Higher Intraoperative Blood Loss Research Articles

Connective tissue disease type mediates branch patency of grafts in open thoracoabdominal aortic reconstruction.

Despite a shared degenerative vascular phenotype, Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS), and other genetically distinct connective tissue diseases (CTDs) have unique extravascular pathologies that impact the outcomes of aortic replacement. The aim of our study was to investigate the association of CTD genotype with postoperative outcomes and branch patency following open thoracoabdominal aortic replacement in a large institutional cohort. All patients undergoing open branched thoracoabdominal aortic replacement at a single academic center from 2006 to 2020 were included and classified as CTD or non-CTD based on the presence of genotypic documentation. Outcomes were compared using analysis of variance and χ2 testing for continuous and discrete variables, respectively. Kaplan-Meier curves were utilized to examine patency of graft branches over time. Overall, 172 patients were included, with a mean follow-up of 30.5± 34.9months. CTD was present in 45 patients (26%); specifically, 32 had MFS, five had LDS, and eight had another CTD. Patients with CTDs had more extent II thoracoabdominal aneurysms (40% vs 15%), more reconstructed branches (3.5 vs 1.8), more frequently reconstructed visceral branches (86.7% vs 22.7%), and higher intraoperative blood loss (13.3 vs 6.8L; all P< .05) compared with non-CTD patients. Patients with MFS were more frequently systemically anticoagulated preoperatively (50% vs 5%) and demonstrated higher rates of postoperative deep vein thrombosis/pulmonary embolism compared with non-CTD patients (9%vs 2%; both P< .05). Five-year renal branch patency was decreased among all patients compared with visceral branches (87.3% vs 95.6%; P= .05), but there were no individual branch patency differences between patients with and without CTDs (P= .086). Overall branch patency at 1 and 5years was significantly higher in patients with MFS than in non-CTD patients (98.9% vs 89.1% at 5years); there were no significant patency differences between non-CTD patients and any other CTD subgroup, mostly due to early patency loss. Open thoracoabdominal reconstruction in patients with CTD is technically challenging and associated with increased transfusion and postoperative thromboembolic events when compared with non-CTD patients. Technical outcomes of the procedure are excellent and are differentially associated with genotype, with patients with MFS experiencing significantly improved branch patency over both non-CTD patients and patients with other CTDs, a finding which has multifactorial drivers.

P-P13 Long-term outcome after portal vein resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matched analysis

Abstract Background Portal vein resection (PVR) with pancreaticoduodenectomy (PD) is often performed to achieve clear margins for patients with vascular involvement in pancreatic ductal adenocarcinoma (PDAC). However, there is evidence to suggest that patients undergoing PVR often have more advanced cancers, therefore the impact of PVR on survival and recurrence remains unclear. The aim of this study is to assess overall (OS) and recurrence free (RFS) survival in patients who underwent PVR during PD, with particular attention to margin positivity. Methods A retrospective analysis was performed on 638 patients who underwent PD during a 12-year period. Exclusion criteria included PD for non-PDAC tumours, neoadjuvant chemotherapy or intra-operative radiotherapy. 374 patients were included in the study (90 PVR and 284 non-PVR). Patient characteristics and histopathological factors associated with OS and RFS were then evaluated using univariate and multivariate Cox regression analyses. 270 patients (90 PVR and 180 non-PVR), were matched by propensity score based on perineural invasion, pT and pN staging. The Kaplan-Meier method was used to calculate survival and log-rank tests. Results Resection margin positivity was associated with shorter OS and RFS (p &amp;lt; 0.0001), and the superior mesenteric vein (SMV) margin was the most significant risk factor for survival on competing risks analysis. Absent adjuvant chemotherapy, nodal metastasis and margin positivity were independent risk factors for OS and RFS on multivariate analysis. PVR was associated with higher intra-operative blood loss (p = 0.009), but was not associated with increased length of stay, complications or readmissions. PVR patients had increased pT staging, nodal metastasis and perineural invasion, however, there was no difference in OS (p = 0.551) or RFS (p = 0.256) between PVR and non-PVR after propensity matching. Conclusions Positive resection margins are associated with shorter survival times, and the SMV margin is the most significant prognostic indicator for overall survival and recurrence compared to other margins. PVR is a relatively safe procedure, however, it does not achieve the intended survival benefits of complete margin clearance. The impact on survival for margin positivity, particularly the SMV margin, and nodal metastasis should be considered when making decisions with regards to vein resection and adjuvant treatments.

