Greater Intraoperative Blood Loss Research Articles

Preoperative factors predicting the need for additional ports during single‐incision laparoscopic cholecystectomy

Single-incision laparoscopic cholecystectomy (SILC) is gaining popularity as a minimally invasive technique that provides some benefits in terms of improved cosmesis. However, the insertion of an additional port is required in a subset of cases. We retrospectively analyzed 308 SILC procedures in patients with benign gallbladder diseases, except acute cholecystitis, to identify preoperative factors predicting the need for an additional port. SILC was completed with a single incision in 272 patients (88%); the insertion of at least one additional port was required in 36 patients (12%). The additional port requirement was associated with a longer operative time (P < 0.0001), greater intraoperative blood loss (P < 0.0001), and longer postoperative hospital stay (P = 0.0002). Multivariate analysis revealed male gender (odds ratio: 2.57, P = 0.0170), prior history of upper abdominal surgery (odds ratio: 5.53, P = 0.0132), and a higher preoperative white blood cell count (odds ratio: 3.62, P = 0.0244) to be independent factors associated with the requirement for an additional port. Our results suggest that gender, prior history of upper abdominal surgery, and white blood cell count can predict the likelihood of requiring an additional port in SILC.

Larger Curve Magnitudes (&gt; 70 Degrees) in Adolescent Idiopathic Scoliosis are Associated with Significantly Higher Cost of Surgical Treatment and a Delayed Return to Function

Introduction Surgical procedures to correct larger curve magnitudes &gt;70°in patients with adolescent idiopathic scoliosis (AIS) are still common globally. Despite the increased complexity associated with surgical correction of these curves, there is limited evidence available assessing the effect of preoperative curve severity on clinical or economical outcomes. This study aimed to examine the impact of preoperative curves &gt;70° versus those ≤ 70° on perioperative, functional and financial outcomes in patients with AIS undergoing posterior spinal fusion (PSF). Material and Methods Seventy seven eligible AIS patients who underwent PSF were prospectively followed-up, until return to postoperative function was reported. Preoperative curves &gt; 70° versus ≤ 70°, were analyzed in relation to surgical duration, estimated blood loss, perioperative complications, length of hospitalisation, return to function and cost of surgical treatment per patient. Results Severe preoperative curves greater than 70°, identified in 21 patients (27.3%), were associated with significantly longer surgical duration (median 6.5 hour versus 5 hour, p = 0.001) and increased blood loss (median 1,250ml versus 1,000ml, p = 0.005) – these patients were 2.1 times more likely to receive a perioperative blood product transfusion (Relative Risk 2.1, Confidence Interval 1.4–2.7, p = 0.004). Curves greater than 70° were also associated with a significantly delayed return to school/college, and an increased cost of surgical treatment (€33,730 versus €28,620, P &lt; 0.0001). Conclusion Surgeons can expect a longer surgical duration, greater intraoperative blood loss and double the blood product transfusion risk when performing PSF procedures on AIS patients with curves greater than 70°versus those ≤ 70°. Surgical correction for curves &gt; 70°, often as a result of lengthy surgical waiting lists, also incurs added expense and results in a partial delay in early functional recovery.

A cohort study of the morbidity of combined anterior-posterior cervical spinal fusions: incidence and predictors of postoperative dysphagia.

To identify risk factors that may lead to the development of dysphagia after combined anterior and posterior (360°) cervical fusion surgery. A single center, retrospective analysis of patients who had same-day, 360° fusion at Henry Ford Hospital between 2008 and 2012 was performed. Variables analyzed included demographics, medical co-morbidities, levels fused, and degree of dysphagia. The overall dysphagia rate was 37.7%. Patients with dysphagia had a longer mean length of stay (p<0.001), longer mean operative time (p<0.001), greater intraoperative blood loss (p=0.002), and fusion above the fourth cervical vertebra, C4, (p=0.007). There were no differences in the rates of dysphagia when comparing patients undergoing primary or revision surgery (p=0.554). Prolonged surgery and fusion above C4 lead to higher rates of dysphagia after 360° fusions. Prior anterior cervical fusion does not increase the risk of dysphagia development.

