemihepatectomy (HH), reducing postoperative liver failure risk. However, its complexity and the large transection area make it challenging, especially with laparoscopic techniques. This study evaluates the feasibility and safety of laparoscopic CH for centrally located HCC, comparing surgical outcomes with those of the HH group. A total of 1592 laparoscopic hepatectomy cases from January 2011 to April 2023 were reviewed in a single institution. Patients undergoing laparoscopic CH were compared to those receiving HH during the same period. Exclusion criteria included non-HCC diagnosis, non-central tumors, and cases involving combined procedures. 70 cases of laparoscopic CH and 32 cases of laparoscopic HH were included. The CH and HH groups showed similar estimated blood loss (median 400ml vs. 290ml, p = 0.187) and intraoperative blood transfusion rates (10% vs. 15%, p = 0.413). Operation time did not significantly differ (median 330min vs. 360min, p = 0.862). Postoperative hospital stay was shorter in CH (median 6days vs. 9days, p = 0.018), with fewer ICU transfers (19% vs. 44%, p = 0.014) and lower 90-day mortality (1% vs. 9%, p = 0.055) compared to HH. Complication rates were similar overall (26% vs. 41%, p = 0.069), but HH had more Clavien-Dindo class I and II complications (13% vs. 19%, p = 0.040). Long-term survival did not significantly differ, but tended to favor the CH group. Despite the complexity, laparoscopic CH offers comparable perioperative outcomes and favorable long-term survival compared to HH. It can be considered a viable option for centrally located HCC, preserving liver function.

Exploring the Potential of Robotic Single-Port Surgery for Gallbladder Cancer: Initial Insights and Future Prospects.

Robotic surgery has demonstrated outcomes comparable or superior to open and laparoscopic surgeries for extended cholecystectomy.1-8 Despite its advantages, the minimally invasive robotic single-port (SP) system remains underutilized in complex hepatobiliary pancreatic surgery due to instrument limitations and retraction issues.9,10 This study evaluated the feasibility, safety, and effectiveness of the da Vinci SP system in gallbladder cancer surgery. The study was approved by the Ethics Committee of OOO University Hospital (IRB no. DAUH IRB-24-081) and conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the study's retrospective design. A 62-year-old woman with a diagnosis of gallbladder cancer was referred for surgery. Preoperative computed tomography (CT) scans showed no evidence of metastasis (T2N0). Therefore, a robotic SP extended cholecystectomy was planned. Figure 1 shows a 30-mm SP port and a 1-mm assistant port inserted for the procedure. Due to the absence of an energy device for the liver wedge resection, Maryland bipolar forceps were used, mimicking the Kelly clamp crushing technique. A monopolar cautery hook was used for lymph node resection of stations 7, 8, 12, and 13 (Fig. 2). Fig. 1 Port placement for robotic extended cholecystectomy using the da Vinci Xi system Fig. 2 Demonstration of full lymph node dissection RESULTS: The total duration of the operation was 226 min, with an estimated blood loss of 200 ml. The CT scan on day 5 showed no abnormalities, and the patient was discharged routinely on day 7 (Fig. 3). The pathologic examination confirmed adenocarcinoma (T2a) with clear resection, and all six lymph nodes tested negative for malignancy. Fig. 3 The wound 2 weeks after surgery CONCLUSIONS: This study underscores the adequacy of robotic surgeries and emphasizes the potential of the da Vinci SP system in hepatobiliary surgery. Despite current challenges related to instrument limitations, the authors are confident that the SP system will evolve into a crucial asset for hepatobiliary surgical practices in the foreseeable future.

Embolization of posterior fossa meningiomas supplied with meningohypophyseal trunk by using n-BCA and dual balloon protection.

Efficacy of tumor embolization for posterior fossa meningioma is controversial due to the lack of adequate embolization for dangerous feeders. Of these, a meningohypophyseal trunk (MHT) has high therapeutic value despite the high risks associated with embolization. To analyze the utility of preoperative MHT embolization for posterior fossa meningiomas using n-BCA with dual balloon protection, a single center retrospective record review was performed on eight consecutive patients who underwent preoperative tumor embolization via the MHT for posterior fossa meningiomas between 2020 and 2024. All patients successfully embolized the MHT using n-BCA. Complete obliteration was achieved in five cases, which is related to the tentorial artery alone as the feeding vessel. None of the patients had cerebral infarction associated with distal embolization. One patient experienced worsening of preoperatively observed abducens nerve palsy due to cranial nerve ischemia. Gross total resection was achieved in seven of eight cases. The mean estimated blood loss during surgical resection was 186 mL (range, 39-392 mL). The mean operative time was 431 min (range, 317-767 min). The MHT embolization of posterior fossa meningiomas by using n-BCA is technically feasible with a high success rate and an acceptable complication rate. MHT=meningohypophyseal trunk; ILT=inferolateral trunk; CPA=Cerebellopontine angle; BGC=balloon guide catheter; PVA=polyvinyl alcohol; GTR=Gross Total Resection; CN=Cranial nerve.