The role of routine postoperative laboratory tests following hip hemiarthroplasty for an elderly femoral neck fracture

BackgroundPerforming postoperative laboratory tests following joint arthroplasty is a regular practice. However, the role of routine postoperative laboratory tests in primary hip arthroplasty is currently in doubt. This study aimed to assess the role of routine postoperative laboratory tests for femoral neck fractures in elderly patients who underwent hip hemiarthroplasty and to evaluate the risk factors for postoperative laboratory testing abnormalities and related interventions.MethodsThis retrospective study reviewed 735 consecutive patients with femoral neck fractures (FNFs) who underwent hip hemiarthroplasty at a single tertiary academic organization. Patient characteristic features and laboratory testing values were recorded. Logistic regression models were calculated to identify risk factors.ResultsA total of 321 elderly patients (> 75 years of age) were ultimately enrolled for analysis. Abnormal postoperative laboratory tests were found in 265 patients (82.6%). Only a minority of the included patients (7.5%) needed medical intervention to treat postoperative laboratory testing abnormalities. Multivariate logistic regression analysis reported that a higher Charlson comorbidity index (CCI) (P = 0.03), abnormal preoperative haemoglobin level (P < 0.01), higher intraoperative blood loss (P < 0.01) and less frequent tranexamic acid use (P = 0.05) were risk factors for abnormal postoperative laboratory tests. Furthermore, a higher CCI has been identified as a risk factor for patients needing clinical interventions related to laboratory abnormalities.ConclusionsBecause 92.5% of laboratory tests did not influence postoperative management, the authors suggest that routine laboratory tests after hip hemiarthroplasty for FNFs are less instructive for the majority of elderly patients. Nevertheless, for patients with identified risk factors, postoperative laboratory tests are still required to identify the abnormalities that need to be managed.

Factors Affecting Postoperative Length of Stay in Patients Undergoing Anterior Lumbar Interbody Fusion

With hospital leaders and policy makers increasingly seeking ways to improve resource use, there has been heightened interest in reducing hospital length of stay (LOS) and performing spine procedures on an outpatient basis. We aimed to determine which risk factors correlated with prolonged LOS after anterior lumbar interbody fusion (ALIF). Medical records for patients who underwent ALIF were retrospectively reviewed. Patients were divided into those who had extended (≥3 days) versus nonextended (<3 days) LOS, and patient demographics, medical comorbidities, and preoperative medications were analyzed. Univariate and multivariate regression were then used to determine preoperative risk factors for extended LOS. A total of 166 patients were included (mean age, 48.7 years). Medical comorbidities included hypertension (31.9%), diabetes (8.4%), and obesity (body mass index>30 kg/m2) (48.8%). LOS was not extended in 121 patients and extended in 45. Mean LOS was 2.2 days (95% confidence interval, 1.9-2.5). On multivariate logistic analysis, age ≥65 years (P= 0.001), preoperative benzodiazepine use (P= 0.014), 12-item Short Form mental component score (P= 0.008), estimated blood loss (P= 0.015), time to mobilization (P < 0.001), and total operative time (P= 0.020) were independent predictors for extended LOS. As attempts are made to perform more spine procedure in ambulatory surgical centers, strict patient selection criteria are all critical in making this possible. Our results suggest that age, preoperative benzodiazepine use, higher intraoperative blood loss, delayed mobilization, and lower 12-item Short Form mental component score were correlated with increased LOS. Therefore, inpatient ALIF may be more suitable for patients with these risk factors.

