Intraoperative Estimated Blood Loss Research Articles

Evaluation of parallel endplate osteotomy for severe rigid spinal deformities: a retrospective analysis of 36 cases with a minimum 2-year follow-up

BackgroundTo report on the technique and results of parallel endplate osteotomy (PEO) for severe rigid spinal deformity.MethodsWe retrospectively reviewed the clinical data of 36 patients with severe rigid spinal deformities who underwent PEO between July 2016 and December 2018 and who were followed up for at least 24 months.ResultsFollowing PEO, the kyphosis and scoliosis correction rates reached 77.4 ± 14.0% and 72.2 ± 18.2%, respectively. The median intraoperative estimated blood loss was 1500 mL and the median operative time was 6.8 h. The SF-36 scores of physical function, role-physical, bodily pain, general health, vitality, social function, role-emotional and mental health changed from 62 ± 28, 51 ± 26, 49 ± 29, 35 ± 30, 53 ± 28, 45 ± 30, 32 ± 34 and 54 ± 18 at baseline to 81 ± 16, 66 ± 41, 72 ± 40, 64 ± 44, 75 ± 25, 71 ± 46, 66 ± 34 and 76 ± 28 at 12 months postoperatively, 82 ± 32, 67 ± 42, 81 ± 30, 71 ± 41, 80 ± 30, 74 ± 36, 68 ± 35 and 85 ± 33 at 18 months postoperatively, and 86 ± 21, 83 ± 33, 88 ± 26, 79 ± 39, 86 ± 36, 86 ± 48, 80 ± 47 and 91 ± 39 at 24 months postoperatively, respectively.ConclusionsPEO is an effective technique for successful correction of spinal deformities. At the two-year follow-up visit, all patients achieved better clinical results based on the SF-36 scores.

Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures.

The outcome differences following surgery for an impending versus a completed pathological fracture have not been clearly defined. The purpose of the present study was to assess differences in outcomes following the surgical treatment of impending versus completed pathological fractures in patients with long-bone metastases in terms of (1) 90-day and 1-year survival and (2) intraoperative blood loss, perioperative blood transfusion, anesthesia time, duration of hospitalization, 30-day postoperative systemic complications, and reoperations. We retrospectively performed a matched cohort study utilizing a database of 1,064 patients who had undergone operative treatment for 462 impending and 602 completed metastatic long-bone fractures. After matching on 22 variables, including primary tumor, visceral metastases, and surgical treatment, 270 impending pathological fractures were matched to 270 completed pathological fractures. The primary outcome was assessed with the Cox proportional hazard model. The secondary outcomes were assessed with the McNemar test and the Wilcoxon signed-rank test. The 90-day survival rate did not differ between the groups (HR, 1.13 [95% CI, 0.81 to 1.56]; p = 0.48), but the 1-year survival rate was worse for completed pathological fractures (46% versus 38%) (HR, 1.28 [95% CI, 1.02 to 1.61]; p = 0.03). With regard to secondary outcomes, completed pathological fractures were associated with higher intraoperative estimated blood loss (p = 0.03), a higher rate of perioperative blood transfusions (p = 0.01), longer anesthesia time (p = 0.04), and more reoperations (OR, 2.50 [95% CI, 1.92 to 7.86]; p = 0.03); no differences were found in terms of the rate of 30-day postoperative complications or the duration of hospitalization. Patients undergoing surgery for impending pathological fractures had lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing surgery for completed pathological fractures when accounting for 22 covariates through propensity matching. Patients with an impending pathological fracture appear to benefit from prophylactic stabilization as stabilizing a completed pathological fracture seems to be associated with increased mortality, blood loss, rate of blood transfusions, duration of surgery, and reoperation risk. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Thoracoscopic Resection of Thoracic Inlet Neuroblastic Tumors in Young Children

