Extensive Blood Loss Research Articles

Technique of Aortic Replacement Through Endovascular Stenting Before Aortic Wall Resection for Primary Leiomyosarcoma of the Abdominal Aorta

Tumors involving the aorta represent a challenging situation because the surgical approach can lead to blood loss and/or clamping-related complications such as ischemia, thrombosis, or reperfusion syndromes. We describe the technique of aortic endograft placement to cover part of the abdominal aorta and provide conditions for extensive aortic wall resection, without clamping or blood loss, followed immediately by aortic reconstruction with bovine pericardium. This technique also allows the surgeon to wait for the results of freeze biopsy without additional clamping time, thus avoiding the risk of leaving residual tumor cells in the aortic wall.

Critical haemoglobine at patients with perioperative extensive blood loss

Zaporozhye State Medical University, Department of Anaesthesiology and Intensive Care, Zaporozhye, Ukraine

Fatal exsanguination from hemodialysis vascular access sites

Exsanguination from hemodialysis vascular sites may cause a rapid death. Due to extensive blood loss at the scene, investigators may initially suspect a homicide or suicide. We reviewed 100 deaths due to hemorrhage from hemodialysis shunt sites. The majority (81%) of these hemorrhages occurred at home and 44% subsequently died at home. Recognition of this medical complication at the scene is important to prevent the dispatch of the crime scene or homicide unit. In these instances, the common causes of kidney failure included hypertensive cardiovascular disease and diabetes mellitus. The manners of death were certified as therapeutic complication (93%), accident (5%), and suicide (2%). These fatal shunt hemorrhages are rapid and large due to their superficial subcutaneous locations and elevated shunt pressures from the arterial-venous anastamosis. The cause of death statement must include the proximate cause of death, which is usually the disease that resulted in kidney failure, if it is known.

A comparison of percutaneous reduction and screw fixation versus open reduction and plate fixation of traumatic symphysis pubis diastasis

Plate fixation, the conventional treatment for traumatic symphysis pubis diastasis, carries the risk of extensive exposure, blood loss and postoperative infections. Percutaneous screw fixation is a minimally invasive treatment. The goal of the present study was to compare the outcome of plate fixation and percutaneous screw technique in the treatment of traumatic pubic symphysis diastasis. Ninety patients with traumatic symphysis pubis diastasis were treated from January 2003 to December 2009 at two level 1 regional trauma centers. The mean time of follow-up was 21 months (18 to 26). Forty-five patients were treated by percutaneous screw fixation. Forty-five patients were treated by plate and screws fixation. The demographic, distribution of fracture patterns, blood loss, incision length, fixation failure, malunion, revision surgery and functional scores were compared. Seven cases were lost during follow-up. Demographics (age and gender), fracture classification and Injury Severity Score were comparable in the two groups (P > 0.05). Blood loss and extensive exposure were much less in screw group (P < 0.01). Patients in screw group achieved better functional performance (P = 0.01). There were no significant differences favoring plate fixation in reduction quality (P = 0.32), implant failure (P = 0.39), malunion (P = 0.15), revision surgery rates (P = 0.27), percentage of impotence in the male patients (P = 0.2) and implant removal time (P = 0.12) between the two groups. Our results indicate that besides lower rate of iatrogenic injuries and better functional outcome, percutaneous screw fixation of the pubic symphysis is as strong as plate fixation.