Misdiagnosis of appendiceal neoplasms as ovarian tumors: Impact of prior gynecologic surgery on definitive cytoreduction and HIPEC

BackgroundFemale patients with pelvic/adnexal masses often undergo gynecologic operations due to presumed ovarian origin. The diagnosis of an appendiceal tumor is often only made postoperatively after suboptimal cytoreduction has been performed. We hypothesized that an index gynecological procedure increases the morbidity of definitive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in patients with appendiceal mucinous tumors. MethodsA single-center retrospective review was performed to identify female patients undergoing CRS/HIPEC for appendiceal tumors from 2012 to 2020. ResultsDuring the 8-year period, CRS/HIPEC was performed in 36 female patients with appendiceal mucinous tumors. Eighteen patients (50.0%) had received a prior pelvic operation by gynecologists (PPO Group) for presumed ovarian origin before referral for definitive CRS/HIPEC. The median peritoneal cancer index (PCI) was higher in the PPO group (21 vs. 9, p = 0.04). The median number of days from gynecologic procedure to definitive CRS/HIPEC was 169 days. Compared to patients who did not undergo a prior gynecologic operation, those in the PPO group had higher intraoperative blood loss (650 vs 100 mL, p < 0.01) during CRS/HIPEC as well as longer length of stay (12 vs 8 days, p = 0.02) and higher overall morbidity (72.3% vs 33.3%, p = 0.02). After controlling for PCI, prior gynecologic operation increased risk of 30-day morbidity after definitive CRS/HIPEC (OR 11.6, p < 0.01). ConclusionA multi-disciplinary approach is needed for the primary evaluation of patients with pelvic masses of undetermined origin. A gynecological resection is associated with increased morbidity during definitive cytoreduction and HIPEC for appendiceal mucinous tumors.

Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture.

ObjectiveThis study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF).MethodsThe subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors.ResultsThere were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients.ConclusionABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).

Clinically relevant pancreatic fistula following pancreatoduodenectomy is associated with high intraoperative blood loss: A multi-institutional propensity score matched analysis

Clinically relevant pancreatic fistula following pancreatoduodenectomy is associated with high intraoperative blood loss: A multi-institutional propensity score matched analysis

Effect of intraoperative blood loss on postoperative pulmonary complications in patients undergoing video-assisted thoracoscopic surgery.

Background We aimed to investigate the impact of intraoperative blood loss on postoperative pulmonary complications in patients who underwent video-assisted thoracoscopic lobectomy for nonsmall cell lung cancer. Methods Data of a total of 409 patients (227 males, 182 females; median age: 62 years; range, 20 to 86 years) who underwent lung resection for Stage I-IIIa non-small cell lung cancer in our clinic between July 2017 and April 2018 were retrospectively analyzed. The receiver operating characteristic analysis was used to confirm the threshold value of intraoperative blood loss for the prediction of postoperative pulmonary complications. Propensity score matching was performed to compare between high-intraoperative blood loss and low-intraoperative blood loss groups. A post-matching conditional logistic regression was conducted to determine the independent risk factors for postoperative pulmonary complications. Results Of the patients, 86 (21.03%) developed postoperative pulmonary complications. In the propensity score matching analysis, intraoperative blood loss was shown to be a predictive factor of postoperative pulmonary complications (3.992; 95% confidence interval [CI]: 1.54-10.35; p=0.004). The rate of postoperative pulmonary complications in high-intraoperative blood loss group was significantly higher than that the low-intraoperative blood loss group (37.5% vs. 13.9%, respectively; p=0.003). The postoperative length of stay and duration of postoperative antibiotic use were significantly prolonged in the high-intraoperative blood loss group. Conclusion Intraoperative blood loss serves as a significant risk factor for postoperative pulmonary complications after lung resection for non-small cell lung cancer. Surgeons should strive to reduce intraoperative blood loss for better surgical outcomes.

Risk factors associated with postoperative respiratory failure in tuberculous empyema patients.

Our objective was to identify independent risk factors for predicting which patients in the Chinese population would likely develop respiratory failure.A descriptive analysis was conducted of demographic and clinical data of patients with tuberculous empyema (TE) admitted to the Beijing Chest Hospital, Capital Medical University between January 2001 and January 2020. Risk factors associated with postsurgical respiratory failure in TE patients were identified based on results of analyses based on univariable and multivariable logistic regression models.A total of 139 TE patients who underwent surgical treatment in the Beijing Chest Hospital, Capital Medical University from January 2001 to January 2020 were enrolled in this study. Cases included 109 male and 30 female patients, with an overall mean age (range 17–73) of 39.3 years. Of 139 TE patients, 26 (18.7%) experienced respiratory failure after surgery. Among significant risk factors for postsurgical respiratory failure, intraoperative blood loss volume greater than 1000 mL had the highest odds ratio value of 6.452. In addition, a pathologic preoperative pulmonary function test result showing a high partial pressure of carbon dioxide level was an independent risk factor for respiratory failure. Moreover, the presence of tuberculosis lesions in the contralateral lung was another significant risk factor for respiratory failure, as determined using multivariate analysis.Respiratory failure is a predominant complication experienced by TE patients undergoing surgery. High intraoperative blood loss, high preoperative high partial pressure of carbon dioxide level, and tuberculosis lesion(s) in the contralateral lung of TE patients were associated with increased risk of postoperative respiratory failure.