Robotic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: is there a benefit?

Open cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a therapeutic option for the management of malignancies with peritoneal carcinomatosis and of peritoneal origin. Robotic surgery shows promise as a minimally invasive approach for select patients. We aimed to evaluate the differences in outcomes between robotic versus open CRS/HIPEC and hypothesized less morbidity and faster recovery in the robotic approach group. We conducted a retrospective cohort study from our HIPEC database including all tumor origins. We included patients aged 18-89years who underwent CRS/HIPEC for curative intent at a single institution between January 1, 2017, and December 31, 2023. Patients were stratified by open versus robotic-assisted surgery. Mann-Whitney U and Fisher Exact tests were used to compare differences in patient characteristics and outcomes. A total of 111 patients underwent CRS/HIPEC for curative intent, with 95 (85.6%) cases performed open and 16 (14.4%) robotically. The groups were demographically similar, except patients undergoing robotic CRS/HIPEC had a significantly higher median income ($83,845 vs. $70,519, p < 0.001). Rate of comorbidities and cancer type, including appendiceal, colorectal, and ovarian, were the same. The peritoneal carcinomatosis index and completion of cytoreduction score were similar between groups. Robotic approach was associated with statistically significant lower estimated blood loss (113 vs. 400mL, p < 0.001) and postoperative transfusions (6.3% vs. 23.2%, p = 0.036). Total complications, readmission rates, and 30-day mortality were similar among groups, but the robotic group had a significantly shorter length of stay (5.5 vs. 9 d., p < 0.001). Robotic CRS/HIPEC holds promise to decrease intraoperative blood loss, blood transfusions, and hospital stay while providing similar immediate postoperative outcomes in select patients. These results should be validated in the setting of a prospective trial and effects on long-term oncologic outcomes should be investigated.

Open vs. laparoscopic vs. robotic pouch excision: unveiling the best approach for optimal outcomes.

Despite advantages for patients with ulcerative colitis, Crohn's disease, and familial adenomatous polyposis, restorative proctocolectomy with ileal pouch-anal anastomosis carries a risk of pouch failure, necessitating pouch excision. The traditional open approach is associated with potential complications. Robotic and laparoscopic techniques are emerging, but comparative outcome data are limited. We conducted a retrospective study of consecutive adult patients undergoing robotic, laparoscopic, and open ileal pouch excision at Mayo Clinic, Rochester, MN, between January 2015 and December 2023. We analyzed data on patient characteristics, perioperative variables, and postoperative outcomes, focusing on short-term complications. Statistical analysis included appropriate tests. The study included 123 patients: 23 underwent robotic-assisted pouch excision, 12 laparoscopic, and 82 open. The robotic approach had the longest median operative time (334 ± 170min, p = 0.03). However, it demonstrated significantly lower estimated blood loss than open (150 ± 200ml vs. 350 ± 300ml, p = 0.002) and laparoscopic surgery (250 ± 250ml, p = 0.005). Robotic and laparoscopic groups required fewer preoperative ureteral stents than the open group (p = 0.001). Additionally, the robotic approach utilized fewer pelvic drainages (p < 0.0001) and had a lower rate of lysis of adhesions > 60min compared to open surgery (p = 0.003). Robotic procedures had significantly lower 30-day postoperative complications than the open approach (30.4% vs. 65.9%, p = 0.002) while also demonstrating fewer 30-day reoperations than the laparoscopic group (p = 0.04). Robotic-assisted pouch excision offered significant benefits, including decreased EBL, reduced need for preoperative ureteral stents, and significantly fewer 30-day postoperative complications compared to open surgery.

Impact of Age on the Occurrence of Vascular Complications in Patients Undergoing Anterior Lumbar Approach Surgery.