Background: Thoracic inlet (TI) tumors are rare, and can be particularly challenging to resect due to proximity to mediastinal vessels and nerves. Traditional resection is typically performed through "trapdoor" or sternoclavicular incisions. The purpose of our study was to evaluate the feasibility and effectiveness of thoracoscopic resection of this group of tumors. Methods: We performed a single-center retrospective chart review for children who presented with TI neuroblastic tumors between 2011 and 2020. Demographics, tumor characteristics, treatment, operative complications, and outcomes were collected and analyzed. Results: Eight patients were identified. The median age at diagnosis was 13 months (interquartile range [IQR] 6-32) with median tumor size at diagnosis of 4.1 cm (IQR 3.6-4.4). Neoadjuvant chemotherapy was given in 50% (4/8) with 38% (3/8) undergoing upfront surgery; 1 patient was observed without chemotherapy or surgery. Ultimately, 6 patients had thoracoscopic resection. For thoracoscopic resections, median intraoperative estimated blood loss was 15 mL (IQR 10-28), median operative room time was 199 minutes (IQR 152-259), and median hospital length of stay was 2 days (IQR 2-3). There were two complications: one recurrent laryngeal nerve injury and one new-onset Horner's syndrome. Complete gross total resection was achieved for all children and there were no recurrences or mortalities with a median follow-up of 3 years. Conclusion: Thoracoscopic resection for TI neuroblastic tumors is feasible with minimal morbidity and can lead to adequate oncological resection.

Influence of Perioperative Antithrombic Agent Discontinuation in Elective Posterior Spinal Surgery: A Propensity-Score-Matched Analysis

To investigate the influence of perioperative antithrombotic agent (antiplatelet agents and anticoagulants) discontinuation in elective posterior spinal surgery in terms of bleeding complications, such as epidural hematoma and postoperative thromboembolism. We enrolled patients undergoing elective posterior spinal surgery at 9 hospitals between April 2017 and August 2020. We collected data regarding patient baseline characteristics, surgical details, intraoperative estimated blood loss, and postoperative complication rates, including epidural hematoma and thromboembolism. We divided the patients into a discontinuation group, in which antithrombic agents were discontinued perioperatively, and a control group without antithrombic agents. Propensity scores for taking any antithrombic agents were calculated, with 1-to-1 matching based on the estimated propensity scores to adjust for patient baseline characteristics and surgical details. Intraoperative estimated blood loss and 30-day postoperative complication rates were compared between the groups. We enrolled 9853 patients, including 1123 patients (11.4%) who discontinued antithrombic agents perioperatively. One-to-one propensity score matching yielded 1111 pairs with and without antithrombic agents. Intraoperative estimated blood loss per 10 minutes (8.2 mL vs. 8.9 mL) and the incidence of epidural hematoma requiring revision (0.97% vs. 0.72%) were similar between the groups. Although postoperative cardiac events and stroke were observed only in the discontinuation group (0.27% and 0.09%, respectively), these incidences were not significantly different between the groups. Perioperative antithrombic agent discontinuation in elective posterior spinal surgery normalized the intraoperative bleeding tendency and the incidence of postoperative epidural hematoma and did not influence in a significative way the incidence of postoperative thromboembolism.

Blood Loss and Transfusion in a Pediatric Scoliosis Surgery Cohort in the Antifibrinolytic Era.

Children and adolescents undergoing posterior spinal fusion for scoliosis experience high rates of bleeding and blood product transfusion. Antifibrinolytic therapy is one key strategy to decrease blood loss and transfusion in pediatric scoliosis surgery. Here we review 172 pediatric scoliosis patients (birth to 21 y) who underwent posterior spinal fusion at our institution from 2017 to 2018. We reported rates of blood loss and transfusion, compared patients receiving tranexamic acid to a ε-aminocaproic acid, and evaluated antifibrinolytic agent and laboratory parameters as predictors of blood loss and transfusion. Intraoperatively, 62% received tranexamic acid and 38% received ε-aminocaproic acid. Overall, blood loss (mean intraoperative estimated blood loss=14.9±9.7 mL/kg, 22% with clinically significant blood loss [>20 mL/kg], and mean calculated hemoglobin mass loss=175.9±70.1 g) and transfusion rates (15% with intraoperative allogeneic red blood cell transfusion and mean intraoperative allogeneic red blood cell transfusion volume=12.5±7.1 mL/kg) were similar to previous cohorts studying intraoperative antifibrinolytics. There was no difference in intraoperative estimated blood loss, clinically significant blood loss, calculated hemoglobin mass loss, or transfusion rates between the antifibrinolytic groups. Antifibrinolytic choice was not predictive of blood loss or transfusion. Routine hematologic laboratory parameters and antifibrinolytic choice were insufficient to predict blood loss or other outcomes. Future prospective laboratory-based studies may provide a more comprehensive model of surgical-induced coagulopathy in scoliosis surgery and provide a better tool for predicting blood loss and improving outcomes.