Exposure to Blood Components and Inflammation Contribute to Pancreatic Cancer Progression

Pancreatectomy is a highly invasive procedure with extensive intraoperative blood loss (IBL) and high risk of postoperative pancreatic fistula (POPF). We conducted an experimental and retrospective clinical study to determine whether the malignant behaviors of pancreatic cancer cells were enhanced by exposure to blood components in vitro and to evaluate the oncological significance of high IBL and POPF in pancreatic cancer. This study included 107 patients undergoing radical pancreatectomy in the University of Yamanashi Hospital between 2011 and 2017, classified into high (n = 29) and low (n = 78) IBL groups. In vitro experiments included functional analyses of Panc-1 pancreatic cancer and normal mesothelial cells exposed to patient blood components, and clinical data were used to assess the contribution of IBL and POPF to patient outcomes. The migration (p = 0.007), invasion (p < 0.001), and proliferation (p < 0.01) of Panc-1 cells were enhanced with platelet coculture. The ability of Panc-1 cells to adhere mesothelial cells was enhanced by plasma coincubation, especially in the presence of inflammation (p < 0.001). High IBL was associated with worse overall survival (p = 0.007) and increased locoregional recurrence (p = 0.003) in patients. POPF enhanced the negative prognostic significance of high IBL (p < 0.001 for overall survival, p = 0.001 for locoregional recurrence), indicating the oncological negative effects of high IBL and POPF. Blood components, especially platelets, and inflammation enhance the malignant behaviors of pancreatic cancer cells, potentially contributing to poor prognosis for pancreatic cancer patients.

Long-Term Efficacy of Bariatric Surgery for the Treatment of Super-Obesity: Comparison of SG, RYGB, and OAGB.

The most appropriate procedure for the treatment of super obesity (BMI > 50 kg/m2) is unknown. We aimed to evaluate the safety, long-term (> 5 years) weight loss, and adverse events between three commonly performed procedures, sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) in super-obese patients. Between January 2002 and December 2015, 498 successive patients with super morbid obesity (BMI > 50), who underwent SG or RYGB or OAGB, were recruited. Surgical outcome, weight loss, resolution of co-morbidities, and late complications were followed and compared between the 3 groups. All data derived from a prospective bariatric database and a retrospective analysis was conducted. The average patient age was 32.1 ± 10.4 years, with a mean body mass index (BMI) of 56.0 ± 6.7 kg/m2. Of them, 190 (38.9%) underwent SG, 62 (12.4%) RYGB, and 246 (49.4%) OAGB. There was no difference in basic characters between the 3 groups except SG had fewer diabetic patients. RYGB group had higher intraoperative blood loss, longer operating time, and hospital stay than the other 2 groups. RYGB had a higher 30-days post-operative major complication rate (4.8%) than SG (0.5%) and OAGB (0.8%). The follow-up rate at 1 and 5 years was 89.4% and 52.0%. At post-operative 5 years, OAGB had a higher total weight loss (40.8%) than SG (35.1%), but not RYGB (37.2%). SG had a lower remission rate in dyslipidemia comparing to OAGB and RYGB, but T2DM remission rate was no different between the groups. The overall revision rate is 5.4% (27/498) of the whole group, and SG had a lower revision rate (2.6%) than RYGB (8.1%) and OAGB (6.9%). SG is an effective and durable primary bariatric procedure for the treatment of super obesity and metabolic disorders. OAGB had a similar operation risk to SG but resulted in a better weight loss than SG.

Intraoperative blood loss in oncological spine surgery.