Efficacy of Tranexamic Acid in Pediatric Craniosynostosis Surgery

Background: Extensive blood loss is common in pediatric craniosynostosis reconstruction surgery. Tranexamic acid (TXA) is increasingly used to reduce perioperative blood loss in various settings, but data on its efficacy are limited in children. The purpose of this randomized, double-blind, placebo-controlled, parallel trial was to evaluate the efficacy of TXA in pediatric craniosynostosis correction surgery. The primary and secondary outcome variables were reduction in perioperative blood loss and reduction in blood transfusion, respectively. Methods: Forty-three children, ages 2 months to 6 yr, received either placebo or TXA in a loading dose of 50 mg·kg ―1 , followed by an infusion of 5 mg·kg ―1 ·h ―1 during surgery. TXA plasma concentrations were measured. Results: The TXA group had significantly lower perioperative mean blood loss (65 vs. 119 ml·kg ―1 , P < 0.001) and lower perioperative mean blood transfusion (33 vs. 56 ml· kg ―1 , P = 0.006) compared to the placebo group. The mean difference between the TXA and placebo groups for total blood loss was 54 ml·kg ―1 (95% CI for the difference, 23-84 ml·kg ―1 ) and for packed erythrocytes transfused was 23 ml·kg ―1 (95% CI for the difference, 7-39 ml·kg ―1 ). TXA administration also significantly diminished (by two thirds) the perioperative exposure of patients to transfused blood (median, 1 unit vs. 3 units; P < 0.001). TXA plasma concentrations were maintained above the in vitro thresholds reported for inhibition of fibrinolysis (10 μg·ml ―1 ) and plasmin-induced platelet activation (16 μg·ml ―1 ) throughout the infusion. Conclusions: TXA is effective in reducing perioperative blood loss and transfusion requirement in children undergoing craniosynostosis reconstruction surgery.

In vivo multispectral photoacoustic and photothermal flow cytometry with multicolor dyes: A potential for real‐time assessment of circulation, dye‐cell interaction, and blood volume

Recently, photoacoustic (PA) flow cytometry (PAFC) has been developed for in vivo detection of circulating tumor cells and bacteria targeted by nanoparticles. Here, we propose multispectral PAFC with multiple dyes having distinctive absorption spectra as multicolor PA contrast agents. As a first step of our proof-of-concept, we characterized high-speed PAFC capability to monitor the clearance of three dyes (Indocyanine Green [ICG], Methylene Blue [MB], and Trypan Blue [TB]) in an animal model in vivo and in real time. We observed strong dynamic PA signal fluctuations, which can be associated with interactions of dyes with circulating blood cells and plasma proteins. PAFC demonstrated enumeration of circulating red and white blood cells labeled with ICG and MB, respectively, and detection of rare dead cells uptaking TB directly in bloodstream. The possibility for accurate measurements of various dye concentrations including Crystal Violet and Brilliant Green were verified in vitro using complementary to PAFC photothermal (PT) technique and spectrophotometry under batch and flow conditions. We further analyze the potential of integrated PAFC/PT spectroscopy with multiple dyes for rapid and accurate measurements of circulating blood volume without a priori information on hemoglobin content, which is impossible with existing optical techniques. This is important in many medical conditions including surgery and trauma with extensive blood loss, rapid fluid administration, and transfusion of red blood cells. The potential for developing a robust clinical PAFC prototype that is safe for human, and its applications for studying the liver function are further highlighted.

Is postoperative intensive care unit admission a prerequisite for elective craniotomy?

Routine postoperative admission to the intensive care unit (ICU) is often considered a necessity in the treatment of patients following elective craniotomy but may strain already limited resources and is of unproven benefit. In this study the authors investigated whether routine postoperative admission to a regular stepdown ward is a safe alternative. Three hundred ninety-four consecutive patients who had undergone elective craniotomy over 54 months at a single institution were retrospectively analyzed. Indications for craniotomy included tumor (257 patients) and transsphenoidal (63 patients), vascular (31 patients), ventriculostomy (22 patients), developmental (13 patients), and base of skull conditions (8 patients). Recorded data included age, operation, reason for ICU admission, medical emergency team (MET) calls, in-hospital mortality, and postoperative duration of stay. Three hundred forty-three patients were admitted to the regular ward after elective craniotomy, whereas there were 43 planned and 8 unplanned ICU admissions. The most common reasons for planned ICU admissions were anticipated lengthy operations (42%) and anesthetic risks (40%); causes for unplanned ICU admissions were mainly unexpected slow neurological recovery and extensive intraoperative blood loss. Of the 343 regular ward admissions, 10 (3%) required a MET call; only 3 of these MET calls occurred within the first 48 postoperative hours and did not lead to an ICU admission. The overall mortality rate in the investigated cohort was 1%, with no fatalities in patients admitted to the normal ward postoperatively. Routine ward admission for patients undergoing elective craniotomies with selective ICU admission appears safe; however, approximately 2% of patients may require a direct postoperative unplanned ICU admission. Patients with anticipated long operation times, extensive blood loss, and high anesthetic risks should be selected for postoperative ICU admission, but further study is needed to determine the preoperative factors that can aid in identifying and caring for these groups of patients.