Safety and feasibility of modified transumbilical laparoendoscopic single-site simple nephrectomy

Objective To evaluate the safety and feasibility of applying modified transumbilical laparoendoscopic single-site surgery(LESS) nephrectomy in the treatment of kidney benign diseases. Methods From June 2012 to February 2014, 15 patients(group A)with benign nonfunctioning kidney were performed transumbilical laparoendoscopic single-site simple nephrectomy by an experienced laparoscopic surgeon. From February 2014 to December 2014, 10 patients(group B)with benign nonfunctioning kidney underwent modified transumbilical laparoendoscopic single-site simple nephrectomy by the same surgeon. Group A has 8 males and 7 females, with an average age of (51.3±5.5)years and an average body mass index of(22.5±1.3)kg/m2. Of the 15 patients, 10 were left benign nonfunctioning kidney while 5 were right. The causes of nonfunctioning kidney included renal calculi(7 cases), ureteral calculi(6 cases), and ureteropelvic junction obstruction(2 cases). Group B contains 4 males and 6 females, with an average age of(48.4±8.3)years and an average body mass index of(21.5±1.7)kg/m2. Of the 10 patients, 6 were left side benign nonfunctioning kidney while 4 were right. The causes of nonfunctioning kidney included renal calculi(4 cases), ureteral calculi(5 cases), and renal tuberculosis(1 case). An approximately 4 cm transverse incision was made below the umbilicus for single-port access in Group A. Operations were performed using 30°10 mm laparoscope with conventional and bending instruments. A 10 mm trocar next to the single-port access was added in group B without making a new skin incision, but with two incisions in the muscular layer. As two independent incisions, one is used for the single-port access, while the other is used for the 10mm trocar. This modified technique improves the procedure of the operation. A comparison was made between the two groups. Clinical indicators were collected before, during and after the operation, and complications of both groups were analyzed retrospectively. Results In group A, one case was converted to conventional laparoscopic nephrectomy, and 2 cases was added a trocar. Total operating time was significantly longer in group A than in group B[(201.0±31.5)min vs.(170.0±19.6)min, P=0.011)], but modified technique resulted in greater intra-operative blood loss[(134.7±42.7)ml vs.(174.4±43.9ml, P=0.034)]. There were no significant differences in resuming diet, leaving bed, removing drainage, visual analogue pain scale and length of hospital stay between the two groups. There was no severe complications in both groups, but an approximately 4 centimeters scar. Conclusions Modified transumbilical laparoendoscopic single-site simple nephrectomy was safe and effective. It can effectively reduce the operating time and learning curve, with improved cosmetic result. Key words: Transumbilical; Single-site; Laparoscopic surgery; Simple nephrectomy

Preoperative curves of greater magnitude (>70°) in adolescent idiopathic scoliosis are associated with increased surgical complexity, higher cost of surgical treatment and a delayed return to function.

Surgical procedures to correct larger curve magnitudes >70° in patients with adolescent idiopathic scoliosis (AIS) are still common; despite their increased complexity, limited research has assessed the effect of preoperative curve severity on outcomes. This study aimed to examine the impact of preoperative curves >70° vs. those ≤70° on perioperative, functional and financial outcomes in patients with AIS undergoing posterior spinal fusion (PSF). Seventy seven eligible AIS patients who underwent PSF were prospectively followed-up, until return to preoperative function was reported. Preoperative curves >70° vs. ≤70° were analysed in relation to surgical duration, estimated blood loss, perioperative complications, length of hospitalisation, return to function and cost of surgical treatment per patient. Severe preoperative curves >70°, identified in 21 patients (27.3%), were associated with significantly longer surgical duration (median 6.5 vs. 5h, p=0.001) and increased blood loss (median 1250 vs. 1000ml, p=0.005)-these patients were 2.1 times more likely to receive a perioperative blood product transfusion (Relative Risk 2.1, CI 1.4-2.7, p=0.004). Curves >70° were also associated with a significantly delayed return to school/college, and an increased cost of surgical treatment (€33,730 vs. €28,620, p<0.0001). Surgeons can expect a longer surgical duration, greater intraoperative blood loss and double the blood product transfusion risk when performing PSF procedures on AIS patients with curves greater than 70° vs. those ≤70°. Surgical correction for curves >70°, often as a result of lengthy surgical waiting lists, also incurs added expense and results in a partial delay in early functional recovery.

Obesity--a risk factor for postoperative complications in general surgery?