Retrospective cohort study. To investigate the impact of age on the incidence of vascular complications in patients undergoing anterior lumbar approach surgery. Anterior approach lumbar spinal surgery may facilitate the use of intervertebral devices with larger endplate coverage and increased lordosis. Despite the advantages of this approach, risks related to vascular injury in older patients have been described in the literature. In total, 751 consecutive patients with degenerative spinal pathology who underwent stand-alone anterior lumbar interbody fusion (ALIF), ALIF combined with posterior fusion and/or instrumentation (360), total disc replacement, or hybrid procedures (ALIF and total disc replacement) were included. Data collected included general patient descriptive data, surgery details, intraoperative vascular injury, and postoperative vascular complications (deep vein thrombosis and/or pulmonary embolism). Rates of vascular complications were compared across age groups. In addition, the mean age of patients was compared between those with versus without vascular complications. Overall mean age was 50.4 years (range: 20-83 yr). The mean estimated blood loss was 91.3mL (range: 10-2800mL). A total of 15 patients, 2.0%, had vascular complications. There were 10 cases (1.3%) of intraoperative injury to iliac arteries or iliolumbar veins (mean blood loss was 721mL, and all were repaired intraoperatively). Postoperatively, 6 patients (0.8%) developed deep vein thrombosis and/or pulmonary embolism (one patient had both). With respect to age, there were no significant differences in rates of intraoperative, postoperative, or combined vascular complication rates across the age group ( P > 0.38). In addition, there were no statistically significant differences in the mean ages of patients with versus those without vascular complications ( P > 0.17). Overall incidence of vascular complications was 2.0%. No relationship between vascular complications and age was demonstrated. These data suggest that increased age may not necessarily be an absolute contraindication for anterior lumbar approach surgery. Level III.

Surgical Outcomes After Preoperative Embolization in Hypervascular Spinal Metastases: A Propensity Scored Study of 191 Patients.

Retrospective propensity-score matched, case control study at 2 academic tertiary care centers. To assess the effect of PE on (1) intraoperative blood loss, defined as conventional estimates of blood loss (EBL) and hemoglobin mass loss, and (2) secondary outcomes in patients with spinal metastases from hypervascular histologies. Preoperative embolization (PE) intends to reduce blood loss during surgery for spinal metastases of hypervascular tumors such as renal cell carcinoma. However, studies investigating the effect of PE in hypervascular tumors often consist of small cohorts, do not correct for confounding factors, and have conflicting results. After propensity score matching (PSM), 46 PE patients were matched to 46 non-PE patients without baseline differences. The constraints of PSM did not allow analysis of patients with tumor volumes>9cm3. Multiple linear regression models were fitted for EBL and hemoglobin mass loss. Poisson regression models were fitted for both intraoperative and postoperative transfusions. There was no difference in EBL (948mL [IQR 500-1750] vs. 1100mL [IQR 388-1925], P=0.68) and hemoglobin mass loss (201g [IQR 119-307] vs. 232g [IQR 173-373], P=0.18) between PE and non-PE patients. Other than higher 1-year survival rates (65% vs. 43%, P=0.05) in PE-patients, there were no differences in secondary outcomes. In multiple regression analyses, PE was not associated with decreased intraoperative blood loss, hemoglobin mass loss or perioperative blood transfusions. Our study demonstrated that, for tumors <9cm3, PE did not reduce EBL, hemoglobin mass loss or perioperative blood transfusions in patients undergoing spine surgery for metastases from hypervascular histologies. These findings suggest that urgent spine surgeries indicated for hypervascular histologies should not be delayed based on the availability of PE and accurate detection of pre-operative hypervascularity, beyond histology, will likely be an important determination of future PE utilization for spinal metastases. Treatment Benefits, Level III.

Routine Use of Indwelling Urinary Catheters During Endovascular Abdominal Aortic Aneurysm Repair is Not Necessary.

Endovascular infra-renal abdominal aortic aneurysm repair (EVAR) has proven to be an effective, less invasive alternative to open aortic aneurysm repair with decreased 30-day mortality. Historically, urinary drainage catheters were routinely placed preoperatively before EVAR in our institution. A shift to reduced catheter placement has occurred in conjunction with percutaneous EVARs becoming more routine. Urethral catheterization carries risk of infection (UTI), urinary retention and prostatic trauma inducing hematuria. The purpose of this study was to evaluate whether avoidance of urinary catheter placement during EVAR is an effective practice to reduce cost and morbidity. This was a single-institution, retrospective review of 177 consecutive patients who underwent elective infrarenal EVAR. Ruptured aneurysms and emergent EVAR were excluded. The study end points were postoperative UTI, urinary retention, length of stay, and readmission within 30 days. Univariable analysis was performed for these four outcomes in patients with (N = 92 and without (N = 65) preoperative urinary catheter placement. A more expansive multivariable investigation for risk of urinary retention following EVAR was conducted with binary logistic regression with co-variates including age, sex, femoral cutdown, estimated blood loss (EBL), urinary catheter, congestive heart failure, diabetes, and postoperative urinary retention as co-variates. Patients who had a Urinary catheter placed had an over two fold higher event rate of urinary retention (10.9% vs 4.6%) This urinary retention trend lacked power to reach significance (OR 2.52 (.665-9.55). Placement of urinary catheter also had a strong trend towards increased rate of UTI but lacking power for significance (7.6% vs 3.10%, OR 1.96 (.556-6.57). There was no difference with or without urinary catheter placement regarding 30-day readmission (yes catheter 7.6% vs no catheter 6.2%, P = .725), or length of stay (yes catheter 2.13 days vs no catheter 1.74 days, P = .723). Urinary retention was significantly associated with the development of a UTI with 23% of patients who had retention developing UTI compared with 4.2% of patients without retention developing UTI (adjusted odds ratio = 17.98, P = .019). Increased blood loss (P = .027) was also associated with increased rate of UTI on multivariable analysis. Avoidance of preoperative urinary catheter placement displays a trend towards avoiding urinary retention and UTI. Patients who develop post EVAR urinary retention experience a significantly increased rate of UTI. Selective urinary catheter placement should be used to help reduce urinary-related complications following elective EVAR.