Comparison of Minimally Invasive Lateral Lumbar Interbody Fusion, Minimally Invasive Lateral Lumbar Interbody Fusion, and Open Posterior Lumbar Interbody Fusion in the Treatment of Single-Level Spondylolisthesis of L4-L5

To compare the outcomes of minimally invasive lateral lumbar interbody fusion (LLIF) with minimally invasive transforaminal lumbar interbody fusion (TLIF) and conventional open posterior lumbar interbody fusion (PLIF) for treating single-level spondylolisthesis at L4-L5. The patients underwent minimally invasive LLIF (n= 18), minimally invasive TLIF (n= 17), and conventional open PLIF (n= 20) for spondylolisthesis at L4-L5. Reduction of slippage, improvement in segmental lordosis, and restoration of foraminal height were measured. Perioperative parameters such as blood loss and operation time and clinical outcomes such as visual analog scale score and Oswestry Disability Index were compared. Compared with the open PLIF group, the minimally invasive LLIF group showed greater restoration of mean foraminal height, significantly smaller mean intraoperative estimated blood loss, and less mean hemoglobin reduction on the third day postoperatively. Compared with the minimally invasive TLIF group, the minimally invasive LLIF group showed greater restoration of mean segmental lordosis. The minimally invasive LLIF group showed a significantly shorter mean time to start walking after surgery compared with the conventional open PLIF and minimally invasive TLIF groups. However, compared with the minimally invasive TLIF group, the minimally invasive LLIF group showed a significantly longer mean operating time. Clinical outcomes were not statistically different among the 3 groups. In the treatment of spondylolisthesis of L4-L5, minimally invasive LLIF provided an effective surgical alternative to minimally invasive TLIF or conventional open PLIF, with the advantages of less blood loss, the faster start of postoperative walking, and comparable improvement in radiologic parameters.

Efficacy of laparoscopic-assisted pancreaticoduodenectomy in Vietnamese patients with periampullary of Vater malignancies: A single-institution prospective study

IntroductionMinimally invasive pancreaticoduodenectomy is a technically complex technique, that is being used to treat periampullary malignancy. We provide our experience with laparoscopic-assisted pancreaticoduodenectomy (LAPD) with statistics on the outcomes of periampullary cancer patients. Material and methodThirty patients underwent surgery between June 1, 2016 and May 30, 2020, with 21 undergoing classical PD and 9 undergoing pylorus-preserving pancreaticoduodenectomy (PPPD). Prospectively gathered data on surgical outcomes and long-term oncological results are given. ResultsThe median operative time was 277.5 min (range, 258.7–330 min), and the median intraoperative estimated blood loss was 319.5 mL (range, 241.2–425 mL). The rate of conversion to OPD, surgical reintervention, and mortality was 20%, 13.3%, and 10% respectively. Cumulative surgery-related morbidity was 33.4%, including bleeding (n = 4), severe POPF (n = 4), biliary fistula (n = 1), DGE (n = 2), and intestinal obstruction (n = 1). Pathologic diagnoses were AoV cancer (n = 23), distal CBD cancer (n = 4), PDAC (n = 2), and AoV NET (n = 1). The mean survival time of the LAPD group was 29.9 months. The long-term survival time of the N0 group was 36.8 months, which was significantly longer than that of the N1 group. The long-term survival times of stages I–B, II-A, and II-B were 36.9, 26.5, and 15.7 months, respectively (p = 0.016). ConclusionLAPD has a high rate of conversion to OPD, morbidity, and mortality. However, LPD is feasible technique for highly selected patients. Lymph node metastasis and stage of disease are the risk factors for long-term survival.

Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway

ObjectiveTo determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. MethodsWe compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher's Exact, and Wilcoxon rank-sum tests were used. ResultsAmong 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p = .004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p < .001) and odds (OR 3.54, 95% CI 1.61–7.76) of AKI. Within ERAS, AKI was associated with older age (median age 65 vs 57, p < .001), Charlson Comorbidity Index score ≥ 3 (71.4% vs 57.9%, p < .001), and higher intraoperative estimated blood loss (400 vs 225 mL, p < .001), fluid administration (net fluid balance +1535 vs 1261 mL, p < .001), and hypotension lasting >5 min (41.7% vs 30.7%, p < .001). ERAS patients with AKI had longer hospital stays (median 4 vs 3 days, p < .001) and more readmissions (19% vs. 10%, p < .001) and grade 3+ complications (26% vs. 7%, p < .001). ConclusionsThe incidence and odds of postoperative AKI was higher after gynecologic surgery within ERAS, and patients with AKI were more likely to have complications. Potential strategies to prevent postoperative AKI include perioperative fluid and blood pressure optimization.