MIS Issue of Techniques in Orthopedics

Minimally invasive spine surgery is a combination of both philosophy and practice. Over the past decade, it has become increasing popular in the field of spinal surgery. Practioners of this burgeoning field theorize that the preservation of the soft tissue envelope surrounding the spine during surgery may lower the morbidity of the surgical approach and may ultimately improve short and long-term outcomes after spinal procedures. Today, the evolving demands of our fractionated heath care system in the United States has evoked greater attention toward safer, more efficacious, and cost-effective treatments regarding patient care. Similarly, patients and practioners have higher expectations of clinical outcomes with a correspondingly lower interest in surgical and postoperative morbidity and complications. Negative postoperative sequelae may exist pertaining to the spinal patient in the immediate perioperative/postoperative period, and in the long-term follow-up period. Short-term issues include prolonged operative procedures, extensive blood loss, and postoperative pain, which may all lead to extended hospital stays. Longer term sequelae include chronic pain that has been attributed to postlaminectomy syndrome, adjacent segment degeneration, and “failed back” syndrome. These issues continue to confound practitioners, and have negative consequences for patient outcomes. Thus, with the potential to diminish the sequelae of more traditional surgical approaches, less invasive approaches and techniques for the treatment of various spinal conditions have emerged. Surgical techniques have evolved along with advances in operative technology, thus allowing the spinal surgeon the ability to access the spine and perform complicated procedures in a relatively less traumatic fashion as compared with traditional “open” procedures. Data has shown that minimally invasive approaches to the spine decreases the amount of trauma imparted to tissue, reduces operative blood loss, shortens hospital stay, and decreases postoperative pain. In the most experienced hands, this approach to spine surgery decreases the operative time as well. All of these factors have contributed to the popularity of this approach to the spine, as both patients and practitioners have a shared interest in improved outcomes. In the interest of expanding upon the rapidly evolving field of minimally invasive spinal techniques, we have assembled a group of experts in the field of this niche of spinal surgery to write about specific techniques, indications, and technologies that have continued to propel the study of this topic forward. These specialists have a shared interested in progressing the field of spine surgery toward innovation, safety, and improved patient outcomes. The emphasis on surgical technique and preparation, along with other pearls and pitfalls of each procedure, illustrate the high level of expertise needed to perform these technically demanding cases. To assemble this group of spinal surgeons, among them being leaders in the field, has been both a great honor and privilege. Our collective hopes are that this work will train and educate future spinal surgeons and patients about the innovative ways to treat spinal conditions. Also, we hope that in the future the work done today will serve as a platform for even greater advances in technology, the surgical treatment of spinal disorders, and even greater strides toward patient care and safety.

Risks for peroperative excessive blood loss in cesarean delivery

To analyze risk factors for peroperative excessive blood loss at cesarean delivery. Case-control study. Twenty-four of 26 maternity units in Norway with at least 500 expected deliveries per year. A total of 2,778 women having singleton deliveries and participating in the Norwegian Breakthrough Project on Cesarean Section. Elective and emergency operations were analyzed separately with extensive blood loss defined as hemorrhage > 1000 ml with controls defined as bleeding < 500 ml. All analyzes were done in SPSS (version 16.0) with chi-squared tests and logistic regression. Adjusted odds ratios (aOR) of extensive peroperative bleeding. The prevalence of excessive blood loss differed between women undergoing elective (2.1%) and emergency cesarean deliveries (3.3%). Among maternal factors, chronic maternal diseases, pregnancy and delivery related conditions, placenta previa (aOR 19.7; 95% CI 5.4-72.2) and transverse lie (aOR 4.9; 95% CI 0.9-26.5) were the only risk factors for extensive blood loss in elective operations, whereas placenta previa (aOR 8.4; 95% CI 2.4-29.9), placental abruption (aOR 2.0; 95% CI 2.0-14.5), intervention at full cervical dilation (aOR 3.2; 95% CI 1.4-7.1) and high BMI (aOR 3.4; 95% CI 1.6-7.2) were risks in emergency operations. The different risk pattern for excessive bleeding in cesarean deliveries should be recognized when planning available obstetric competence for surgery.