BackgroundObesity is generally believed to be a risk factor for the development of postoperative complications. Although being obese is associated with medical hazards, recent literature shows no convincing data to support this assumption. Moreover a paradox between body mass index and survival is described. This study was designed to determine influence of body mass index on postoperative complications and long-term survival after surgery.MethodsA single-centre prospective analysis of postoperative complications in 4293 patients undergoing general surgery was conducted, with a median follow-up time of 6.3 years. We analyzed the impact of bodyweight on postoperative morbidity and mortality, using univariate and multivariate regression models.ResultsThe obese had more concomitant diseases, increased risk of wound infection, greater intraoperative blood loss and a longer operation time. Being underweight was associated with a higher risk of complications, although not significant in adjusted analysis. Multivariate regression analysis demonstrated that underweight patients had worse outcome (HR 2.1; 95 % CI 1.4-3.0), whereas being overweight (HR 0.6; 95 % CI 0.5–0.8) or obese (HR 0.7; 95 % CI 0.6–0.9) was associated with improved survival.ConclusionObesity alone is a significant risk factor for wound infection, more surgical blood loss and a longer operation time. Being obese is associated with improved long-term survival, validating the obesity paradox. We also found that complication and mortality rates are significantly worse for underweight patients. Our findings suggest that a tendency to regard obesity as a major risk factor in general surgery is not justified. It is the underweight patient who is most at risk of major postoperative complications, including long-term mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-015-0096-7) contains supplementary material, which is available to authorized users.

Metabolic changes and factors influencing base deficit in infants undergoing craniosynostosis surgery: a retrospective study.

Corrective craniosynostosis surgery is often associated with a large amount of blood loss and metabolic disturbances. In the present study, we investigated the severity, duration of metabolic disturbances, and causal risk factors in infants. A retrospective analysis was performed of 36 infants who underwent craniosynostosis surgery. We analyzed the following: demographics, duration of surgery, intraoperative blood loss, RBC, FFP and fluids transfused, urine output, hemodynamic parameters, and electrolyte and base deficit (BD) values. The lowest intraoperative BD value and time required (period I: <6 h; period II: 6-12 h; period III: >12 h) for BD values to return to normal (-4 to +2) in the postoperative period were determined. In addition, we recorded the postoperative length of stay in the ICU and hospital, postoperative blood loss, and early complications. We detected that 88% of the patients had subnormal BD levels and 22% had metabolic acidosis. The lowest average BD measured during the operation was -8.4 ± 2.6 mmol/l. We carried out a multiple regression analysis, which revealed that lower BD values were associated with a longer duration of hypotension (p = 0.002, R(2) = 0.453) and greater intraoperative blood loss (p = 0.002, R(2) = 0.674). We examined the amount of intraoperative blood loss and found that that there were fewer blood product transfusions in period I patients and longer hypotensive episodes in period III patients. Also, a negative correlation was detected between the lowest intraoperative BD value with ICU duration (p = 0.004, r = -0.466) and hospital stay (p < 0.001, r = -0.764). Almost all patients developed intraoperative negative BD, which was prolonged in the postoperative period. The most important risk factors for developing negative BD are the amount of blood loss and duration of hypotension.

Factors Influencing Blood Loss and Postoperative Morbidity in Children Undergoing Craniosynostosis Surgery: A Retrospective Study

Background: Craniosynostosis is a condition resulting from the premature fusion of cranial sutures. Corrective surgery is often associated with a large amount of blood loss, with transfusion of red blood cells (RBC) and fresh frozen plasma (FFP). The aims of this study were to determine the variables associated with increased blood loss and postoperative complications. Methods: A retrospective analysis was performed of 42 pediatric patients who underwent craniosynostosis surgery. We analyzed the following: demographic parameters, duration of surgery, intraoperative blood loss, RBC, FFP and fluid transfusion, urine output, and hemodynamic parameters. In addition, we recorded the postoperative length of stay in the intensive care unit and hospital, postoperative blood loss and early complications. Results: The mean age, weight and surgical duration were 9.2 ± 3.2 months, 9.3 ± 2.0 kg and 255.8 ± 46.7 min, respectively. Intraoperative blood loss was 61.2 ± 15.3 ml/kg and RBC, FFP and fluid transfusion were 27.3 ± 7.1 ml/kg, 16.5 ± 4.7 ml/kg and 21.7 ± 4.6 ml/kg/h, respectively. Greater intraoperative blood loss was associated with longer surgical duration (p = 0.001, correlation coefficient = 0.495, R² = 0.245) and lower patient weight (p < 0.001, correlation coefficient = -0.557, R² = 0.311). Longer hospital stay was associated with greater intraoperative blood loss (p < 0.001, correlation coefficient = 0.754, R² = 0.568) and greater intraoperative RBC transfusion (p < 0.001, correlation coefficient = 0.795, R² = 0.632). Conclusion: Severe blood loss occurred in all children who underwent craniosynostotic corrections. Furthermore, the duration of surgery, patient weight and certain surgical procedures correlated with greater blood loss. Careful hemodynamic monitoring and evaluation of a patient's hematocrit value and volume status together may be helpful in maintaining the balance between insufficient and excessive blood product transfusion.