201. Prospective randomized controlled trial of tranexamic acid use during elective lumbar spine surgery, preliminary results

<h3>BACKGROUND CONTEXT</h3> Current literature demonstrates that tranexamic acid (TXA) use during spine surgery is safe and effective at reducing intraoperative blood loss and need for blood transfusion. TXA use is increasing and it is now being used in both major and minor spine procedures. Literature comparing the use of topical TXA and intravenous (IV) TXA in reducing blood loss and transfusion rates in elective lumbar spine procedures is scarce. <h3>PURPOSE</h3> This study aimed to compare the efficacy of topical and IV TXA in reducing intraoperative and postoperative blood loss in adult patients undergoing elective lumbar spine surgery. <h3>STUDY DESIGN/SETTING</h3> Prospective randomized controlled trial at a single tertiary academic center. <h3>PATIENT SAMPLE</h3> This is a preliminary report on 125 prospectively enrolled patients who underwent elective decompressive lumbar laminectomy of one to four levels, with or without lumbar fusion. In total, 195 patients will be enrolled; we currently are presenting data from the 125 patients who have completed the protocol to date. <h3>OUTCOME MEASURES</h3> Primary outcomes included intraoperative estimated blood loss, perioperative change in hemoglobin / hematocrit, transfusion rates, and postoperative drain output. Secondary outcomes included operative and anesthesia time, hospital length of stay (LOS), postoperative complications including venous thromboembolism and infection, and postoperative visual analog scale (VAS) pain scores with morphine milligram equivalents (MME) per day. <h3>METHODS</h3> A total of 125 patients were randomized preoperatively into one of three treatment arms: control (n=34), topical TXA (n=35), or IV TXA (n=56). The control group received normal saline and did not receive either topical or IV TXA. The topical TXA group received 3g TXA diluted in 250ml of normal saline, which bathed the surgical site undisturbed for 2 minutes prior to wound closure. The IV TXA group received a 10 mg/kg bolus prior to incision followed by a second 10mg/kg dose three hours after the initial dose. The primary and secondary outcome measures were compared between the three groups. Descriptive, ANOVA, chi-squared, and multiple logarithmic regression analysis were utilized. <h3>RESULTS</h3> No differences were found between the control, IV TXA, and topical TXA groups in intraoperative estimated blood loss (211.2 ± 152.5ml vs 157.1 ± 119.2ml vs 175.6 ± 153ml, p=0.207), postoperative change in hematocrit (7.7 ± 2.9 vs 6.2 ± 3.2 vs 7.0 ± 2.9, p=0.176), and blood transfusion rates (2.9% vs 3.6% vs 0%, p=.5496). Patients who received IV TXA and topical TXA both had significantly less drain output on postoperative day 1 (POD1) than the control group (172 ± 98.2ml vs 72.8 ± 52.9ml vs 52.0 ± 50.0ml, p=0.0001); however, there was no difference in POD1 drain output between the IV and topical groups (p=0.089). There was a decreased risk of requiring pain medication in oral morphine equivalents in the IV and topical TXA groups compared to controls. There were no significant differences in LOS, operative and anesthesia time, pain scores, and postoperative complications. <h3>CONCLUSIONS</h3> There were significant decreases in POD1 drain output and pain medication requirements in IV and topical TXA patients, when compared to controls, in adult elective lumbar spine patients. There were no observed differences between intraoperative blood loss, postoperative change in hematocrit, or transfusion rates. There were no major TXA-related complications. <h3>FDA DEVICE/DRUG STATUS</h3> Tranexamic acid (Approved for this indication).