Wounded warriors' perspectives: Helping others to heal

[ILLUSTRATION OMITTED] They have walked the walk and paid the price. A very high price. They are veterans who sustained major limb loss during the Vietnam or Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts. Their names are Juan Arredondo, Ned Foote, and Jonathan Pruden. All three have adapted to their limb loss, but daily struggles still exist for them, as well as for others who have moved on with their postmilitary lives. Jonathan Pruden and Juan Arredondo served during a different military era (OIF/OEF) than did Ned Foote (Vietnam); but despite the differences in age, the three men share a common goal, a common passion: to see that all wounded servicemembers receive the best possible care through a supportive rehabilitation process and a smooth transition from Active Duty into the Veterans Healthcare System and, especially, to receive comprehensive prosthetic care services and other benefits they deserve. Their mission now is to help other wounded warriors navigate through the recovery process and restore a satisfying lifestyle. As active volunteers in national programs that assist fellow wounded warriors, they were invited to participate in the Expert Panel meeting, convened in Seattle, Washington, in 2008, to examine rehabilitation care issues and prosthetic device challenges for the study described in this issue of the JRRD. In addition, they participated in a joint interview to discuss their experience through the recovery process and share valuable lessons learned on how best to adapt to limb We hope their stories will provide guidance and inspiration to others with disabilities. THE BATTLEFIELD INJURY Ned Foote was drafted into the U.S. Marine Corps and was sent to Vietnam in 1969 with the 3rd Marine Division as an infantryman. While Foote was on patrol in the demilitarized zone, a mine was detonated during an ambush, killing two and injuring Foote and six others. His severely injured foot was later amputated on a hospital ship. He was sent to Guam for further surgery. As a result of infections and other complications, his amputation was later revised to above the knee. He returned home to New York to continue his medical rehabilitation, including physical therapy and fitting and training for his prosthetic device at the Department of Veterans Affairs (VA), Veterans Health Administration. Juan Arredondo, a U.S. Army sergeant in the 2nd Infantry Division, was driving on patrol in Iraq with two other servicemembers in 2006. A cellular phone-detonated device exploded through the door of their vehicle, seriously injuring all three men. The explosion instantly severed Arredondo's left hand below the elbow and inflicted extensive damage to his legs. Although the injuries to his legs were not life-threatening, his severed hand could not be reattached. He was sent to Brooke Army Medical Center in San Antonio, Texas, to begin his recovery process. Jonathan Pruden, a lieutenant in the U.S. Army serving in Iraq in 2003, was wounded on July 1, 2003, becoming one of the first improvised explosive device casualties of OIF. He was hit with 173 pieces of shrapnel and 1 bullet. After initial surgeries in Iraq, he was medevaced to Landstuhl Regional Medical Center in Germany for additional surgeries and then transported to Walter Reed Army Medical Center (WRAMC). Arriving at WRAMC was the first step in his recovery. Over 3 years at seven different military hospitals, he had 20 surgeries, including the amputation of his right leg. Pruden, now a retired captain, recalls his many surgeries and long rehabilitation process with a positive light: I would have died even 20 years ago due to the extensive injuries and blood loss. STEPS TO RECOVERY During the Vietnam conflict, nearly 25 percent of wounded servicemembers succumbed to their injuries, largely because of the inability to reach mobile surgical hospitals [1]. With improvements in protective gear, Kevlar vests, and rapid medical evacuation to medical or surgery units, nearly 90 percent of servicemembers wounded during the OIF/OEF conflicts survive [2]. …