The Role of a Community Surgeon in the Care of Hepatopancreatobiliary Patients: Short-Term Outcomes and Learning Curve.

Background Owing to the well-established volume-outcome relationship, hepatopancreatobiliary (HPB) surgery is commonly regionalized to academic, teaching hospitals. However, regionalization is associated with decreased access for some populations in need, as well as geographic and financial barriers for patients. If high surgeon and institutional volumes can be achieved, the community, non-teaching HPB surgical practice could help alleviate some issues associated with regionalization. The HPB experience of a community surgeon immediately after surgical oncology training was reviewed, hypothesizing that high volumes with acceptable short-term outcomes could be achieved, although a learning curve may be observed. Materials and methods Electronic medical records from 2013 to 2023 were reviewed. Data included patient demographics, perioperative details, pathology, complications, and deaths over 90 postoperative days. Perioperative quality metrics were assessed for trends over time in pancreaticoduodenectomy (PD) and liver resection subgroups. Results A total of 295 patients underwent 176 (59.7%) pancreatic and 119 (40.3%) hepatobiliary operations. The most common operations were PD (n=87; 49.4%) and partial hepatic lobectomy (n=56; 41.1%). In the pancreas group, morbidity was 25% (n=44), and mortality was 4.5% (n=8). In the hepatobiliary group, morbidity and mortality were 19.3% (n=23) and 5.0% (n=6), respectively. Within the PD and liver resection subgroups, operative time, estimated blood loss, and hospital length of stay (LOS) trended downward over time, with LOS decreasing significantly. Conclusion High HPB volumes with acceptable short-term outcomes can be achieved by a solo practitioner in the community, non-teaching setting. For PDs and liver resections, perioperative metrics trended downward over time, illustrating the learning curve encountered after training.

Perioperative Outcomes Related to Thoracic and Lumbar Spine Exposure During Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Large, Single-institution Retrospective Review

BackgroundVertebral body tethering (VBT) is a novel non-fusion technique for the management of scoliosis. Despite growing popularity, data concerning complications and thoracic surgery-related outcomes are lacking. MethodsA single-institution retrospective review was conducted of patients who underwent VBT with video-assisted thoracic surgical exposure from 1/1/2015–3/1/2022. Data obtained included demographics, comorbidities, hospital course, and outcomes. Results106 patients (81 % female) were identified with a mean age at surgery of 12.7 ± 1.5 (range 9–16). Most patients underwent single curve tethering (n = 93, 87.7 %) with a mean number of vertebral bodies tethered of 8.0 (range 5–13). The mean operative time was 236 ± 96 min (range 129–661) minutes with an estimated blood loss of 165 ± 143 mL (range 20–750) and no patients required allogeneic blood transfusion. The extent of tethering was significantly associated with increased operative time, fluids received, and chest tube output. Excluding instrument-related complications, the complication rate was 13.2 %, mostly occurring within the first 30 days after surgery and pleural effusion being the most common event. Two patients experienced a postoperative hemothorax requiring reoperation. No patients experienced sequelae of spinal cord ischemia secondary to the division of intercostal and/or lumbar vessels during surgical exposure and no deaths occurred. ConclusionVBT is a seemingly safe alternative to spinal fusion in skeletally immature adolescents, however, there are notable complications of this procedure related to thoracic exposure. Our experience indicates clinically significant pulmonary complications are uncommon and the extent of vertebral body exposure/tethering was strongly associated with operative duration, fluids, and chest tube output. Levels of EvidenceThis original article represents a treatment study of Level IV evidence.