Comparison of transabdominal and transthoracic surgical approaches in the treatment of Siewert type II esophagogastric junction cancers: A propensity score-matching analysis

BackgroundThe appropriate surgical approach for Siewert type II esophagogastric junction (EGJ) cancer remains under discussion. We compared surgical outcomes between transabdominal (TA) and transthoracic (TT) approaches for treating type II EGJ cancers. Materials and methodsThis retrospective study reviewed 397 type II EGJ cancer patients who underwent surgery from January 2001 to May 2019. We used a 1:3 propensity score-matching method for the analysis. The matching factors were age, sex, American Society of Anesthesiologists score, period of operation, and pathologic stage. Matching was performed using the MatchIt package of R 4.0.2. ResultsA total of 46 patients in the TT group was matched to 126 patients in the TA group. R0 resection was achieved in both groups and was not statistically different between groups (p = 0.455). In the TA group, the operation time and in-hospital stay length were significantly shorter (p < 0.001) and the intraoperative estimated blood loss (EBL) was significantly lower than in the TT group (p = 0.011). The postoperative complication rate between the two groups was significantly different (p = 0.003). There was marginal difference in the five-year OS rate (p = 0.049) and significant difference in the five-year DFS (p = 0.039). However, surgical approach was not a significant prognostic factor in multivariate analysis of OS or DFS. ConclusionsThere was no clear survival benefit of one approach over the other. However, less intraoperative bleeding, lower postoperative complication rate, shorter operation time, and reduced in-hospital stay length were correlated with the TA approach.

Robotic retroauricular thyroidectomy with additional axillary port: Early personal experiences.

ObjectiveThis study aimed to analyze the usefulness of an additional axillary port in robotic retroauricular thyroidectomy by comparing the perioperative data and postoperative function between the operations with and without an additional axillary port.Materials and methodsA retrospective review of the medical records of 11 patients who underwent robotic thyroid operations using a unilateral retroauricular approach with or without an additional axillary port between 2016 and 2021 was conducted. Patient demographics, operation time, drainage amount, hospital stay, complication, postoperative cosmetic satisfaction, and postoperative neck and shoulder pain were analyzed.ResultsAmong the 11 patients who underwent robotic retroauricular thyroidectomy, an additional axillary port was used in 6 patients and not used in 5 patients. The total operation time was significantly shorter in the axillary port group (174.5 ± 23 minutes) compared to the without the axillary port group (207.6 ± 20.1 minutes) (P = .033). The intraoperative estimated blood loss (P = .525), total amount of drainage (P = .172), and postoperative hospital stays (P = .092) were not different between the 2 groups. There was no postoperative recurrent laryngeal nerve palsy, hypoparathyroidism, hematoma, seroma in the two groups. There was no significant difference for either group in the pain score and cosmetic satisfaction at 2 weeks (P = .378, P = .650) and 6 weeks (P = .242, P = .546) postoperatively.ConclusionRobotic retroauricular thyroidectomy using an additional axillary port was a novel, safe, and feasible procedure. Dissection was easy due to the availability of the fourth robotic arm to retract the thyroid gland.Level of Evidence: 4.

Suturectomies Assisted by Cranial Orthosis Remodeling for the Treatment of Craniosynostosis Can Be Performed Without an Endoscope.

Minimally-invasive endoscopic strip-craniectomy (or suturectomy) for the repair of craniosynostosis combined with postoperative cranial orthotic molding has been widely adopted in the past 2 decades, proving itself as a safe and effective procedure. Over time the authors transitioned from performing an endoscopic strip-craniectomy, to performing the same surgery without the endoscope. The authors here describe our technique and compare its results to those published in the literature for endoscopic suturectomies. A retrospective chart review was performed for patients with nonsyndromic craniosynostosis who underwent minimally-invasive nonendoscopic suturectomy between 2019 and 2020 at our institution. Thirteen patients (11 males; 2 females) were operated including 5 Metopic, 5 Sagittal, 2 coronal, and 1 lambdoid craniosynostosis. The average age at surgery was 4.35 months. The average length of surgery was 71 minutes. Averaged intraoperative estimated blood loss was 31.54 mL. Eleven patients received a blood transfusion (most before performing the skin incision) with a mean amount of 94.62 mL of blood transfused during surgery. The mean hemoglobin at discharge was 10.38 mg/dL. There was only 1 intraoperative mild complication. The mean intrahospital length of stay was 1.77 days with no postoperative complications noted. All patients initiated remodeling orthotic treatment following surgery. Long-term follow-up scans were available for 8 patients (5 metopic, 2 sagittal, and 1 lambdoid) with an average follow-up of 9 months. In all cases, there was a significant improvement in the skull width at the synostosis location as well as in the skull proportions and symmetry. The above outcomes are similar to those published in the literature for endoscope-assisted strip-craniectomies. Suturectomies assisted with cranial orthosis remodeling for the treatment of all types of nonsyndromic craniosynostosis can be performed without an endoscope while maintaining minimal-invasiveness, good surgical results, and low complication rates.