Early transfusion and crystalloid infusion strategy in infants undergoing cranioplasty surgery

IR—Cranioplasty for craniosynostosis is a procedure associated with large incision of the vascular scalp and resection of the bone (1). This represents major surgery for young infants that have small blood volumes. The extensive blood loss requires transfusion of packed red cells in most patients (2). The exact determination of blood loss and fluid deficit in these procedures may be difficult because the absolute amount of shed blood is small although relatively high for the patient itself. Furthermore, 20–50% of the patient’s blood volume may be lost in less than 30 min (3). Transfusion strategies currently developed are based on the acceptance of intraoperative level of hemoglobin (Hb) of 7 gAEdl )1 and hemodilution [hematocrit (Hct) lower than 30] in absence of hemodynamic instability. We wish to describe our retrospective clinical study investigating the effectiveness of a preemptive transfusion

The Kocher-Langenbeck Approach: Differences in Outcome of Transverse Acetabular Fractures Depending on the Patient's Position.

The Kocher-Langenbeck approach is most frequently used for open reduction and internal fixation of transverse acetabular fractures, the positioning of the patient still falling to the preference of the surgeon. The impact of 'prone' and 'lateral' positioning on radiographic outcome and postoperative complication rates was evaluated by this retrospective study. Between 2002 and 2007, 27 consecutive cases of transverse acetabular fractures were treated randomly by four attending surgeons at a Level I trauma center, 18 done in a lateral and nine in a prone position, with no significant difference in age and pre- and intraoperative parameters; no patients were excluded. The complication rate was analyzed by medical records. After an average of 9 months postoperatively, the radiographic outcome was evaluated by plain X-rays and computed tomography (CT) scans using the Matta system, the Epstein classification, and the Brooker grades. Post-traumatic arthrosis and avascular necrosis of the femoral head were documented. We found a significantly poorer quality of fracture reduction (p = 0.032) and higher rate of posttraumatic arthrosis (p = 0.049) for patients who were operated for transverse acetabular fracture in the lateral versus the prone position. No revision surgery was needed; no infection was detected overall, whereas two iatrogenic nerve damages (one temporary, one persistent) were found only in the lateral group. There was no significant difference concerning extensive blood loss, femoral head necrosis, Epstein grades, heterotopic ossification, and secondary surgery needed. The weight of the leg may make reduction more difficult in the lateral position, leading to a poorer radiographic outcome.

Prevalence and Risk Factors Predisposing to Coagulopathy in Patients Receiving Epidural Analgesia for Hepatic Surgery

Patients undergoing liver resection may have marginal preoperative liver function, extensive intraoperative blood loss, and perioperative hepatic dysfunction. We evaluated the prevalence and types of coagulopathic conditions that occur in patients with epidural catheters undergoing hepatic resection. A retrospective chart review was conducted of all patients undergoing hepatic surgery who received epidural analgesia between June 1995 and September 2003 at our institution. Forty-nine surgical cases had an epidural catheter placed preoperatively. Data were collected included age, weight, American Society of Anesthesiologists physical status; preoperative partial thromboplastin time (PTT), international normalized ratio (INR), and platelet count (PLT); estimated blood loss (EBL); and volume of hepatic resection. Forty-nine cases received an epidural catheter before hepatic resection. Preoperative PTT, INR, and PLTs were within reference ranges in 47 of 49 patients. Twenty-three (47%) of 49 patients were coagulopathic in the postoperative period. The most common abnormality was an INR greater than 1.4 in 16 patients. Nine patients had a PLT of less than 100,000/microL, and 4 patients had a PTT of greater than 40 secs. Patients who developed a hemostatic abnormality were likely to have greater median EBL (400 vs 1400 mL; Mann-Whitney = 100.5, P = 0.0004) and have a greater median volume of liver resected (166 vs 1688 cm; Mann-Whitney = 57.0, P = 0.0004). There was no causal relationship to preoperative laboratory values, age, weight, or American Society of Anesthesiologists classification. A high prevalence of hemostatic abnormalities in patients undergoing major hepatic resection while receiving epidural analgesia occurred. Important considerations may include discussion with the surgical team, measuring coagulation, and heightened clinical monitoring in the postoperative period.