Intraoperative blood loss in patients undergoing oncological spine surgery poses a major challenge for vulnerable patients. The goal of this study was to assess how the surgical procedure, tumor type, and tumor anatomy, as well as anesthesiological parameters, affect intraoperative blood loss in oncological spine surgery and to use this information to generate a short preoperative checklist for spine surgeons and anesthesiologists to identify patients at risk for increased intraoperative blood loss. The authors performed a retrospective analysis of 430 oncological patients who underwent spine surgery between 2013 and 2018 at the university medical spine center. Enrolled patients had metastatic tumor of the spine requiring surgical decompression of neural structures and/or stabilization including tumor biopsy using an open, percutaneous, and/or combined dorsoventral approach. Patients requiring vertebro- and kyphoplasty or biopsy only were excluded. Statistical analyses performed included a multiple linear regression analysis. The mean intraoperative blood loss in the study patient cohort was 1176 ± 1209 ml. In total, 33.8% of patients received intraoperative red blood cell transfusions. The statistical analyses showed that tumor histology indicating myeloma, operative procedure length, epidural spinal cord compression (ESCC) score, tumor localization, BMI, and surgical strategy were significantly associated with increased intraoperative blood loss or risk of needing allogeneic blood transfusions. Anesthesiological parameters such as the American Society of Anesthesiologists (ASA) Physical Status classification score were not associated with blood loss. Multiple linear regression analysis demonstrated good predictive value (r = 0.437) for a five-item preoperative checklist to identify patients at risk for high intraoperative blood loss. The analyses performed in this study demonstrated key factors affecting intraoperative blood loss and showed that a simple preoperative checklist including these factors can be used to identify patients undergoing surgery for metastatic spine tumors who are at risk for increased intraoperative blood loss. ABT = allogeneic blood transfusion; ASA = American Society of Anesthesiologists; ESCC = epidural spinal cord compression; KW = Kruskal-Wallis; MET = metabolic equivalent of task; RBC = red blood cell.

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.

Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery

Background: Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion.Methods: Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared.Results: Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion.Conclusion: Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia.Level of Evidence: Therapeutic Level III

Predictive factors for intraoperative blood loss in surgery for adolescent idiopathic scoliosis

BackgroundAdolescent idiopathic scoliosis (AIS) is a common spinal deformity. Posterior spinal fusion remains an important surgical treatment for AIS. This study aims to determine the predictive factors for intraoperative blood loss in AIS surgery.MethodsPatients who had undergone posterior spinal fusion for adolescent idiopathic scoliosis in a single university hospital were reviewed over a 7-year period. Predictive factors for intra-operative blood loss were studied by multivariate analysis to derive a regression model. Receiver operating characteristic analysis was performed to determine the cut-off values of factors contributing to significant intraoperative blood loss (≥500 ml).ResultsTwo hundred and twelve patients were included. Intraoperative blood loss was found to be correlated with gender (rs = 0.30 (0.17–0.43)), preoperative hemoglobin level (rs = 0.20 (0.04–0.31)), preoperative Cobb angle (rs = 0.20 (0.02–0.29)), number of fused levels (rs = 0.46 (0.34–0.58)), operation duration (rs = 0.65 (0.54–0.75)), number of anchors (rs = 0.47 (0.35–0.59)), and p-value ranged from < 0.001 to < 0.05. Significant intraoperative blood loss was influenced by the male gender, operation duration greater than 257.5 min and more than 10 anchors used.ConclusionsMale gender, increased operation duration and higher number of anchors predicted higher intra-operative blood loss.

Controlled DCD Liver Transplantation Is Not Associated With Increased Hyperfibrinolysis and Blood Loss After Graft Reperfusion.

The specific effect of donation after circulatory death (DCD) liver grafts on fibrinolysis, blood loss, and transfusion requirements after graft reperfusion is not well known. The aim of this study was to determine whether transplantation of controlled DCD livers is associated with an elevated risk of hyperfibrinolysis, increased blood loss, and higher transfusion requirements upon graft reperfusion, compared with livers donated after brain death (DBD). A retrospective single-center analysis of all adult recipients of primary liver transplantation between 2000 and 2019 was performed (total cohort n = 628). Propensity score matching was used to balance baseline characteristics for DCD and DBD liver recipients (propensity score matching cohort n = 218). Intraoperative and postoperative hemostatic variables between DCD and DBD liver recipients were subsequently compared. Additionally, in vitro plasma analyses were performed to compare the intraoperative fibrinolytic state upon reperfusion. No significant differences in median (interquartile range) postreperfusion blood loss (1.2 L [0.5-2.2] versus 1.3 L [0.6-2.2]; P = 0.62), red blood cell transfusion (2 units [0-4] versus 1.1 units [0-3]; P = 0.21), or fresh frozen plasma transfusion requirements (0 unit [0-2.2] versus 0 unit [0-0.9]; P = 0.11) were seen in DCD compared with DBD recipients, respectively. Furthermore, plasma fibrinolytic potential was similar in both groups. Transplantation of controlled DCD liver grafts does not result in higher intraoperative blood loss or more transfusion requirements, compared with DBD liver transplantation. In accordance with this, no evidence for increased hyperfibrinolysis upon reperfusion in DCD compared with DBD liver grafts was found.