Loop versus end colostomy reversal: has anything changed?

Though primary repair of colon injuries is preferred, certain injury patterns require colostomy creation. Colostomy reversal is associated with significant morbidity and healthcare cost. Complication rates may be influenced by technique of diversion (loop vs. end colostomy), though this remains ill-defined. We hypothesized that reversal of loop colostomies is associated with fewer complications than end colostomies. This is a retrospective, multi-institutional study (four, level-1 trauma centers) of patients undergoing colostomy takedown for trauma during the time period 1/2006-12/2012. Data were collected from index trauma admission and subsequent admission for reversal and included demographics and complications of reversal. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests. Over the 6-year study period, 218 patients underwent colostomy takedown after trauma with a mean age of 30; 190 (87%) were male, 162 (74%) had penetrating injury as their indication for colostomy, and 98 (45%) experienced at least one complication. Patients in the end colostomy group (n = 160) were more likely to require midline laparotomy (145 vs. 18, p < 0.001), had greater intra-operative blood loss (260.7 vs. 99.4 mL, p < 0.001), had greater hospital length of stay (8.4 vs. 5.5 days, p < 0.001), and had more overall complications (81 vs. 17, p = 0.005) than patients managed with loop colostomy (n = 58). Local takedown of a loop colostomy is safe and leads to shorter hospital stays, less intra-operative blood loss, and fewer complications when compared to end colostomy.

Incidence of postoperative deep vein thrombosis after robotic-assisted laparoscopic prostatectomy: a prospective study in Chinese patients.

To investigate the incidence of deep vein thrombosis (DVT) in Chinese patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer and the need for prophylactic anticoagulation. From August 2007 to September 2010, patients with prostate cancer undergoing RALP in our center were prospectively recruited for the study. Perioperative parameters, including patients' age, disease stage and pathology, and intraoperative findings were collected. All patients underwent Doppler ultrasonographic evaluation of their bilateral lower limbs on postoperation day 3 for any evidence of DVT. The incidence of and possible predisposing factors for DVT were determined. One hundred and nine consecutive patients were recruited during the study period. The incidence rate of post-RALP DVT was 16.9 % (18 cases), with only one patient (1 %) developing above-knee DVT. No patient developed DVT-associated complications during follow-up. Patients with DVT were older (69.2 ± 4.4 vs. 65 ± 5.8 years old; p = 0.05), had greater intraoperative blood loss (775 vs. 264.7 ml; p = 0.001) and required lengthier hospitalization (8.1 vs. 6.0 days; p = 0.013). However, no difference in smoking history, body mass index, history of diabetes, lymph node dissection or disease stage was observed between patients with and without DVT. The post-RALP incidence of DVT in Chinese populations is not low. However, the majority of DVT cases are below the knee level and asymptomatic.

Salvage treatment for local recurrence of hepatocellular carcinoma after local ablation therapy

Local recurrence of hepatocellular carcinoma (HCC) after local ablation therapy (LAT) is a serious problem; however, the optimal treatment strategy remains unclear. A retrospective analysis was conducted of 50 patients with local recurrence of HCC after LAT that underwent either salvage hepatectomy (n = 23) or radiofrequency ablation (RFA; n = 27). Their background characteristics, intraoperative data, and postoperative short- and long-term outcome were analyzed. The RFA group was found to be significantly associated with an impaired liver functional reserve, smaller number and size of tumors. The hepatectomy group showed a significantly longer operation time, greater intraoperative blood loss and more frequent red blood cell transfusion. In-hospital stay mortality and morbidity rate did not significantly differ. The disease-free and overall survival showed no significant difference between the groups. Although local recurrence after salvage treatment was found in zero (0%) for hepatectomy and in seven (25.9%) for RFA, that did not affect the overall survival. The tumor size at the prior LAT was identified as an independent prognostic factor for disease-free survival and serum albumin for overall survival. Whereas salvage hepatectomy for local recurrent HCC is recommended for selected patients in terms of its good local control effect, salvage RFA is also acceptable because it is less invasive and also has a reasonable long-term outcome.