Thromboelastometry-guided administration of fibrinogen concentrate for the treatment of excessive intraoperative bleeding in thoracoabdominal aortic aneurysm surgery

Thoracoabdominal aortic aneurysm operations are associated with extensive blood loss and high requirements for allogeneic blood product transfusion. We assessed the efficacy of intraoperative post-cardiopulmonary bypass administration of fibrinogen concentrate in elective thoracoabdominal aortic aneurysm surgery. In a retrospective group (group A, n = 12) of patients undergoing elective thoracoabdominal aortic aneurysm surgery, clinically relevant diffuse bleeding after weaning from cardiopulmonary bypass was treated with allogeneic blood products (platelet concentrates, followed by fresh frozen plasma) according to a predetermined algorithm. In a prospective group (group F, n = 6) a first therapy step with fibrinogen concentrate was added to the algorithm. The dose of fibrinogen concentrate was estimated by using thromboelastometric data (ROTEM FIBTEM). Before each step of hemostatic therapy, blood loss in the range of 60 to 250 g per 5 minutes was confirmed. In group F, administration of 7.8 +/- 2.7 g of fibrinogen concentrate established hemostasis, completely avoiding intraoperative transfusion of fresh frozen plasma and platelet concentrates. Transfusion of blood products after cardiopulmonary bypass and during the 24 hours after surgical intervention was markedly lower in group F than in group A (2.5 vs 16.4 units; 4/6 patients in group F required no transfusion of blood products), as was 24-hour drainage volume (449 vs 1092 mL). Fibrinogen plasma levels, standard coagulation parameters, and hemoglobin and hematocrit values were comparable between the 2 groups on the first postoperative day. FIBTEM-guided post-cardiopulmonary bypass administration of fibrinogen concentrate resulted in improved intraoperative management of coagulopathic bleeding in thoracoabdominal aortic aneurysm operations and reduced transfusion and 24-hour drainage volume.

Hybrid Approach for Treatment of Behind the Knee Popliteal Artery Aneurysms

We describe herein a combined approach to the treatment of popliteal artery aneurysms (PAA) that averts extensive dissections and potential blood loss particularly in cases of behind-the-knee aneurysms. Over the last 4 years, 13 patients (12 males) with mean age of 75 +/- 8 years were treated for PAAs at our institution with a combined surgical and endovascular approach. The mean size of popliteal aneurysms was 2.9 cm +/- 1.7 cm. One of the 13 cases (8%) was performed for acute ischemia and an additional 5 (38%) for claudication. All operations were performed under general anesthesia in supine position. Vein conduits (eight ipsilateral great saphenous veins, two contralateral great saphenous veins and one arm vein) were utilized for 11 bypasses. Of these, eight were from superficial femoral artery (SFA) to below the knee popliteal artery, two popliteal to popliteal and one SFA to posterior tibial artery. In addition, two expanded polytetrafluoroethylene femoral popliteal bypasses were performed. The distal anastomosis was performed after the popliteal artery was ligated distal to the aneurysm. Next, coil embolization of the aneurysmal sac was performed under fluoroscopic or ultrasound guidance. Coils were embolized through a 5F sheath. Lastly, the popliteal artery was ligated distal to the proximal anastomosis. Completion studies were obtained with duplex in six cases and arteriography in the remaining five cases. Mean follow-up was 11.6 months +/- 9.6. One bypass occluded in 2 months after surgery. One patient demonstrated continued growth of his aneurysm despite coil embolization twice and underwent an open ligation of the branches perfusing the aneurysm from within the sac through a posterior approach. This approach may be particularly useful for PAAs located behind the knee where optimal surgical exposure is often difficult and the collateral circulation is abundant. The proposed technique is simple, effective and averts extensive dissections required to minimize blood loss.