Efficacy and safety of ultrasound-guided quadratus lumborum block in patients receiving percutaneous nephrolithotomy under general anaesthesia.

The aim of this study was to explore the overall efficacy and safety of ultrasound-guided quadratus lumborum block combined with general anaesthesia in patients undergoing percutaneous nephrolithotomy (PCNL). The study included 76 patients who underwent PCNL at our hospital between October 2018 and October 2019. The patients were randomly divided into the study group (ultrasound-guided quadratus lumborum block combined with general anaesthesia, 38 cases) and the control group (general anaesthesia, 38 cases). The intra-operative estimated blood loss, operative time and intra-operative anaesthetic usage were recorded. Moreover, the effective pressing times of the posterior cerebral artery (PCA) and the dosage of sufentanil in patient-controlled intravenous analgesia (PCIA) were observed within 48hours after operation. The dosage of propofol and remifentanil, the time of intestinal exhaust recovery time and the hospital study in the study group were lower than those in the control group. The HR and MAP of the two groups, with a trend towards gradual decrease at T0 and T1, were lower than those at T0. At 2, 6, 8 and 24hours after operation, the visual analogue scale/score (VAS) of the study group was lower than that of the control group. The analgesic rescue rate, the dosage of sufentanil and the effective PCA compression times in the study group were lower than those in the control group. The total incidence of adverse reactions in postanaesthesia care unit in the study group was significantly lower than that in the control group (8/38 vs 18/38). The combination of ultrasound-guided quadratus lumborum block and general anaesthesia effectively exerts beneficial outcomes in terms of validly reducing the dose of tranquilisers and anaesthetic analgesics during PCNL, which is able to treat patients with anaesthetic mode of low opioids.

The effect of different levels of pneumoperitoneum pressures on regional cerebral oxygenation during robotic assisted laparoscopic prostatectomy

Background/aimThis study aimed to evaluate the effect of low- and high-pressure pneumoperitoneum pressures applied during robotic-assisted laparoscopic prostatectomy (RALP) using near-infrared spectroscopy (NIRS) on regional cerebral oxygenation saturation (rSO2). Materials and methodsThe prospective, comparative, and observational study included patients aged 18–80 years, with the American Society of Anesthesiologists (ASA) physical status I-II, who would undergo elective RALP. The patients were divided into two groups (12 mmHg of pneumoperitoneum pressure group, n=22 and 15 mmHg of pneumoperitoneum pressure group, n=23). Patients’ demographic data, durations of anesthesia, surgery, pneumoperitoneum, and Trendelenburg position, intraoperative estimated blood loss, fluid therapy, urine output, hemodynamic and respiratory data, and rSO2 values were recorded at regular intervals.Results The rSO2 values increased significantly during the pneumoperitoneum combined with steep Trendelenburg position (from t 3 to t 6 ) and at the end of the surgery ( t 7 ) in both groups, compared to the values 5 min after the onset of pneumoperitoneum in the supine position ( t 2 ) (P < 0.05), but no statistical significance was observed between the two groups. No cerebral desaturation was observed in any of our patients. Hemodynamic and respiratory parameters were preserved in both groups. The blood lactate levels were significantly higher in patients operated at high-pressure pneumoperitoneum, compared to those with low-pressure pneumoperitoneum (P < 0.05). Conclusion We believe that low-pressure pneumoperitoneum, especially in robotic surgeries, such as robotic-assisted laparoscopic prostatectomy (RALP), can be applied safely.

Tranexamic acid reduces blood loss in paediatric proximal femoral and/or pelvic osteotomies.