Revision to reverse total shoulder arthroplasty: do short stem and stemless implants reduce the operative burden compared to convertible stems?

BackgroundRevision of prior hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) to reverse shoulder arthroplasty (RSA) is a technically challenging procedure with high complication rates. The purpose of this study was to compare intraoperative complications between convertible humeral stems and nonconvertible humeral stems stratified by stem length for conversion of TSA or HA to RSA. Materials and methodsA multicenter retrospective analysis of patients undergoing revision of a primary TSA or HA to RSA was conducted. Patients were divided into 2 groups based on convertible or nonconvertible humeral stem design from the index surgery. The primary outcome measures were the following intraoperative variables and complications: total operative time, blood loss, intraoperative fracture, overall complication rate, and blood transfusions. Rates were compared between groups and analyzed according to primary stem length for the nonconvertible group. ResultsA total of 279 patients were included in the study, 70 with convertible stems and 209 with nonconvertible stems. About 70% of convertible stems were successfully retained. Operative time was similar between the 2 groups overall. Patients with nonconvertible stems had higher intraoperative blood loss (P = .0001), higher overall complication rate (P = .009), and greater risk of intraoperative fracture (P= .002). Revising stemless and short stems to RSA had significantly reduced operative time compared to standard length stems (97 and 116 minutes vs. 141 minutes, P < .0001 and P = .035, respectively). When revising stemless implants, there was a significantly lower rate of intraoperative fracture (3.6%) compared to short stems (24%, P = .004) and standard stems (23.4%, P = .001). When revising stemless implants to RSA, there was shorter operative time (P= .0001) and similarly low rate of intraoperative fracture (P= .820) compared to convertible stems. ConclusionIn revision of anatomic TSA to RSA, convertible stems lead to lower blood loss and intraoperative fracture rate compared to nonconvertible stems when broadly including all stem types. However, differences appear to be based on stem type. Among nonconvertible stems, revision of short stem and stemless implants are associated with reduced operative time compared to standard length stems. Revision of stemless implants to RSA is associated with the shortest operative time of all implant types as well as a similar rate of intraoperative fracture compared to convertible stems. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

Periprosthetic Joint Infection after Primary Total Knee Arthroplasty With and Without Sinus Tract: Treatment Outcomes

Background. Sinus tract appears up to 20% of patients with periprosthetic joint infection (PJI) after primary total joint arthroplasty (TJA). The adverse effect of different patient related risk factors is well known, but the role of the sinus tract in PJI recurrence wasn’t properly investigated. The purpose of the study was to analyze the influence of a sinus tract on the effectiveness of two-stage reimplantation in PJI. Material and Methods. In order to reduce the influence of known risk factors on effectiveness of infection eradication several including criteria were introduced: patients with PJI after primary total knee arthroplasty (TKA), without surgeries before TKA and after infection manifestation and without attempts of antibiotic suppression. Finally, 119 of 475 patients with PJI after primary TKA, treated with two-stage protocol, were retrospectively analyzed: 33 patients with presence of the sinus tract, 86 — without sinus tract. Pathogen type, comorbidities, PJI type, bone defects, duration of surgery, intraoperative blood loss and the effectiveness of twostage reimplantation were analyzed. Results. Pathogen structure in analyzed groups was comparable. Staphylococci were the leading cause of PJI in compared groups: 64.4% of patients without sinus tract and 59.1% of patients with sinus tract. Wherein S. aureus was more frequently isolated in case of active sinus tract while S. epidermidis played the leading role in compared group. Polymicrobial PJI was more likely to develop in patients with sinus tract (p = 0.09). Massive bone defects of femur and tibia (type 3 according AORI classification) were identified only in patients with sinus tract PJI, as well as significantly longer duration of the spacer implantation and higher intraoperative blood loss at this stage (p0.05). Infection eradication after spacer implantation stage was achieved in 98.8% (n = 79) of patients without sinus tract while only 81% (n = 17) of patients with sinus tract PJI successfully passed this stage of surgical treatment (p0.05), effectiveness of revision knee arthroplasty was 98.7% (n = 78) and 76.5% (n = 13) respectively (p0.05). Finally, complex effectiveness of twostage reimplantation in patients with sinus tract was significantly lower (61.9%) than in patients of compared group (97.5%), p0.05. Conclusion. Presence of the sinus tract in patients with PJI after primary TKA adversely effects on the effectiveness of two-stage reimplantation, this fact could be explained by aggressive development of infection, caused by more virulent pathogens and higher frequency of polymicrobial cases among this cohort of patients. The established patterns require further research to develop tactics for managing this category of patients in order to increase the effectiveness of two-stage reimplantation.