Risk factors for mortality and morbidity related to radical cystectomy

To evaluate the risk factors for mortality and morbidity related to radical cystectomy (RC) in a medium-sized academic centre, and to analyse the rate and trends of perioperative morbidity and mortality, as although complications related RC to are lower in modern than historic series, RC is still associated with marked risks. The study included 258 patients undergoing RC for bladder cancer in Turku University Hospital in 1986-2005. Basic patient characteristics and in-hospital, early (from hospital discharge to 3 months) and combined morbidity and mortality were analysed. Risk analysis included 16 risk factors for complications. Trends were analysed by comparing the two study decades (1986-1995 vs 1996-2005). The total complication rate was 34%, with minor and major complications in 26%, and 11% of patients, respectively. There were no significant changes in total morbidity, but the number of myocardial infarctions and atrial fibrillations decreased significantly (P = 0.045). Operative mortality was 2.7%, with an insignificant decrease (4.2% to 0.9%, P = 0.11) over time. Salvage RC, high American Society of Anesthesiologists (ASA) score (> or = 3), extensive blood loss (>3 L), a high number of transfusions (five or more), several comorbidities (two or more), age (> or = 65 vs <65 years), and extravesical tumours were significant risk factors for major complications. An ASA score of > or = 3 and five or more transfusions were the only factors associated with mortality. A high ASA score (odds ration 3.25, 95% confidence interval 1.08-9.74) and high number of transfusions (2.74, 1.05-7.15) were independent risk factors for major complications. Although RC is associated with acceptable morbidity, attention should be given to risk factors identified at the time of patient selection, and to meticulous haemostasis at the time of surgery. A predictable outcome comparable to that in high-volume centres is also possible in a medium-sized hospital.

Acute perioperative normovolaemic haemodilution in major maxillofacial surgery

Extensive blood loss can occur when patients have major operations for head and neck neoplasia. The risks and costs of allogeneic blood transfusion have been well documented. Acute perioperative normovolaemic haemodilution (APNH) is a method of saving blood and autologous transfusion. The purpose of this study was to compare a group of patients having major head and neck operations who had APNH, with a historical group, to assess the need for allogeneic transfusion. Of the 21 patients who had APNH only one patient required allogeneic blood. In the historical group of 24 patients, 15 patients had required allogeneic blood (p = 0.0001). APNH is an economic, safe and practical way of saving blood.

Comparing the Ultrasonically Activated Scalpel (Harmonic) with High-Frequency Electrocautery for Postoperative Serous Drainage in Massive Weight Loss Surgery

Sir: Ultrasonic dissection using the Harmonic scalpel has recently emerged as a safe and reliable alternative to high-frequency electrocautery. The Harmonic ultracision scalpel and scissor has been used successfully by surgeons in laparoscopic and open surgical procedures, including cholecystectomy and breast cancer dissections.1–4 The aim of this prospective, single-blinded, two-arm study was to investigate the clinical merits of the ultrasonic scalpel (Harmonic) versus high-frequency electrocautery in body lift operations with regard to postoperative serous drainage time and volume. Lower body lift procedures without simultaneous tightening of the medial aspect of the thigh were carried out in 20 patients with two treatment arms. Tissue dissection and resection were performed using the ultrasonic scalpel (Harmonic) on one side (treatment arm 1, n = 20) and electrocautery on the other (treatment arm 2, n = 20). All operations were performed by the senior author (D.F.R.). Drainage days (i.e., number of days until drain removal) and total drainage (i.e., postoperative wound secretion via the individual drains) were assessed as primary endpoints. In addition, operative time (from first skin incision until last skin suture), postoperative complications, and the difference in preoperative and postoperative thigh circumference were recorded; the pain score (per day) was measured using a 10-point visual analog scale, with 0 = no pain and 10 = the worst imaginable pain (secondary endpoints). Student t tests for independent samples were used for inferential statistical analysis. Total serous drainage volume was significantly lower in the Harmonic scalpel group (891.67 ± 392.09 ml) compared with the electrocautery group (1414.38 ± 656.90 ml) (p = 0.007). Similarly, the number of drainage days was significantly lower in the Harmonic scalpel group (5.35 ± 1.14 days, compared with 7.04 ± 1.92 days for electrocautery; p = 0.002). Patients in the Harmonic scalpel group reported lower pain intensity scores (mean score ± SD for postoperative days 1 through 15, 1.84 ± 0.58, compared with 2.44 ± 0.71 for electrocautery; p = 0.011). The incidence of complication was assessed for each side of the body. On the electrocautery side, seroma formation was observed in five patients (25 percent) and treated by aspiration [Harmonic side, two patients (10 percent)]. Two of these five patients presented with bilateral seroma formation in the area of the lateral thigh, and the other three patients showed a unilateral mass formation that required treatment by aspiration. No patient had postoperative bleeding, but one patient (5 percent) required a postoperative blood transfusion due to extensive intraoperative blood loss that included both the electrocautery and Harmonic sides. Three patients (15 percent) had delayed wound healing due to local wound infections that involved both sides. No wound necrosis requiring treatment was assessed in this study. The Harmonic scalpel allows for safe and efficient tissue dissection in massive weight loss procedures. In addition, the results show that use of the Harmonic scalpel in tissue dissection significantly reduces the postoperative serous drainage time and volume as well as postoperative pain in comparison with electrocautery, with increased patient comfort postoperatively. DISCLOSURES Drs. Reichenberger and Stoff have no financial interest in any of the products, devices, or drugs mentioned in this article. Dr. Richter has a consulting agreement with Ethicon. Alexander Stoff, M.D. Matthias A. Reichenberger, M.D. Dirk F. Richter, M.D. Department of Plastic and Reconstructive Surgery Dreifaltigkeits Hospital Wesseling, Germany