PurposeProximal femoral and/or pelvic osteotomies (PFPO) are associated with significant blood loss, which can be harmful, especially in paediatric patients. Therefore, considering methods to reduce blood loss is important. The purpose of this study was to examine the efficacy of tranexamic acid (TXA) in reducing intraoperative estimated blood loss (EBL) in paediatric patients undergoing a PFPO.MethodsPaediatric patients who had a PFPO between 2014 and 2019 were retrospectively reviewed. Outcome measures included patient demographics, TXA use (none, preoperative and/or intraoperative bolus, pump), EBL, transfusion rate and thromboembolic complications. Univariate and multivariate analyses were performed to assess associations between investigated outcome measures and EBL.ResultsA total of 340 PFPO (263 patients) were included. Mean age at surgery was 8.0 years (sd 4.3). In all, 269 patients received no TXA, 20 had a preoperative bolus, 43 had an intraoperative bolus and eight patients had other TXA regimes (preoperative and intraoperative bolus or pump). Overall, mean blood loss was 211 ml (sd 163). Multivariate analysis showed significant associations between higher EBL and higher age at surgery, male sex, higher body mass index and longer procedure time. There was a significant association between lower EBL and a preoperative TXA bolus: 66 ml (33%) less EBL compared with patients without TXA (95% confidence interval -129 to -4; p = 0.04). No thromboembolic complications were reported in any of the studied patients.ConclusionPreoperative TXA administration is associated with a decreased EBL in PFPO. No thromboembolic events were reported. Administering TXA preoperatively appears to be effective in paediatric patients undergoing a PFPO.Level of evidenceLevel III – retrospective comparative study.

An Analysis of the Risk Factors for Postoperative Complications and Their Effects on Hospital Stay in Taiwanese Geriatric Surgical Patients.

Surgical outcomes and complications in geriatric patients may be affected due to their increased number of underlying diseases. This study was conducted to evaluate the risk factors for postoperative complications and their effects on hospital stay in geriatric surgical patients (aged ≥ 80 years). A total of 404 geriatric patients (aged ≥ 80 years) who underwent noncardiac surgery were enrolled in this study. Their preoperative, perioperative, and postoperative data were collected and subjected to univariate and multivariate analyses to calculate the odds ratio of risk factors. The risk of discharge was analyzed by calculating the hazard ratio to evaluate their relationship with postoperative complications. Approximately three-fourths (76.0%) of the patients had hypertension preoperatively, and 5.9% of them developed at least one postoperative complication. Respiratory disorders were the most frequent postoperative complications. Multivariate analysis revealed emergency surgery, preoperative renal diseases, preoperative anemia, and nonextubation as risk factors for postoperative respiratory complications. Intraoperative estimated blood loss of ＞ 500 mL and intraoperative low blood pressure were identified as risk factors for postoperative neurological complications. Intraoperative hypothermia was found to be a risk factor for postoperative renal complications. Postoperative respiratory complications, postoperative neurological complications, and infection statistically significantly prolonged the length of hospital stay. The in-hospital mortality rate was 1.0%. Patients aged ≥ 80 years under certain conditions need more attention to prevent the development of different types of postoperative complications. Those who did develop postoperative respiratory complications, postoperative neurological complications, and infection might require prolonged hospitalization. Physicians must pay more attention preoperatively to the risk factors that increase postoperative complications.

Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective.

Jugular paragangliomas represent a surgical challenge due to their vascularity and proximity to vital neurovascular structures. Preoperative embolization aids in reducing intraoperative blood loss, transfusion requirements, and improves surgical visualization. Several embolization agents have been used. The aim of this study is to evaluate the safety and efficacy of PVA in pre-operative embolization of jugular paragangliomas. A retrospective review of all patients who underwent jugular paraganglioma resection with pre-operative embolization between 2000 and 2020 was performed. Pre-operative data including baseline patient and tumor characteristics were documented. Outcomes of preoperative embolization including extent of devascularization and post-embolization complications were recorded. Early and long-term postoperative outcomes were reported. Twenty-nine patients met study criteria with a median age of 38 years. Average tumor size was 3.4±1.8 cm. The most commonly encountered arterial feeder was the ascending pharyngeal artery followed by the posterior auricular artery. More than 50% reduction in tumor blush was achieved in 25 patients (86.2%). None of the patients experienced new or worsening cranial neuropathy following embolization. Gross total or Near total resection was achieved in 13 patients (44.8%). A STR or NTR was chosen in these patients to preserve cranial nerve function or large vessel integrity. Average intraoperative estimated blood loss was 888 ml, 9 patients (31%) required intra-operative transfusion of blood products. Extent of resection and post-operative complications did not correlate with extent of devascularization. Pre-operative embolization of jugular paraganglioma tumors with PVA particles is an effective strategy with a high safety profile.