Postoperative complications following neoadjuvant bevacizumab treatment for advanced colorectal cancer

Attempts have been made to use bevacizumab (BEV) in an adjuvant or neoadjuvant setting. However, BEV is known to cause various adverse events, and the safety of neoadjuvant BEV has not yet been fully evaluated. This study assessed the postoperative complications in patients receiving neoadjuvant BEV for colorectal cancer. The data for 78 patients with resectable advanced or metastatic colorectal cancer who received neoadjuvant BEV followed by surgical resection were retrospectively analyzed. The median interval between the last BEV dose and surgery was 9 weeks. The most common postoperative complication was pelvic sepsis, which occurred in 11 patients (14 %). A biliary fistula developed in four of 23 patients who underwent liver resection. Anastomotic leakage occurred in six of 24 patients with a colorectal anastomosis, four of whom required re-laparotomy. In a univariate analysis, male gender and a greater intraoperative blood loss were associated with postoperative complications of any grade. Colorectal anastomosis was a risk factor for major complications. In a multivariate analysis, intraoperative blood loss was an independent risk factor for postoperative complications of any grade (HR 6.338; P = 0.003). With regard to major postoperative complications, colorectal primary anastomosis was the only independent predictive risk factor (HR 8.285; P = 0.013). In patients with colorectal cancer who underwent elective surgery after BEV treatment, the interval between BEV and surgery was not a risk factor for postoperative complications (based on a median interval of 9 weeks). Colorectal primary anastomosis was the only independent risk factor for major postoperative complications.

Niezamierzona śródoperacyjna hipotermia

Inadvertent perioperative hypothermia complicates a large percentage of surgical procedures and is related to multiple factors. Strictly regulated in normal conditions (± 0.2°C), the core body temperature of an anaesthetised patient may fall by as much as 6°C, while a 2°C decrease is very common. This is due to a combination of anaesthesia-related impairment of the central thermoregulatory control and a cool operating room temperature, which, when superimposed on insufficient insulation and a failure to actively warm the patient, may result in profound temperature disturbances. As a result, prolonged wound healing, increased risk of wound infection, a higher rate of cardiac morbidity, and greater intraoperative blood loss and postoperative blood transfusion requirements may occur. The reasons for this are said to include underlying changes in microcirculation, coagulation, immunology and an increase in the duration of action of most anaesthesia medications. As effective methods have been available for a number of years now, it is currently indicated to maintain intraoperative normothermia in order to minimise procedure-related risk and improve patient comfort.

Examining Reoperation and Readmission after Hepatic Surgery

Although the perioperative mortality from hepatic resection has improved considerably, this procedure is still associated with substantial morbidity and resource use. The goal of this investigation was to characterize the incidence, patterns, and risk factors for early reoperation and readmission after hepatectomy. Perioperative outcomes of 1,281 patients undergoing hepatic resection at an academic center from 1996 to 2009 were analyzed. The indications for early reoperation and readmission (90 days) were reviewed. Multivariate logistic regression analysis was performed to determine variables associated with reoperation and readmission. A scoring system was generated to predict the need for readmission after hepatectomy. Eighty-seven patients (6.8%) required reoperation. The perioperative mortality in patients requiring reoperation was significantly higher than for those not requiring reoperation (23.0% vs 3.4%; p < 0.001). Variables associated with reoperation included male sex, performance of concomitant major nonhepatic procedures, and greater intraoperative blood loss. One hundred and eighty-four patients (14.4%) required readmission. Variables associated with readmission included major hepatectomy, development of major postoperative complications, and index hospitalization >7 days. A Readmission Prediction Score ranging from 0 to 4 was generated and directly correlated with need for readmission. In the current era of hepatic surgery, early reoperation and readmission remain relatively frequent. As we care for patients who are increasingly receiving regionalized care far from home, we must be mindful of patients at increased risk for readmission. The development of strategies to minimize the complications that necessitate reoperation and readmission is critical to improving patient care.