Impact of Intraoperative Blood Loss on the Survival of Patients With Stage II/III Colorectal Cancer: A Multicenter Retrospective Study.

Resection of the primary lesion with radical lymph node dissection is the most promising treatment avenue for patients with cancer. On the other hand, these procedures often induce excessive intraoperative blood loss (IBL) and require perioperative blood transfusion. The influence of IBL on the long-term postoperative outcomes of patients with digestive cancer is controversial. We investigated the impact of IBL on survival and recurrence after curative surgery in patients with colorectal cancer (CRC) in a single study group. In total, 1,597 patients who underwent radical resection for CRC at three group hospitals between 2000 and 2019 were reviewed. Patients were classified into a group with high IBL (≥200 ml) or low IBL (<200 ml). The risk factors for disease-free (DFS) and overall (OS) survival were analyzed. A total of 489 and 1,108 patients were classified into the high and low IBL groups, respectively. The OS and DFS rates at 5 years after surgery were 89.3% and 63.4%, respectively, for the high IBL group and 96.9% and 77.8% for the low IBL group; these differences were statistically significantly (p<0.001). The multivariate analysis demonstrated that IBL was a significant independent risk factor for OS and DFS. The amount of IBL was associated with significant differences in the OS and DFS of patients with stage II/III CRC who received curative resection. The surgical procedure, surgical strategy, and perioperative care should be carefully planned to avoid causing IBL.

Risk Factors of Serious Postoperative Complications after Laparoscopic Pancreatoduodenectomy: Single Center Retrospective Study

Background: Two hundred and ninety laparoscopic pancreatoduodenectomies (LPDE) were performed by single surgical team. Objective: to assess the short-term and long-term outcomes of LPDE and to reveal the risk factors for having the Clavien-Dindo IIIa-V complication. Methods: 290 patients underwent LPDE during last 10 years. 169 were females and 131 were males. Mean age was 60 years (range 29-82). 244 patients were operated on because of malignancies and 46 because of benign diseases. Postoperative complications were graded according Clavien-Dindo classification. 109 perioperative factors and parameters including laboratory test results were analyzed in order to reveal their influence on developing of postoperative complications. Results: Mean operative time was 419min and mean blood loss was 350cc. Total Clavien-Dindo IIIa-V complications (CRPOC) rate was 36.8% (107 patients). Among them IIIa - 16,2%, IIIb - 10.7%, IV - 3,8%, V - 6,2%. CRPOPF were diagnosed in total of 20,3% patients (15,5% grade B POPF, 4,8% grade C). DGE was diagnosed in 4,8% of patients. PPH complicates the postoperative course of 20 patients (6,9%). Sixteen of them had concomitant PF. Univariate analysis revealed that the age ≥65, male sex, the soft pancreatic tissue, absent of pancreatic hypertension, high intraoperative blood loss (≥400 cc), high BMI (≥30), diagnosis other than pancreatic adenocarcinoma, were independent risk factors for having serious complications. Conclusion: age ≥65, male sex, the soft pancreatic tissue, absent of pancreatic hypertension, high intraoperative blood loss (≥400 cc), high BMI (≥30), diagnosis other than pancreatic adenocarcinoma were independent risk factors for having serious complications.