Robotic Surgery in Rectal Cancer

AbstractRectal cancer is an important cause of morbidity and mortality worldwide. The most effective and curative treatment is surgery, and the standard procedure is total mesorectal excision, initially performed by open surgery and posteriorly by minimally invasive techniques. Robotic surgery is an emerging technology that is expected to overcome the limitations of the laparoscopic approach. It has several advantages, including a stable camera platform with high definition three-dimensional image, flexible instruments with seven degrees of freedom, a third arm for fixed retraction, fine motion scaling, excellent dexterity, ambidextrous capability, elimination of physiological tremors and better ergonomics, that facilitate a steady and precise tissue dissection. The main technical disadvantages are the loss of tactile sensation and tensile feedback and the complex installation process. The aim of the present study is to review the importance and benefits of robotic surgery in rectal cancer, particularly in comparison with the laparoscopic approach. Intraoperative estimated blood loss, short and long-term outcomes as well as pathological outcomes were similar between robotic and laparoscopic surgery. The operative time is usually longer in robotic surgery and the high costs are still its major drawback. Robotic surgery for rectal cancer demonstrated lower conversion rate to open surgery and benefits in urinary and sexual functions and has been established as a safe and feasible technique.

The effect of high intraoperative blood loss on pancreatic fistula development after pancreatoduodenectomy: An international, multi-institutional propensity score matched analysis

BackgroundThe association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. MethodsIn total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003–2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated blood loss and clinically relevant pancreatic fistula occurrence. The study was powered to detect a 33% clinically relevant pancreatic fistula increase in the high estimated blood loss group, with α = 0.05 and β = 0.2. ResultsThe propensity score model included 966 patients with high estimated blood loss and 966 patients with lower estimated blood loss; all covariate imbalantces were solved. Patients with high estimated blood loss patients experienced higher clinically relevant pancreatic fistula rates (19.4 vs 12.6%, odds ratio 1.66; P < .001), as well as higher severe complication rates (27.8 vs 15.6%), transfusions (50.1 vs 14.3%), reoperations (9.2 vs 4.0%), intensive care unit transfers (9.9 vs 4.8%) and 90-day mortality (4.7 vs 2.0%, all P < .001). High estimated blood loss was an independent predictor for clinically relevant pancreatic fistula (odds ratio 1.78, 95% confidence interval 1.37–2.32), as were prophylactic Octreotide administration (odds ratio 1.95, 95% confidence interval 1.46–2.61) and soft pancreatic texture (odds ratio 5.32, 95% confidence interval 3.74–5.57; all P < .001). Moreover, a second model including 1,126 pancreatoduodenectomies was derived including vascular resections as additional confounder (14.0% vascular resections performed in each group). On multivariable regression, high estimated blood loss was confirmed an independent predictor for clinically relevant pancreatic fistula reduction (odds ratio 1.80, 95% confidence interval 1.32–2.44; P < .001), whereas vascular resection was not (odds ratio 0.64, 95% confidence interval 0.34–1.88; P = .156). ConclusionThis study better establishes the relationship between estimated blood loss and outcomes after pancreatoduodenectomy. Despite inherent contributions to blood loss, its minimization is an actionable opportunity for clinically relevant pancreatic fistula reduction and performance optimization in pancreatoduodenectomy. Accordingly, practical insights are offered to achieve this goal.

Application of the surgical Apgar score (SAS) to predict postoperative complication(s) in the patients with traumatic brain injury: Study of single center in Indonesia

BACKGROUND: Traumatic brain injury (TBI) is a major health problem. Surgery in patients with TBI is associated with a high rate of complications and mortality. The surgical Apgar score (SAS) is a simple quantitative and objective intraoperative tool for predicting major post-operative complications including mortality. AIM: Our study aimed to analyze the use of SAS as a predictor of post-operative complications in patients with TBI. METHODS: This was a prospective cohort study at our center in RSHS, Bandung, Indonesia, throughout 2017 by assessing SAS based on calculating intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate for each patient with TBI, as well as the incident complications within 30 days post-operative were recorded. RESULTS: One hundred fifty-six patients with TBI underwent surgery in 2017 with 123 patients met the inclusion criteria. Among those, 63 patients (51.2%) developed major complications with 8 patients (12.7%) experienced death. The mean SAS for patients without complication was 8.20, whereas for patients with complication was 6.11. SAS has an inverse correlation (r = –0.754) and an association (p &lt; 0.005) with post-operative complication (s) within 30 days. CONCLUSIONS: The SAS has an inverse correlation and an association with incidence of complications thus potentially useful as an intraoperative predictor for incident complications within 30 days post-operative care in patients with TBI.