Impact of postoperative morbidity on long-term survival after oesophagectomy

Oesophageal malignancy is a disease with a poor prognosis. Oesophagectomy is the mainstay of curative treatment but associated with substantial morbidity and mortality. Although mortality rates have improved, the incidence of perioperative morbidity remains high. This study assessed the impact of postoperative morbidity on long-term outcomes. A prospective database was designed for patients undergoing oesophagectomy for malignancy from 1998 to 2011. An observational cohort study was performed with these data, assessing intraoperative technical complications, postoperative morbidity and effects on overall survival. Some 618 patients were included, with a median follow-up of 51 months for survivors. The overall complication rate was 64·6 per cent (399 of 618), with technical complications in 124 patients (20·1 per cent) and medical complications in 339 (54·9 per cent). Technical complications were associated with longer duration of surgery (308 min versus 293 min in those with no technical complications; P = 0·017), greater operative blood loss (448 versus 389 ml respectively; P = 0·035) and longer length of stay (22 versus 13 days; P < 0·001). Medical complications were associated with greater intraoperative blood loss (418 ml versus 380 ml in those with no medical complications; P = 0·013) and greater length of stay (16 versus 12 days respectively; P < 0·001). Median overall and disease-free survival were 41 and 43 months. After controlling for age, tumour stage, resection margin, length of tumour, adjuvant therapy, procedure type and co-morbidities, there was no effect of postoperative complications on disease-specific survival. Technical and medical complications following oesophagectomy were associated with greater intraoperative blood loss and a longer duration of inpatient stay, but did not predict disease-specific survival.

Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy

Single-incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC). MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis. Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port-site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD -0·97, 95% of c.i. -1·51 to -0·43; P < 0·001) and Cosmesis score (WMD -2·46, 95% of c.i. -2·95 to -1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used. SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety.

Liver resection for complicated hepatocellular carcinoma: Challenges but opportunity for long‐term survivals

Hepatocellular carcinoma (HCC) is often diagnosed late because of the lack of pathognomonic symptoms. This study evaluated outcomes following liver resection (LR) for patients with HCC presenting with large tumor size (over 10 cm), adjacent organ invasion, or ruptured tumor, which we termed as complicated HCC (cHCC). We retrospectively reviewed 660 HCC patients who underwent LR between January 2001 and July 2005. The patients were grouped into cHCC and non-cHCC according to the defined criteria. The clinicopathological features were analyzed and compared between the two groups. Patients in the cHCC group required longer operative times and resulted in greater intraoperative blood loss and more severe surgical complications. The cHCC group had a higher incidence of HCC recurrence after LR, and the HCC recurrence had a tendency to be associated with extrahepatic metastasis. The 5-year RFS (P < 0.0001) and OS (P < 0.0001) of cHCC and non-cHCC patients were 18.5% and 28.9% versus 37.5% and 57.6%, respectively. LR for cHCC can be a great challenge for liver surgeons. However, with comparable operative mortality rates and acceptable survival times, surgical resection should always be considered performing in patients with cHCC, if clinically feasible.

Su1532 Outcomes After Transhiatal and Transthoracic Esophagectomy for Esophageal Cancer