Le kyste osseux anévrismal primitif : quoi de neuf en 2006 ?: Aneurysmal bone cyst in 2006

The etiology of aneurysmal bone cyst is probably multifactorial. Recent progress in genetics and immunohistochemistry tends to prove that aneurysmal bone cyst is tumor and not a pseudo-tumor. Involvement of chromosomes 17p11-13 or 16q22 has been described. MRI is indispensable. Signs highly suggestive of aneurysmal bone cyst are: well-limited expansive bone lesion, low intensity T1 signal associated with high intensity T2 signal (liquid component), a low intensity peripheral line with enhancement after contrast injection, septal partitioning and fluid levels. Gadolinium injection is informative since it demonstrates the thick regular septal partitioning and the amorphous contents (lack of contrast uptake), a structure which is not seen in any other tumors, particularly malignant tumors. Plain x-ray and MRI contribute well to diagnosis but histological confirmation is always required. The debate on Ethibloc ® remains open. For certain authors, this technique is an effective safe treatment which can be proposed as a first-line option. Ethibloc ® should however be reserved for specialized teams because of the serious complications reported in the literature. A new treatment has also been reported to be promising, but further results will be required for confirmation. With this technique demineralized allogenic bone particles associated with autologous bone marrow are implanted in the cyst to achieve an osteogenic effect. This induces the cyst to pass from the destructive resorption phase to the repairing osteogenic phase. Curettage is not necessary. This method, which avoids extensive surgery and blood loss, is well adapted to difficult localizations such as the pelvis.

Extensive bleeding during surgical treatment for gingival overgrowth in a patient on haemodialysis — A case report and review of the literature

Before performing renal transplantation, a most important concern is to control any infection, including oral infections before transplantation. The bleeding diathesis of patients with uraemia is a significant clinical concern, especially when surgery is required. A 44-year-old female patient on haemodialysis was referred for evaluation of gingival overgrowth. The patient was planning a renal transplantation two months later. As the lesions were not considered successfully treatable before transplantation, a gingivectomy and teeth extraction was performed. In pre-operative examinations, an abnormal bleeding time was not detected and other coagulation tests were normal. Under general anaesthesia, 19 teeth were extracted and overgrown gingiva was removed. During the operation, extensive blood loss of 1650ml occurred and four units of concentrated red blood cells were transfused. This study suggests that patients with renal failure undergoing dental surgery require careful pre-surgical evaluation including assessment of their coagulation ability.