Background: Controversy persists as to the preferred operative approach to esophageal cancer. Therefore, we investigated the peri-operative, short-term, and mid-term outcomes between transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) at our institution. Methods: We conducted a retrospective review of 114 patients who had undergone esophagectomy for esophageal cancer, in our tertiary care center. Among those patients who underwent THE or TTE we compared: a) clinical characteristics; b) pathologic findings; and c) outcomes. Parametric and non-parametric tests of significance were performed, and survival was determined by Kaplan-Meier analysis. Results: We identified 32 patients who underwent THE, and 82 patients who underwent TTE. Age, gender, race/ethnicity, alcohol and tobacco use, weight loss and body mass index at the time of surgery, operative risk, chemoradiation regimen, tumor stage, and pathologic findings were similar between groups. Those who underwent THE had a greater intra-operative blood loss (p=0.003), required more intra-operative blood transfusions (p<0.0001), spent a longer time on the ventilator (p<0.0001) and in the intensive care unit (p=0.002), and had a higher 30-day mortality (p=0.023). Likewise, those who underwent THE had a greater prevalence of post-operative vocal cord dysfunction (17% vs 3%, p=0.027) and anastomotic leak (29% vs. 1%, p<0.0001). Compared to THE, patients undergoing TTE had a greater number of lymph nodes sampled (mean 13.0 vs 13.6, respectively) and frequency of lymph nodes positive for carcinoma (29% vs 35%, respectively). Finally, survival at 3-years was significantly less after THE than after TTE (26% vs. 53%, p=0.035), as was overall 5-year survival (p=0.039) (Figure 1). Conclusions: These data demonstrate a short-term survival advantage and lower morbidity of TTE as compared to THE at our institution. We speculate that the higher morbidity after THE may account for the worse outcomes associated with this approach.

Su1533 Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Esophagogastric Carcinoma

Background: Controversy persists as to the preferred operative approach to esophageal cancer. Therefore, we investigated the peri-operative, short-term, and mid-term outcomes between transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) at our institution. Methods: We conducted a retrospective review of 114 patients who had undergone esophagectomy for esophageal cancer, in our tertiary care center. Among those patients who underwent THE or TTE we compared: a) clinical characteristics; b) pathologic findings; and c) outcomes. Parametric and non-parametric tests of significance were performed, and survival was determined by Kaplan-Meier analysis. Results: We identified 32 patients who underwent THE, and 82 patients who underwent TTE. Age, gender, race/ethnicity, alcohol and tobacco use, weight loss and body mass index at the time of surgery, operative risk, chemoradiation regimen, tumor stage, and pathologic findings were similar between groups. Those who underwent THE had a greater intra-operative blood loss (p=0.003), required more intra-operative blood transfusions (p<0.0001), spent a longer time on the ventilator (p<0.0001) and in the intensive care unit (p=0.002), and had a higher 30-day mortality (p=0.023). Likewise, those who underwent THE had a greater prevalence of post-operative vocal cord dysfunction (17% vs 3%, p=0.027) and anastomotic leak (29% vs. 1%, p<0.0001). Compared to THE, patients undergoing TTE had a greater number of lymph nodes sampled (mean 13.0 vs 13.6, respectively) and frequency of lymph nodes positive for carcinoma (29% vs 35%, respectively). Finally, survival at 3-years was significantly less after THE than after TTE (26% vs. 53%, p=0.035), as was overall 5-year survival (p=0.039) (Figure 1). Conclusions: These data demonstrate a short-term survival advantage and lower morbidity of TTE as compared to THE at our institution. We speculate that the higher morbidity after THE may account for the worse outcomes associated with this approach.

Surgical management of giant hepatic hemangiomas : complications and review of the literature

Hepatic hemangiomas are the most common benign hepatic tumors, and they are usually asymptomatic with normal liver function. When hepatic hemangiomas reach 4 cm, we define them as giant hemangiomas. Treatment options for giant hemangiomas are observation, surgical resection, and transcatheter arterial embolization. The aim of this study was to identify the risk factors for surgical complications. In this study, the records of 61 patients with giant hepatic hemangiomas treated with surgical resection at Chang Gung Memorial Hospital, Linkou were retrospectively reviewed. Data on clinical variables including symptoms, the size, number, and location of the tumors, preoperative liver function tests, operative method, operation time, and operative blood loss were collected and analyzed. There were 8 patients (13.1%, 95% confidence interval 5.8% to 24.2%) with complications after resection or enucleation. Postoperative complications were associated with large tumor size (p = 0.021) and tumors that were symptomatic (p = 0.017). In addition, complications were associated with greater use of intraoperative inflow control (p = 0.053), longer operative time (p = 0.001), and greater intraoperative blood loss (p = 0.022). Most complications could be treated conservatively, but invasive interventions such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangial drainage were required for management of grade III complications. Most giant hepatic hemangiomas can be treated with enucleation or resection. Important factors associated with complications were large tumor size, the presence of symptoms, surgical bleeding, and prolonged surgery. Most complications were grade I and could be treated conservatively. Both resection and enucleation were relatively safe with an acceptable complication rate (13.1%) and no mortality in our study.